Title: Reducing rates of avoidable hospital admissions: Optimising an evidence-based intervention to improve care for Ambulatory Care Sensitive conditions in nursing homes.
Funder: Department of Health and Social Care

Abstract: AIM The aim of this PG is to build on our PDG to reduce rates of hospital admissions from nursing homes for Ambulatory Care Sensitive (ACS) conditions, defined in policy terms as conditions which, if not detected early and actively managed in the nursing home, can lead to unplanned hospital admissions. In our PG we will optimise and pilot test a pragmatic, acceptable, evidence-based intervention for proactive care of ACS conditions. BACKGROUND Nursing home residents are amongst the frailest and most vulnerable members of society. Most have significant functional and cognitive impairments and complex health care needs. Most will have a number of chronic conditions such as obstructive pulmonary disease or congestive cardiac failure and these will be subject to relapse and acute exacerbation. In addition, intercurrent infections (such as those of the urinary tract) and acute events such as falls may often occur. Many of these health conditions, for example chronic obstructive airways disease and cardiac failure, can be classified as ACS conditions, whereby early detection and treatment of exacerbations may allow the condition to be treated in the community. In the UK guidance on best practice for treating common chronic conditions has been developed and financial incentives have been made available to primary care. Yet despite efforts to improve the management of ACS conditions, rates of unplanned admissions for these conditions have not reduced. Rather, across the UK population as a whole, they have increased by 40%, the greatest rise being in those over 80 years of age, many of whom will reside in nursing homes. We can improve care for ACS conditions in nursing homes. This will reduce rates of avoidable hospital admission and improve residents health-related quality of life. IMPORTANCE Hospitalisation is costly to the NHS and is distressing to the person, their family and nursing home staff. Reducing rates of hospitalisation for ACS conditions is a government priority within the 2013/2014 Clinical Commissioning Group Outcomes Indicator Set for the National Health Service. The consultation on 2014/15 indicators include: Reducing time spent in hospital by people with long-term conditions: Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults) (NHS OF 2.3.i)http://www.nice.org.uk/aboutnice/ccgois/CCGOIS.jsp. NEED FOR RESEARCH Despite this policy imperative, our PDG systematic literature review confirmed the paucity of research in this area in the UK and across Europe. Multi-component interventions for reducing rates of avoidable hospitalisations have only been evaluated in US nursing homes, where there are some indications of their effectiveness. PAST AND CURRENT RESEARCH In our PDG we identified few studies in this area that were conducted in the UK. We noted the ACS conditions most commonly associated with hospitalisation from nursing homes as including acute exacerbation of congestive cardiac failure, respiratory and urinary tract infections and dehydration. We identified promising multi-component interventions which focused on a) enhancing knowledge and skills of nursing home staff; b) clinical guidance and decision-support tools (care pathways); c) engaging with families; and d) implementation support. RESEARCH PLANS Following the MRC guidance for the development, evaluation and implementation of complex interventions to improve health, we will: WS1: design the optimal format of a pragmatic and acceptable intervention and support for its implementation; WS2: conduct a pilot study with a nested process evaluation. RESEARCH TEAM This multi disciplinary research team is based on an established and successful collaboration between NHS professionals, care home providers, experts by experience (family members) and academics. RESEARCH ENVIRONMENT The Programme will be based at the Bradford Institute for Health Research (BIHR). BIHR has been awarded several prestigious NIHR applied programme grants and has a track record in conducting high quality applied health research that makes a difference. OUTPUTS A multi component acceptable and practical intervention to support nursing home staff and families to work in partnership to reduce avoidable hospital admissions incorporating: Clinical guidance and decision-support tools (care pathways) for commonly occurring ACS conditions for use in UK nursing homes; An acceptable and pragmatic approach to enhancing the skills of nursing home staff in timely health care for ACS conditions in nursing homes. IMPACT The research will contribute to setting standards and informing guidelines for detecting, assessing and reporting acute changes in residents' physical health and ensuring timely health care of ACS conditions in nursing homes. Co-applicants in the NHS and nursing home sectors will ensure outputs are widely available and easily accessed. ETHICAL IMPLICATIONS We will adhere to the Mental Capacity Act (2005) and safeguarding principles in addressing ethical issues.

Lay abstract: Reducing rates of hospitalisation for Ambulatory Care Sensitive (ACS) conditions is a government priority. ACS conditions is a term used in policy for conditions which, if not actively managed, can lead to unplanned hospital admissions. By definition, ACS conditions are a potential cause of avoidable hospital admissions. They include acute exacerbation of congestive heart failure, respiratory and urinary tract infections and dehydration. Hospitalisation is costly to the NHS and distressing to the person, their family and nursing home staff. Nursing home residents are amongst the frailest and most vulnerable members of society. Most have complex health care needs and more than two thirds have dementia. Early identification of changes in residents health is essential to ensure active management of ACS conditions in nursing homes. Our Programme Development Grant (PDG) identified multi-component interventions which, when tested in US nursing homes, showed promise in reducing avoidable admissions. They involve a combination of: a) skills enhancement of nurses and care assistants; b) clinical guidance and decision-support tools (care pathways); c) family involvement; and d) implementation support. Nursing home staff in our PDG were keen to ensure their residents got timely medical care and did not have to go to hospital for conditions that could have been cared for in the home, if detected and reported earlier. We will now build on our PDG through a programme of 2 work streams (WSs) to develop, optimise and pilot test a pragmatic, evidence-based, multi-component intervention to reduce rates of avoidable hospital admissions from nursing homes. In WS1 we will review promising interventions identified in our PDG for a UK setting. We will do this by working in collaboration with primary and secondary care clinicians, nursing home staff and family members to: a) develop clinical guidance and decision support systems (care pathways) for UK nursing homes; b) determine optimal methods to enhance the skills of nursing home staff; c) clarify the role of family members; d) work in collaboration with stakeholders to develop implementation support and guidance for the intervention. In WS2 we test the intervention and implementation guidance in two nursing homes to optimise them for practical use. We then conduct a pilot evaluation of this optimised intervention and implementation guidance in 14 nursing homes to determine the impact on avoidable hospital admissions and on a range of resident, staff, family and system-related secondary outcomes. In this WS we will further optimise the intervention with stakeholder feedback. If our results suggest that the intervention reduces avoidable admissions from nursing homes, we will seek further funding to evaluate the intervention in a larger number of nursing homes around the country.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE