Realist evaluation comparison of dementia-friendly communities in England and Netherlands

IntroductionDementia-friendly communities coordinate activities and events which offer social inclusion and participation of people with dementia. Initiatives can include memory cafés, sports, tourist and heritage visits. This study explored how dementia-friendly initiatives are developed and sustained in England drawing comparisons with an equivalent case-study in the Netherlands. MethodsWe present a case study of dementia-friendly initiatives, of one city in England. Selection of this case study was on the basis of being a leading dementia-friendly community. We interviewed a variety of stakeholders, including people with dementia and their care partners, volunteers and staff. Semi-structured interviews were recorded, and transcripts were analysed using qualitative analysis software using a realist evaluation interpretation. Realist theories described within this English case study were compared with those described within the Dutch cases studies.FindingsFive context mechanism outcome configurations were described. The dementia action alliance for the city was a coordinator of initiatives and provided funding and resources. The alliance facilitated advocates to partner with organisations with a shared commitment to plan activities. On the level of individual interactions, staff or volunteers were involved in communicating with local community members which may lead to improvement in awareness. Initiatives had various ways to listen and incorporate views of people with dementia. The five mechanisms identified within the English case study resonated with mechanisms identified within the larger Dutch case study, with differences in contexts due to local policies and practices.ConclusionStrategic coordination is an important factor for development and sustainability. The national policy in England has set the pattern for local structures, while the Dutch approach is ‘bottom-up’ with local leadership. Community advocates and public support were important factors in development of dementia-friendly initiatives in both countries

GPs’ involvement to improve care quality in care homes in the UK: a realist review

BackgroundOrganising health-care services for residents living in care homes is an important area of development in the UK and elsewhere. Medical care is provided by general practitioners in the UK, and the unique arrangement of the NHS means that general practitioners are also gatekeepers to other health services. Despite recent focus on improving health care for residents, there is a lack of knowledge about the role of general practitioners.ObjectivesFirst, to review reports of research and quality improvement (or similar change management) in care homes to explore how general practitioners have been involved. Second, to develop programme theories explaining the role of general practitioners in improvement initiatives and outcomes.DesignA realist review was selected to address the complexity of integration of general practice and care homes.SettingCare homes for older people in the UK, including residential and nursing homes.ParticipantsThe focus of the literature review was the general practitioner, along with care home staff and other members of multidisciplinary teams. Alongside the literature, we interviewed general practitioners and held consultations with a Context Expert Group, including a care home representative.InterventionsThe primary search did not specify interventions, but captured the range of interventions reported. Secondary searches focused on medication review and end-of-life care because these interventions have described general practitioner involvement.OutcomesWe sought to capture processes or indicators of good-quality care.Data sourcesSources were academic databases [including MEDLINE, EMBASE™ (Elsevier, Amsterdam, the Netherlands), Cumulative Index to Nursing and Allied Health Literature, PsycInfo® (American Psychological Association, Washington, DC, USA), Web of Science™ (Clarivate Analytics, Philadelphia, PA, USA) and Cochrane Collaboration] and grey literature using Google Scholar (Google Inc., Mountain View, CA, USA).MethodsRealist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidelines were followed, comprising literature scoping, interviews with general practitioners, iterative searches of academic databases and grey literature, and synthesis and development of overarching programme theories.ResultsScoping indicated the distinctiveness of the health and care system in UK and, because quality improvement is context dependent, we decided to focus on UK studies because of potential problems in synthesising across diverse systems. Searches identified 73 articles, of which 43 were excluded. To summarise analysis, programme theory 1 was ‘negotiated working with general practitioners’ where other members of the multidisciplinary team led initiatives and general practitioners provided support with the parts of improvement where their skills as primary care doctors were specifically required. Negotiation enabled matching of the diverse ways of working of general practitioners with diverse care home organisations. We found evidence that this could result in improvements in prescribing and end-of-life care for residents. Programme theory 2 included national or regional programmes that included clearly specified roles for general practitioners. This provided clarity of expectation, but the role that general practitioners actually played in delivery was not clear.LimitationsOne reviewer screened all search results, but two reviewers conducted selection and data extraction steps.ConclusionsIf local quality improvement initiatives were flexible, then they could be used to negotiate to build a trusting relationship with general practitioners, with evidence from specific examples, and this could improve prescribing and end-of-life care for residents. Larger improvement programmes aimed to define working patterns and build suitable capacity in care homes, but there was little evidence about the extent of local general practitioner involvement.Future workFuture work should describe the specific role, capacity and expertise of general practitioners, as well as the diversity of relationships between general practitioners and care homes.Study registrationThis study is registered as PROSPERO CRD42019137090

Ethnic disparity in access to the memory assessment service between South Asian and white British older adults in the United Kingdom: A cohort study

Background: Equality of access to memory assessment services by older adults from ethnic minorities is both an ethical imperative and a public health priority.Objective: To investigate whether timeliness of access to memory assessment service differs between older people of White British and South Asian ethnicity.Design: Longitudinal cohort.Setting: Nottingham Memory Study; outpatient secondary mental healthcare.Subjects: Our cohort comprised 3,654 White British and 32 South Asian older outpatients.Methods: The criterion for timely access to memory assessment service was set at 90 days from referral. Relationships between ethnicity and likelihood of timely access to memory assessment service were analysed using binary logistic regression. Analyses were adjusted for socio-demographic factors, deprivation and previous access to rapid response mental health services.Results: Among White British outpatients, 2,272 people (62.2%) achieved timely access to memory assessment service. Among South Asian outpatients, fourteen people (43.8%) achieved timely access to memory assessment service. After full adjustment, South Asian outpatients had a 0.47-fold reduced likelihood of timely access, compared to White British outpatients (odds ratio 0.47, 95% confidence interval 0.23-0.95, p-value=0.035). The difference became non-significant when restricting analyses to outpatients reporting British nationality or English as first language. Older age, lower index of deprivation and previous access to rapid response mental health services were associated with reduced likelihood of timely access, while gender was not.Conclusions: In a UK mental healthcare service, older South Asian outpatients are less likely to access dementia diagnostic services in a timely way, compared to White British outpatients

Role of comprehensive geriatric assessment in healthcare of older people in UK care homes: realist review.

OBJECTIVES:Comprehensive geriatric assessment (CGA) may be a way to deliver optimal care for care home residents. We used realist review to develop a theory-driven account of how CGA works in care homes. DESIGN:Realist review. SETTING:Care homes. METHODS:The review had three stages: first, interviews with expert stakeholders and scoping of the literature to develop programme theories for CGA; second, iterative searches with structured retrieval and extraction of the literature; third, synthesis to refine the programme theory of how CGA works in care homes.We used the following databases: Medline, CINAHL, Scopus, PsychInfo, PubMed, Google Scholar, Greylit, Cochrane Library and Joanna Briggs Institute. RESULTS:130 articles informed a programme theory which suggested CGA had three main components: structured comprehensive assessment, developing a care plan and working towards patient-centred goals. Each of these required engagement of a multidisciplinary team (MDT). Most evidence was available around assessment, with tension between structured assessment led by a single professional and less structured assessment involving multiple members of an MDT. Care planning needed to accommodate visiting clinicians and there was evidence that a core MDT often used care planning as a mechanism to seek external specialist support. Goal-setting processes were not always sufficiently patient-centred and did not always accommodate the views of care home staff. Studies reported improved outcomes from CGA affecting resident satisfaction, prescribing, healthcare resource use and objective measures of quality of care. CONCLUSION:The programme theory described here provides a framework for understanding how CGA could be effective in care homes. It will be of use to teams developing, implementing or auditing CGA in care homes. All three components are required to make CGA work-this may explain why attempts to implement CGA by interventions focused solely on assessment or care planning have failed in some long-term care settings. TRIAL REGISTRATION NUMBER:CRD42017062601

General Practitioners’ Role in Improving Health Care in Care Homes: A Realist Review

Background Despite recent focus on improving health care in care homes, it is unclear what role general practitioners (GPs) should play. To provide evidence for future practice we set out to explore how GPs have been involved in such improvements. Methods Realist review incorporated theory-driven literature searches and stakeholder interviews, supplemented by focussed searches on GP-led medication reviews and end-of-life care. Medline, Embase, CINAHL, PsycInfo, Web of Science, and the Cochrane library were searched. Grey literature was identified through internet searches and professional networks. Studies were included based upon relevance. Data were coded to develop and test contexts, mechanisms, and outcomes for improvements involving GPs. Results Evidence was synthesized from 30 articles. Programme theories described: (i) “negotiated working with GPs,” where other professionals led improvement and GPs provided expertise; and (ii) “GP involvement in national/regional improvement programmes.” The expertise of GPs was vital to many improvement programmes, with their medical expertise or role as coordinators of primary care proving pivotal. GPs had limited training in quality improvement (QI) and care home improvement work had to be negotiated in the context of wider primary care commitments. Conclusions GPs are central to QI in health care in care homes. Their contributions relate to their specialist expertise and recognition as leaders of primary care but are challenged by available time and resources to develop this role

General practitioners' role in improving health care in care homes: a realist review

Background: Despite recent focus on improving health care in care homes, it is unclear what role general practitioners (GPs) should play. To provide evidence for future practice we set out to explore how GPs have been involved in such improvements. Methods: Realist review incorporated theory-driven literature searches and stakeholder interviews, supplemented by focussed searches on GP-led medication reviews and end-of-life care. Medline, Embase, CINAHL, PsycInfo, Web of Science, and the Cochrane library were searched. Grey literature was identifed through internet searches and professional networks. Studies were included based upon relevance. Data were coded to develop and test contexts, mechanisms, and outcomes for improvements involving GPs.  Results: Evidence was synthesized from 30 articles. Programme theories described: (i) “negotiated working with GPs,” where other professionals led improvement and GPs provided expertise; and (ii) “GP involvement in national/regional improvement programmes.” The expertise of GPs was vital to many improvement programmes, with their medical expertise or role as coordinators of primary care proving pivotal. GPs had limited training in quality improvement (QI) and care home improvement work had to be negotiated in the context of wider primary care commitments. Conclusions: GPs are central to QI in health care in care homes. Their contributions relate to their specialist expertise and recognition as leaders of primary care but are challenged by available time and resources to develop this role.</p