Setting priorities to inform assessment of care homes’ readiness to participate in healthcare innovation: a systematic mapping review and consensus process

© 2020 The Author(s). This is an open access article distributed under the Creative Commons Attribution License which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly citedOrganisational context is known to impact on the successful implementation of healthcare initiatives in care homes. We undertook a systematic mapping review to examine whether researchers have considered organisational context when planning, conducting, and reporting the implementation of healthcare innovations in care homes. Review data were mapped against the Alberta Context Tool, which was designed to assess organizational context in care homes. The review included 56 papers. No studies involved a systematic assessment of organisational context prior to implementation, but many provided post hoc explanations of how organisational context affected the success or otherwise of the innovation. Factors identified to explain a lack of success included poor senior staff engagement, non-alignment with care home culture, limited staff capacity to engage, and low levels of participation from health professionals such as general practitioners (GPs). Thirty-five stakeholders participated in workshops to discuss findings and develop questions for assessing care home readiness to participate in innovations. Ten questions were developed to initiate conversations between innovators and care home staff to support research and implementation. This framework can help researchers initiate discussions about health-related innovation. This will begin to address the gap between implementation theory and practice.Peer reviewe

Anticholinergic Drug Exposure and the Risk of Dementia: A Nested Case-Control Study

IMPORTANCE Anticholinergic medicines have short-term cognitive adverse effects, but itis uncertain whether long-term use of these drugs is associated with an increased risk of dementia.OBJECTIVE To assess associations between anticholinergic drug treatments and risk of dementia in persons 55 years or older.DESIGN, SETTING, AND PARTICIPANTS This nested case-control study took place in general practices in England that contributed to the QResearch primary care database. The study evaluated whether exposure to anticholinergic drugs was associated with dementia risk in 58 769 patients with a diagnosis of dementia and 225 574 controls 55 years or older matched by age, sex, general practice, and calendar time. Information on prescriptions for 56 drugs with strong anticholinergic properties was used to calculate measures of cumulative anticholinergic drug exposure. Data were analyzed from May 2016 to June 2018.EXPOSURES The primary exposure was the total standardized daily doses (TSDDs) of anticholinergic drugs prescribed in the 1 to 11 years prior to the date of diagnosis of dementia or equivalent date in matched controls (index date).MAIN OUTCOMES AND MEASURES Odds ratios (ORs) for dementia associated with cumulative exposure to anticholinergic drugs, adjusted for confounding variables.RESULTS Of the entire study population (284 343 case patients and matched controls), 179 365 (63.1%) were women, and the mean (SD) age of the entire population was 82.2 (6.8) years. The adjusted OR for dementia increased from 1.06 (95%CI, 1.03-1.09) in the lowest overall anticholinergic exposure category (total exposure of 1-90 TSDDs) to 1.49 (95%CI, 1.44-1.54) in the highest category (>1095 TSDDs), compared with no anticholinergic drug prescriptions in the 1 to 11 years before the index date. There were significant increases in dementia risk for the anticholinergic antidepressants (adjusted OR [AOR], 1.29; 95%CI, 1.24-1.34), antiparkinson drugs (AOR, 1.52; 95%CI, 1.16-2.00), antipsychotics (AOR, 1.70; 95% CI, 1.53-1.90), bladder antimuscarinic drugs (AOR, 1.65; 95%CI, 1.56-1.75), and antiepileptic drugs (AOR, 1.39; 95%CI, 1.22-1.57) all for more than 1095 TSDDs. Results were similar when exposures were restricted to exposure windows of 3 to 13 years (AOR, 1.46; 95%CI, 1.41-1.52) and 5 to 20 years (AOR, 1.44; 95%CI, 1.32-1.57) before the index date for more than 1095 TSDDs. Associations were stronger in cases diagnosed before the age of 80 years. The population-attributable fraction associated with total anticholinergic drug exposure during the 1 to 11 years before diagnosis was 10.3%.CONCLUSIONS AND RELEVANCE Exposure to several types of strong anticholinergic drugs is associated with an increased risk of dementia. These findings highlight the importance of reducing exposure to anticholinergic drugs in middle-aged and older people

Care home readiness: a rapid review and consensus workshops on how organisational context affects care home engagement with health care innovation

Summary The NHS Five-Year Forward view recognises that the NHS needs to do more to support older people living with frailty in care homes. This paper presents the findings from a rapid review and consensus events that explored how organisational context affects uptake of healthcare innovation in long term care settings. Care home managers and front line staff, care home researchers, NHS commissioners and NHS practitioners participated in the workshops. The review found that uptake is likely to be better when contextual factors are addressed. Leadership and care home culture were important but there was a limited consensus about how to identify this or, for example, what kind of leadership made a difference. A few studies highlighted the importance of making sure that the priorities of care home and health care practitioners were aligned and establishing that care home staff had the resources and time to implement the change. Workshop participants agreed that the different contextual factors discussed in the literature were important and resonated with their experience. NHS services and practitioners had not however, structured their work with care homes to take these factors into account. Also discussed was the need to consider if NHS services understood how to work with care homes. In deciding how and when to allocate resources to care homes to support new initiatives, the NHS needs to consider carefully the organisational contexts and assess them appropriately. Based on the combined findings we suggest ten key questions for commissioners and service providers working with care home providers. Ideally these questions can be used prior to working with care homes. They can also help to structure reviews of uptake of innovations to enhance health in care homes. 1. Does this intervention align with care home priorities? Or are there other potential interventions that care homes identify as more pressing? 2. What evidence is there of senior management interest and enthusiasm for this intervention at organisation & unit level? Are they willing and able on a daily basis to take a leadership role in supporting the proposed change? 3. Do care home staff have enough “slack and flexibility” to accommodate the change into their current workload, is this recognised as core to their work? 4. How is change discussed (formally and informally) in the care home setting? Who needs to be involved in decision-making about what is being proposed and how it is implemented? 5. What are the recent changes or health related projects this care home has been involved with? 6. Is there a champion in both the care home and in the linked NHS service with protected time to help facilitate change? 7. What are the pre-existing working relationships between NHS services and care home staff and networks of care and support around the care home? ( e.g. GPs, visiting specialists, links with local hospital) 8. Could the intervention appear judgemental by signalling in a negative way that the care home needs to change? 9. How well do existing care home training programmes and work schedules fit with what is proposed? 10. Will care home staff have to collect and enter new data or is it held in existing systems? The report concludes by suggesting some strategies that might support how NHS practitioners and care home staff address their capacity and readiness to work together

Mementos from Boots multisensory boxes: qualitative evaluation of an intervention for people with dementia: innovative practice

This qualitative study explored a multisensory (including olfactory) intervention for people with dementia. Six themed boxes (e.g. Childhood) containing items chosen from the Boots archive designed to encourage conversation were used in weekly group sessions. Session participants were people with dementia and care staff from a local care home, a trained facilitator and archivists from Boots UK. Semi-structured interviews explored participants’ experiences of the sessions. Interviews were analysed using Thematic Analysis. The three major themes Engagement (subthemes: Inclusiveness; Emotional involvement; Factors that supported engagement), What’s in the box (subthemes: Contents stimulate memories; Mystery, variety and age of items; Value of olfactory stimuli), and A conversation starter (subtheme: Opportunity for self-expression) reveal the success of the intervention and the value of olfactory stimuli. Multisensory boxes including olfactory stimulation can be an engaging intervention with scope to refine it for people with dementia and their carers in the wider community

Sustaining health care innovation in care homes: the SUSTAIN-CH study protocol

Introduction: Sustaining effective interventions that improve quality and safety of care is a key challenge in improving the outcomes of healthcare. In recent years in the UK, there have been innovations to improve healthcare in care homes. They were led by dedicated project teams and had time-limited funding. This study aims to determine whether and how any improvements brought about by these innovations were sustained. Methods and analysis: This study will examine three care home healthcare improvement projects: Enhanced Health in Care Homes; Proactive Healthcare of Older People in Care Homes (PEACH); and Safer Salford Care Homes. Each of these projects sought to improve the quality of care in care homes. The study will collate administrative documentation from each project, and carry out approximately 32 semi-structured interviews with project managers, health and social care professionals, support staff, quality improvement experts, and clinical/care home experts. Data will be used to create a description of the three interventions, applying the Template for Intervention Description and Replication (TIDieR) framework. Interview data will be analysed thematically by two independent researchers using the Consolidated Framework for Sustainability (CFS) to examine which factors impact on sustainability in the care home setting, and explore why and how these factors influence sustainability. The findings will be used to develop guidance and practical strategies for future teams working on quality improvement in care homes

Is late-life dependency increasing or not? A comparison of the Cognitive Function and Ageing Studies (CFAS)

Background: Little is known about how dependency levels have changed between generational cohorts of older people. We estimated years lived in different care states at age 65 in 1991 and 2011 and new projections of future demand for care. Methods: Two population-based studies of older people in defined geographical areas conducted two decades apart (the Cognitive Function and Ageing Studies) provided prevalence estimates of dependency in four states: high (24-hour care); medium (daily care); low (less than daily); independent. Years in each dependency state were calculated by Sullivan’s method. To project future demand, the proportions in each dependency state (by age group and sex) were applied to the 2014 England population projections. Findings: Between 1991 and 2011 there were significant increases in years lived from age 65 with low (men:1·7 years, 95%CI 1·0-2·4; women:2·4 years, 95%CI 1·8-3·1) and high dependency (men:0·9 years, 95%CI 0·2-1·7; women:1·3 years, 95%CI 0·5-2·1). The majority of men’s extra years of life were independent (36%) or with low dependency (36%) whilst for women the majority were spent with low dependency (58%), only 5% being independent. There were substantial reductions in the proportions with medium and high dependency who lived in care homes, although, if these dependency and care home proportions remain constant in the future, further population ageing will require an extra 71,000 care home places by 2025. Interpretation: On average older men now spend 2.4 years and women 3.0 years with substantial care needs (medium or high dependency), and most will live in the community. These findings have considerable implications for older people’s families who provide the majority of unpaid care, but the findings also supply valuable new information for governments and care providers planning the resources and funding required for the care of their future ageing populations

Quality improvement collaborative aiming for Proactive HEAlthcare of Older People in Care Homes (PEACH)

Introduction This protocol describes a study of a quality improvement collaborative (QIC) to support implementation and delivery of comprehensive geriatric assessment (CGA) in UK care homes. The QIC will be formed of health and social care professionals working in and with care homes and will be supported by clinical, quality improvement and research specialists. QIC participants will receive quality improvement training using the Model for Improvement. An appreciative approach to working with care homes will be encouraged through facilitated shared learning events, quality improvement coaching and assistance with project evaluation. Methods and analysis The QIC will be delivered across a range of partnering organisations which plan, deliver and evaluate health services for care home residents in four local areas of one geographical region. A realist evaluation framework will be used to develop a programme theory informing how QICs are thought to work, for whom and in what ways when used to implement and deliver CGA in care homes. Data collection will involve participant observations of the QIC over 18 months, and interviews/focus groups with QIC participants to iteratively define, refine, test or refute the programme theory. Two researchers will analyse field notes, and interview/focus group transcripts, coding data using inductive and deductive analysis. The key findings and linked programme theory will be summarised as contextmechanism-outcome configurations describing what needs to be in place to use QICs to implement service improvements in care homes. Ethics and dissemination The study protocol was reviewed by the National Health Service Health Research Authority (London Bromley research ethics committee reference: 205840) and the University of Nottingham (reference: LT07092016) ethics committees. Both determined that the Proactive HEAlthcare of Older People in Care Homes study was a service and quality improvement initiative. Findings will be shared nationally and internationally through conference presentations, publication in peer-reviewed journals, a graphical illustration and a dissemination video

Are dementia services and support organisations meeting the needs of Lesbian, Gay, Bisexual and Transgender (LGBT) caregivers of LGBT people living with dementia? A scoping review of the literature

Objectives More than 60% of people with dementia live at home, where assistance is usually provided by informal caregivers. Research on the experiences of the Lesbian, Gay, Bisexual and Transgender (LGBT) caregivers is limited. This scoping review of the literature synthesizes international evidence on support provision for the population of LGBT caregivers. Methods Eight electronic databases and Google Scholar were searched using terms including ‘Dementia’, ‘LGBT’ and ‘Caregiver’ for all types of articles, including empirical studies, grey literature and sources from charity/third sector/lobbying organisations. Article selection was performed by two raters. Data were analysed through deductive thematic analysis, and three themes were established a priori: Distinct experiences of LGBT caregivers; current barriers to support; strategies to overcome the current challenges. Results Twenty articles were included. Distinct experiences of LGBT caregivers included a loss of LGBT identity, the impact of historical events, families of choice, and disclosing LGBT identities. Current barriers to support included poor representation of LGBT caregivers in support services, negative attitudes of staff and reluctance of caregivers to seek support. Strategies to overcome the current challenges included staff awareness training and kite-marking inclusion. Conclusion Limited cultural competency of staff and a subsequent reluctance to seek help have an impact on use of support services among LGBT caregivers. Implications for practice include the development of cost-effective, feasible, and acceptable inclusiveness training for services. Implications for policy include implementation in organisations of top-down agendas supporting staff to understand sexuality and non-heteronormative relationships in older age

