Title: Optimal NHS service delivery to care homes: a realist evaluation of the features and mechanisms that support effective working for the continuing care of older people in residential settings
Funder: Department of Health (England)

Abstract: The aim of this study is to identify ways in which the delivery of existing NHS services to care homes may be optimized for the ongoing benefit of residents relatives and staff and the best use of NHS resources. Our primary objective is to carry out a realist evaluation (Pawson and Tilley 1997) which will address the following research questions:1.What is the range of health service delivery models designed to maintain care home residents outside of hospital?2.What features (in realist evaluation terms: mechanisms) of these delivery models are the ‘active ingredients’ associated with positive outcomes for care home residents? (Models may include general medical services (GMS) linked community services outreach clinics community matrons specialist nurses or care home support teams pharmacist-led services designated NHS hospital beds and enhanced payment schemes for GPs.)3.How are these features/mechanisms associated with key outcomes including medication use use of out-of-hours services resident and carer satisfaction unplanned hospital admissions (including A&E) and length of hospital stay?4.How are these features/mechanisms associated with costs to the NHS and from a societal perspective? 5.What configuration of these features/mechanisms would be recommended to promote continuity of care for older people resident in care homes at reasonable cost?There are two phases to this realist evaluation:PHASE ONE: Addresses questions 1 and 2. It brings together multiple sources of evidence to identify key features or mechanisms that are necessary to achieve positive outcomes in 5 areas of interest ( hospital admission (including A&E) length of stay out of hours service use medication management and user satisfaction) There are three strands:1. Interviews with stakeholders ( NHS LA and care home managers residents and their families)2.A review of survey evidence on the range and organisational models of current NHS provision to care homes with and without nursing3.A review of the evidence for the effectiveness of different service delivery models for residents with complex needs in the five areas of interest.Synthesis and analysis of the data will enable us to map the range of service provision to care homes (e.g. GMS provided by local GP practices linked community services outreach clinics specialist nurses or support teams pharmacist-led services designated NHS hospital beds and enhanced payment schemes for GPs)and establish agreed and operational definition of key features or mechanisms present in these different models(e.g financial incentives case/care manager roles use of protocols and integrated care pathways)judged to be necessary to deliver effective care in the five outcome measures. Key to this final analysis will be the development of a consensus on how the study findings differentiate between what are the mechanisms of service delivery to care homes and the contexts that support or inhibit that process.The findings from phase one will enable us to produce a list of propositions of the key mechanisms or features of service delivery (and the quality of the supporting evidence)and the different contexts ranked according to evidence available that have most influence on all or some of the five outcomes of interest. PHASE TWO : addresses research questions 3-6It will adopt a longitudinal case study methodology to describe and compare the delivery of continuing healthcare to 12 care homes and their residents across three geographically disparate areas. One will be selected as an example of usual care i.e. an approach to commissioning and care delivery for care homes in their area where there is little or no differentiation between services provided to people living at home and those in care homes. Two will be selected on the basis of models of commissioning and care delivery showing different configurations of mechanisms or features believed to support optimal working between care homes and the NHS (i.e. augmented service delivery ). It is likely that one site will reflect mechanisms that dominate within NHS led models of service delivery (e.g. GP Local enhanced services community matronsspecialist teams) and one site will have mechanisms that reflect care home based initiatives or models developed with care homes (e.g. co-design approach to service delivery use of shared protocols and frameworks/ educational programmes to support care home staff absorb NHS work). We will match the first four care homes recruited where usual care is provided with the remaining eight care homes in the two sites for resident population staffing ratios and proximity to secondary care. For 12 months we will track the impact of the mechanisms/features of interest on the five areas of care taking a wider perspective in order to understand what works and why for which groups of residents and in what context. The analysis of care home resident and staff level data and process data will initially be analysed and reported separately and then synthesised to provide a detailed description of how the presence or absence of key features or mechanisms influence the delivery of healthcare resource use and resident family and care home staff satisfaction. Particular attention will be given to how continuity of care and processes that support integrated working are achieved. Descriptive statistics will compare the baseline characteristics of recruited residents from each care home. For each recruited resident the number of contacts with primary careout of hours services use of emergency services and secondary care will be separately summed over the 12 months. Service use for each item will be converted to costs ( Curtis 2012; Dept. of Health 2011) and summed to provide a total cost for primary and community care secondary care and emergency services. High users of the key service use outcome variables will be identified so that variability between care homes and within and between service delivery models with respect to the mechanisms established in phase 1 can be explored. Descriptive statistics will be used to explore the other main outcome variables (medication reviews and resident and carer satisfaction). Regression modeling will be used to investigate which resident characteristics are most strongly associated with costs.


Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE