Care home admission following acute hospitalisation is a lived reality across Scotland,
experienced by over 8,000 people annually. The aim of this thesis was to develop an
understanding of new care home admission following acute hospitalisation. Methods and
findings from the mixed-methods approach are presented in three parts.
Part One: Identifying relevant research – includes a review of quality assessment tools for
systematic reviewing; a systematic review and meta-analysis of quantitative data from
observational studies of predictors of care home admission from hospital; and a methodological
chapter on developing a search filter to improve accessibility of existing research findings
supported by the findings of an international survey of care home researchers.
The systematic review identified 53 relevant studies from 16 countries comprising a total
population of 1,457,881 participants. Quantitative synthesis of the results from 11 of the studies
found that increased age (OR 1.02 per year increase; 95%CI 1.00-1.04), female sex (OR 1.41;
95%CI 1.03-1.92), dementia & cognitive impairment (OR 2.14; 95%CI 1.24-3.70) and functional
dependency (OR 2.06; 95%CI 1.58-2.69) were all associated with an increased risk of care home
admission after hospitalisation. Despite international variation in service provision, only two
studies described the model of care provided in the care home setting.
The survey identified that there is a lack of shared terminology in the published literature to
describe settings for adults who are unable to live independently in their own homes and
require care in a long-term institutional setting. A search filter to identify relevant research
could help to overcome differences in terminology and improve synthesis of existing research
evidence.
Part Two: Exploring current clinical practice – reports the findings of a retrospective cohort
study of new care home admissions from hospital using case-note review methodology
accompanied by findings from inductive thematic analysis of a single dataset from a qualitative
case study design exploring the experiences of a patient, their family, and practitioners (n=5).
The cohort study (n=100) found a heterogeneous picture with long hospital admissions (range
14-231 days), frequent transfers of care (31% experienced three or more transfers), varied
levels of documented assessment and a lack of documented patient involvement in the decision-making
processes. The qualitative interviews allowed the patient voice to emerge, alongside the
professional and family narrative which dominated case-note documentation. Inductive
thematic analysis identified nine major themes exploring how decisions are made to discharge
individuals directly into a care home from the acute hospital setting: biography & personality;
professional role; family role; limitations in local model of care; ownership of decision; risk;
realising preferences; uncertainty of care home admission process; and psychological impact of
in-hospital care.
Part Three: Harnessing routinely-collected data – includes the challenges of identifying care
home residency at admission and discharge from hospital, presenting analysis of the accuracy of
Scottish Morbidity Record 1 (SMR01) coding in NHS Fife and the Community Health Index (CHI)
Institution Flag in NHS Fife and NHS Tayside. This is followed by a descriptive analysis of the
Scottish Care Home Census (2013-16) as a novel social care data source to explore care home
admissions from hospital and the methodology for a data linkage study using these data.
Identifying care home residents in routine data sources is challenging. In 18,720 admissions to
NHS Fife, SMR01 coding had a sensitivity of 86.0% and positive predictive value of 85.8% in
identifying care home residents on admission. At discharge the sensitivity was 87.0% and
positive predictive value was 84.5%. From a sample of 10,000 records, the CHI Institution Flag
had a sensitivity of 58.6% in NHS Fife and 89.3% in NHS Tayside, with positive predictive values
of 99.7% and 97.7% respectively.
From 2013-16, of 21,368 admissions to care homes in Scotland, 56.7% were admitted from
hospital. There was significant regional variation in rates of care home admission from hospital
(35.9-64.7%) and proportion of Local Authority funded places provided to admissions from
hospital (34.4-73.9%). Those admitted from hospital appeared to be more dependent and sicker
than those admitted from home.
This thesis has established a series of challenges in how care homes and their residents are
identified. It has questioned the adequacy of the evidence to guide practitioners and sought to
raise the profile of this vulnerable and complex population and how best to support them in
making decisions regarding admission from the acute hospital. It has progressed our
understanding of this under-explored area and proposes a programme of future mixed-methods
research involving patients, families, practitioners and policy-makers