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

Background Care homes are the institutional providers of long-term care for older people. The OPTIMAL study argued that it is probable that there are key activities within different models of health-care provision that are important for residents’ health care. Objectives To understand ‘what works, for whom, why and in what circumstances?’. Study questions focused on how different mechanisms within the various models of service delivery act as the ‘active ingredients’ associated with positive health-related outcomes for care home residents. Methods Using realist methods we focused on five outcomes: (1) medication use and review; (2) use of out-of-hours services; (3) hospital admissions, including emergency department attendances and length of hospital stay; (4) resource use; and (5) user satisfaction. Phase 1: interviewed stakeholders and reviewed the evidence to develop an explanatory theory of what supported good health-care provision for further testing in phase 2. Phase 2 developed a minimum data set of resident characteristics and tracked their care for 12 months. We also interviewed residents, family and staff receiving and providing health care to residents. The 12 study care homes were located on the south coast, the Midlands and the east of England. Health-care provision to care homes was distinctive in each site. Findings Phase 1 found that health-care provision to care homes is reactive and inequitable. The realist review argued that incentives or sanctions, agreed protocols, clinical expertise and structured approaches to assessment and care planning could support improved health-related outcomes; however, to achieve change NHS professionals and care home staff needed to work together from the outset to identify, co-design and implement agreed approaches to health care. Phase 2 tested this further and found that, although there were few differences between the sites in residents’ use of resources, the differences in service integration between the NHS and care homes did reflect how these institutions approached activities that supported relational working. Key to this was how much time NHS staff and care home staff had had to learn how to work together and if the work was seen as legitimate, requiring ongoing investment by commissioners and engagement from practitioners. Residents appreciated the general practitioner (GP) input and, when supported by other care home-specific NHS services, GPs reported that it was sustainable and valued work. Access to dementia expertise, ongoing training and support was essential to ensure that both NHS and care home staff were equipped to provide appropriate care. Limitations Findings were constrained by the numbers of residents recruited and retained in phase 2 for the 12 months of data collection. Conclusions NHS services work well with care homes when payments and role specification endorse the importance of this work at an institutional level as well as with individual residents. GP involvement is important but needs additional support from other services to be sustainable. A focus on strategies that promote co-design-based approaches between the NHS and care homes has the potential to improve residents’ access to and experience of health care. Funding The National Institute for Health Research Health Services and Delivery Research programme

Understanding the theoretical underpinning of the exercise component in a fall prevention programme for older adults with mild dementia: a realist review protocol

Background Older adults with mild dementia are at an increased risk of falls. Preventing those at risk from falling requires complex interventions involving patient-tailored strength- and balance-challenging exercises, home hazard assessment, visual impairment correction, medical assessment and multifactorial combinations. Evidence for these interventions in older adults with mild cognitive problems is sparse and not as conclusive as the evidence for the general community-dwelling older population. The objectives of this realist review are (i) to identify the underlying programme theory of strength and balance exercise interventions targeted at those individuals that have been identified as falling and who have a mild dementia and (ii) to explore how and why that intervention reduces falls in that population, particularly in the context of a community setting. This protocol will explain the rationale for using a realist review approach and outline the method. Methods A realist review is a methodology that extends the scope of a traditional narrative or systematic evidence review. Increasingly used in the evaluation of complex interventions, a realist enquiry can look at the wider context of the intervention, seeking more to explain than judge if the intervention is effective by investigating why, what the underlying mechanism is and the necessary conditions for success. In this review, key rough programme theories were articulated and defined through discussion with a stakeholder group. The six rough programme theories outlined within this protocol will be tested against the literature found using the described comprehensive search strategy. The process of data extraction, appraisal and synthesis is outlined and will lead to the production of an explanatory programme theory. Discussion As far as the authors are aware, this is the first realist literature review within fall prevention research and adds to the growing use of this methodology within healthcare. This synthesis of evidence will provide a valuable addition to the evidence base surrounding the exercise component of a fall intervention programme for older adults with mild dementia and will ultimately provide clinically relevant recommendations for improving the care of people with dementia