Researchers who studied NHS data found 41% of admissions were potentially avoidable because they were for conditions that could have been prevented or treated in the community or were the result of poor care or neglect.
“Hospital is not the best place for most frail elderly people and nurses are often the solution”
Their findings suggest it is possible to cut the number of distressing emergency hospital trips experienced by elderly care home residents and help reduce pressure on already hard-pushed NHS services.
According to the analysis by the Improvement Analytics Unit – a joint initiative between NHS England and the Health Foundation – the overall number of permanent care home residents aged 65 and over arriving at A&E in 2016-17 was 269,000 – 6.5% of all attendances for people from that age group in England.
Meanwhile, there were an estimated 192,000 emergency admissions – 7.9% of the total number of emergency admissions among that age group.
However, the research team concluded “a large number” of emergency admissions might have been prevented because they were down to poor care or neglect or were for conditions like chest infections, pressure ulcers and urinary tract infections that could have been managed, treated and ideally prevented outside of a hospital setting.
They were surprised to find emergency admissions were particularly high in residential care homes compared with nursing homes where residents are generally more seriously ill and require care from registered nurses.
People in residential care homes attended A&E on average 1.12 times in 2016-17 compared with 0.86 times in nursing homes.
Meanwhile, there were 0.77 emergency admissions per resident per year from residential homes compared with 0.63 admissions from nursing homes.
“One possible explanation is that staff in residential homes may have less support in managing health needs within the homes and therefore rely more on emergency services,” said the report.
“Also, health needs may not be detected as early in residential homes as in nursing homes,” it added.
Researchers went on to look in detail at four initiatives to improve health and care in care homes, which included developing much closer links with local health services.
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In three out of the four there were noticeable reductions in emergency hospital trips among residents who received extra support.
For example, in Rushcliffe in Nottinghamshire efforts to boost the health and wellbeing of care home residents included aligning care homes with general practices, regular visits from a named GP, and improved support from community nurses, who also helped train care home staff on topics including preventing falls and pressure ulcers.
The measures also included additional support from the voluntary sector and a programme to engage and support care home managers.
As a result, care home residents were admitted to hospital as an emergency 23% less often than a comparison group and had 29% fewer A&E attendances, researchers found.
The NHS Long Term Plan in England, published this year, included a commitment to roll out the Enhanced Health in Care Homes framework across the country. One of the key goals of the framework is to reduce emergency admissions from care homes.
The researchers said their work showed it was important to understand the difference between residential care homes and nursing homes when implementing the framework and trying to drive improvements.
Overall, their findings suggested it may be easier to reduce emergency admissions and A&E attendances from residential homes compared with nursing homes.
This could be down to the fact nursing homes residents tended to have more serious health conditions such as cancer and chronic pulmonary disease and were more often nearing the end of life – making it harder to avoid hospital care.
Another factor may be that nursing home residents already benefitted from greater input from a wider range of health professionals including GPs, making efforts to reduce emergency admissions “more challenging”.
However, the report went on to suggest that one issue that may make it harder to drive improvements in nursing homes was a disconnect with wider health services.
It found “co-production” between health professionals and care homes was essential to developing effective interventions.
However, more work may be needed to forge those relationships with nursing homes and engage key nursing staff, the report suggested.
“Nurses in nursing homes, who have clinical expertise, may feel more responsibility for their residents’ clinical health needs than other staff,” said the report.
“This may require more emphasis on co-design and early engagement to create good working relationships and ensure that in-house nurses feel like partners,” it added.
The researchers said a project in Wakefield – where most of the care home residents involved in the initiative lived in nursing homes – showed there was scope to reduce emergency admissions from this sector.
Under the scheme care homes had access to enhanced primary care support and the input of a multi-disciplinary team, which screened residents to identify care needs that could lead to inappropriate emergency hospital use if not addressed.
The Improvement Analytics Unit’s evaluation, covering the first phase of the initiative, found residents receiving the enhanced support had 27% fewer admissions for potentially avoidable conditions than a matched control group.
However, there was no conclusive evidence that there was an effect on overall A&E attendances or emergency admissions.
“Nurses in nursing homes may feel more responsibility for their residents’ clinical health needs”
Researchers suggested a more targeted approach focusing on specific preventable conditions or residents with frequent hospital admissions may be useful in nursing homes.
In order to do this staff needed access to relevant data to review and track residents’ hospital admissions, said the report.
The Royal College of Nursing stressed nursing staff in all care homes were keen to avoid emergency admissions but often had little choice.
“Nursing staff in care homes want more than anyone to try and prevent the residents they care for from being admitted to hospital as emergencies,” said Wendy Preston, RCN head of nursing practice.
“But, at present, if a care home resident has a fall or develops a urinary tract infection, particularly out of hours, staff have very few options and are often advised to call an ambulance by NHS 111 or managers.”
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She said the solution was dedicated primary care teams that included advanced practice nurses who could promptly assess and treat residents who fall or injure themselves.
“A few areas currently have such teams, but we need them to be rolled out nationwide. Hospital is not the best place for most frail elderly people and nurses are often the solution to this problem despite services not always receiving the correct funding,” said Ms Preston.
Sally Copley, director of policy and campaigns at the Alzheimer’s Society, also stressed the need to boost community health and social care services.
“Through our Fix Dementia Care campaign we know thousands of people with dementia every year are hospitalised by things that could have been prevented with better or more widely available care in the community, and people are often then trapped in hospital because of the lack of social care when they’re well enough to leave,” she said.
She called on new prime minister Boris Johnson to take action and invest in an NHS Dementia Fund “to give people the vital financial support they need whilst also addressing long term reform”.