Effective health care for older people living and dying in care homes: A realist review

Background: Care home residents in England have variable access to health care services. There is currently no coherent policy or consensus about the best arrangements to meet these needs. The purpose of this review was to explore the evidence for how different service delivery models for care home residents support and/or improve wellbeing and health-related outcomes in older people living and dying in care homes. Methods: We conceptualised models of health care provision to care homes as complex interventions. We used a realist review approach to develop a preliminary understanding of what supported good health care provision to care homes. We completed a scoping of the literature and interviewed National Health Service and Local Authority commissioners, providers of services to care homes, representatives from the Regulator, care home managers, residents and their families. We used these data to develop theoretical propositions to be tested in the literature to explain why an intervention may be effective in some situations and not others. We searched electronic databases and related grey literature. Finally the findings were reviewed with an external advisory group. Results: Strategies that support and sustain relational working between care home staff and visiting health care professionals explained the observed differences in how health care interventions were accepted and embedded into care home practice. Actions that encouraged visiting health care professionals and care home staff jointly to identify, plan and implement care home appropriate protocols for care, when supported by ongoing facilitation from visiting clinicians, were important. Contextual factors such as financial incentives or sanctions, agreed protocols, clinical expertise and structured approaches to assessment and care planning could support relational working to occur, but of themselves appeared insufficient to achieve change. Conclusion: How relational working is structured between health and care home staff is key to whether health service interventions achieve health related outcomes for residents and their respective organisations. The belief that either paying clinicians to do more in care homes and/or investing in training of care home staff is sufficient for better outcomes was not supported.This research was funded by National Institute of Health Research Health Service Delivery and Research programme (HSDR 11/021/02)

Nurse-Led Medicines' Monitoring for Patients with Dementia in Care Homes: A Pragmatic Cohort Stepped Wedge Cluster Randomised Trial

People with dementia are susceptible to adverse drug reactions (ADRs). However, they are not always closely monitored for potential problems relating to their medicines: structured nurse-led ADR Profiles have the potential to address this care gap. We aimed to assess the number and nature of clinical problems identified and addressed and changes in prescribing following introduction of nurse-led medicines' monitoring.Pragmatic cohort stepped-wedge cluster Randomised Controlled Trial (RCT) of structured nurse-led medicines' monitoring versus usual care.Five UK private sector care homes.41 service users, taking at least one antipsychotic, antidepressant or anti-epileptic medicine.Nurses completed the West Wales ADR (WWADR) Profile for Mental Health Medicines with each participant according to trial step.Problems addressed and changes in medicines prescribed.Information was collected from participants' notes before randomisation and after each of five monthly trial steps. The impact of the Profile on problems found, actions taken and reduction in mental health medicines was explored in multivariate analyses, accounting for data collection step and site.Five of 10 sites and 43 of 49 service users approached participated. Profile administration increased the number of problems addressed from a mean of 6.02 [SD 2.92] to 9.86 [4.48], effect size 3.84, 95% CI 2.57-4.11, P <0.001. For example, pain was more likely to be treated (adjusted Odds Ratio [aOR] 3.84, 1.78-8.30), and more patients attended dentists and opticians (aOR 52.76 [11.80-235.90] and 5.12 [1.45-18.03] respectively). Profile use was associated with reduction in mental health medicines (aOR 4.45, 1.15-17.22).The WWADR Profile for Mental Health Medicines can improve the quality and safety of care, and warrants further investigation as a strategy to mitigate the known adverse effects of prescribed medicines.ISRCTN 48133332

The Impact of Music and Memory on Resident Level Outcomes in California Nursing Homes

OBJECTIVES: To study the effects of a nonpharmacologic intervention, Music and Memory (M&M), on residents with dementia and/or behavioral problems living in nursing homes (NHs). DESIGN: This was a prospective, mixed-methods cohort study. SETTING AND PARTICIPANTS: In total, 4107 residents in 265 California NHs and that reported data at least twice during the 3-year study period were enrolled. MEASURES: We used a quarterly rolling enrollment process; participants provided data at baseline and quarterly via an online survey that included select resident level data from the Minimum Data Set (psychotropic drug use, cognition, behaviors, mood, pain, and falls), experience with the M&M program, and resident use of music. NHs were eligible if they were Medicare- and Medicaid-certified and had 15 residents with a diagnosis of dementia or cognitive impairment or exhibited significant behavioral symptoms. RESULTS: M&M was associated with reductions in psychotropic medication use, reduced behaviors, and improved mood. The odds of antipsychotic use declined by about 11%, of antianxiety medications by 17%, and antidepressants by 9% per quarter. Aggressive behaviors, depressive symptoms, pain, and falls also declined significantly over time. The odds of residents exhibiting aggressive behaviors declined by 20% per quarter, depressive symptoms by 16%, reported pain by 17%, and falls by 8%. CONCLUSIONS AND IMPLICATIONS: This is the largest study of M&M to date. We found clinically and statistically significant reductions in psychotropic medications and improved behaviors in residents using M&M. Although the study showed positive results overall, the lack of a control group was a significant limitation that precluded determining how much more improvement participating residents experienced compared with nonparticipants. Future studies should include a control group so that better conclusions can be drawn regarding the effectiveness of the M&M program

Advance care planning at life milestones

Much progress has been made in advance care planning (ACP), especially related to end of life and palliative care. These advances have moved thinking about ACP from a checklist approach to an upstream recognition that ACP is an iterative process that should begin early in adulthood and be revisited with each milestone or life-changing event. It is recognized that there are many stages and milestones in adult life that contribute to changing loci of responsibility and life goals. These changes impact how individuals view their lives, the complexity of health care, and the myriad of health conditions they may encounter. ACP discussions should routinely be started and reexamined at the time of key life events like starting a career or a marriage and not delayed until hospitalization, the occurrence of a serious accident, or the development of a catastrophic illness.12 month embargo; published: 16 April 2022This item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

Interprofessional education: an overview of six initiatives across the schools of health at a single university.

Abstract The benefits of interprofessional education (IPE) amongst health professionals are well documented, however, the implementation of interprofessional initiatives across the USA is inconsistent. This report describes the development and content of a number of IPE initiatives that are in the early stages of development and implementation at the University of California, Davis, USA. The article describes several important factors that were found to be necessary for the initial implementation of these IPE initiatives. Evaluation data from these initiatives, which is providing a range of positive outcomes, are also presented and discussed in relation to the wider IPE literature