“Sometimes rewarding, sometimes challenging, but always educational”
The first in a series of lessons from the Proactive Health Care of Older People in Care Homes (PEACH) study about how to do improvement work around healthcare with care homes
Reena Devi is Senior Fellow in Care Home Research at the University of Leeds, she tweets as @_DrReenaDevi
Adam Gordon is Associate Professor of the Medicine of Older People at the University of Nottingham, he tweets as @adamgordon1978
The Proactive Healthcare for Older People Living in Care Homes (PEACH) study was funded as part of the Dunhill Medical Trust’s Improving the Care of Frail Older People Initiative. We worked with care home staff and healthcare professionals to improve healthcare for care home residents.
We used an approach called Quality Improvement Collaboratives. These have been used in a number of healthcare settings to bring people with shared improvement goals together, and provide them with expert improvement support. Improvement Collaboratives are reported to achieve better outcomes than if individual professionals work in isolation.
Our Collaborative comprised four groups of professionals from different parts of Nottinghamshire. Each group had at least two care home staff members and one lay member, one general practitioner, one healthcare commissioner, and other local practitioners able to implement change to healthcare in care homes.
We asked our Collaborative to work on an approach called Comprehensive Geriatric Assessment. This uses detailed assessment by a multidisciplinary team to guide a comprehensive care and management plan. It has been shown to be a highly effective way to provide healthcare for older people with frailty because it provides a structured approach to their complex health and social care needs.
The project took place from 2016 – 2018. It was at times rewarding and at times challenging, but always educational. Each group took a strikingly different approach to improving care. One group started multidisciplinary assessment meetings for care home residents, whilst another set up a way to identify and respond to residents who were at risk of deterioration. The remaining two groups chose much narrower approaches, with one focussing on pharmacist-led medication reviews, and another on dietician-led nutrition reviews. We found, though, that these narrower approaches attracted multidisciplinary support over time and gradually became a focus for comprehensive assessment and management planning.
Over the next few months, we’ll be sharing a series of blogs about our learning from the PEACH study. We’ll describe how Comprehensive Geriatric Assessment operates in care homes, and how successful quality improvement collaboratives can be established to work with the care home sector.
As this is our first blog, though, we thought we’d share a few overarching lessons from the project.
It’s best to focus on making improvements where you have influence. Improvement teams in PEACH often made the best progress when they sought to improve aspects of care directly in their control. The group who focussed on medication reviews were led by a pharmacist who was able to work with colleagues in care homes to start the process, learn from both successes and failures, and move the project forward. By contrast, a team who aimed to implement changes to information technology at a regional level found that they spent a lot of time waiting for things to happen that were out of their control.
Collaboratives need to set goals that are permissive and allow teams to work to their strengths. The initial PEACH goal, to work towards Comprehensive Geriatric Assessment in care homes, did not work well. This is because some teams struggled to understand Comprehensive Geriatric Assessment. Other teams, meanwhile, didn’t have enough influence to pull together a complex multidisciplinary assessment and management package. By loosening the objective to “improving care for older people living with frailty in care homes”, teams were able to work on projects that complemented their expertise and influence.
Time spent on developing relationships is important. Lots of previous research studies have shown the importance of establishing a collaborative culture when working with care homes. This needs to be designed into improvement work. Using principles of appreciative enquiry, we asked the collaborative to establish their own ground rules for effective team-working and we revisited these every time we met. Examples of the types of ‘ground rules’ set were rules such as (i) no question is a silly question, (ii) everyone listen to who is speaking, (iii) mobile phones put away and on silent. Icebreaker activities were also used at all the meetings, and were designed to get participants to speak about themselves outside of their professional role in order to build human relationships. Facilitators worked hard to highlight and praise good practice.
Ensuring that residents and relatives have a voice can be difficult. Residents are often frail and attending half- or full-day collaborative meetings was not possible. Appeals through our care home representatives for relatives to attend did not yield volunteers. Two of the improvement teams invited AGE UK advocacy service representatives to be involved. We found their involvement informed improvements, for example when an AGE UK worker insisted that residents or relatives should be consulted about concerns and priorities ahead of multidisciplinary team meetings. More work is required, though, to work out how to access the voice of residents and relatives more directly.
Planning data collection takes time and effort. It has to be relevant to staff if they are expected to participate. Data on health care delivery in care home residents is not currently collected or compiled in a standardised way. In keeping with good improvement practices, we asked teams to think about how they would measure improvement. These discussions, though, frequently focussed mostly on the challenges, and resource implications of collecting the data. This was particularly the case where teams believed strongly in their improvement plan: “Why do we need to measure the effect, we know it’s going to work?!” In practice, we were only able to get teams to collect data when it involved information regularly encountered or used in their day-to-day work.
Quality improvement infrastructure and expertise is essential. Although participants in the collaborative were care home enthusiasts, we were frequently told that this work would not have progressed without the structure of the PEACH study. The PEACH study team helped broker and support relationships. They helped teach clinical and commissioning staff about improvement methodologies that they hadn’t previously encountered. They coached teams when they got stuck with an idea. They provided data analyst support to collate and analyse data, where teams agreed this was important.
The PEACH study has moved forward our understanding of how to do quality improvement around healthcare in care homes. Keep your eye out for our forthcoming blogs with more detail about how to make things work.
To hear more about the project, please do come to our 2019 annual lecture where Adam Gordon will be presenting the findings.