• In January 2019, the NHS published its 10-year Long Term Plan, including a commitment to improve NHS support in care homes, rolling out the Enhanced Health in Care Homes (EHCH) framework across England. One of the aims of the framework is to reduce emergency admissions from care homes which, although essential for delivering medical care, can expose residents to stress, loss of independence and risk of infection. Care home residents often prefer to be treated in the care home or avoid the need to seek urgent treatment in the first place. Therefore reducing emergency admissions could be good for residents, as well as help reduce pressure on the NHS.
• In this briefing, we firstly present our analysis of a national linked dataset identifying permanent care home residents aged 65 and older and their hospital use in the year 2016/17. In the second part of the briefing we synthesise learning from four evaluations of the impact of initiatives to improve health and care in care homes carried out by the Improvement Analytics Unit (IAU).
• Our analysis, using a new data linkage method that allows us to identify permanent care home residents aged 65 and older in NHS datasets, found that during 2016/17 care home residents went to A&E on average 0.98 times and were on average admitted as an emergency 0.70 times. The overall number of emergency admissions from care homes in 2016/17 was an estimated 192,000, comprising 7.9% of the total number of emergency admission for England for people aged 65 years or older. The overall number of A&E attendances from care homes was 269,000, comprising 6.5% of the total number of attendances for people aged 65 years and older. Reducing emergency hospital use from care homes therefore has the potential to reduce pressure on hospitals.
• A large number of these emergency admissions may be avoidable, with 41% of emergency admissions from care homes being for conditions that are potentially manageable, treatable or preventable outside of a hospital setting, or that could have been caused by poor care or neglect.
• Surprisingly, emergency admissions are particularly high in residential care homes (0.77 admissions per resident per year) compared with nursing care homes (0.63 admissions per resident per year). This is the case even though residential care homes provide 24-hour personal care, while nursing homes also provide nursing care and therefore one would expect residential care home residents to be less seriously ill than nursing home residents. People in residential care homes attended A&E on average 1.12 times in the year 2016/7, compared with 0.85 times in nursing care homes. One possible explanation is that staff in residential care homes may have less support in managing health needs within the home, and therefore rely more on emergency services. Also, health needs may not be detected as early in residential homes as in nursing homes.
• The IAU has evaluated four initiatives to improve health and care in care homes that were associated with the NHS’s New Care Models programme. For several of these we concluded there were reductions in at least some measures of emergency hospital use for residents who received enhanced support: in Rushcliffe we found care home residents were admitted to hospital as an emergency 23% less often than a comparison group, and had 29% fewer A&E attendances; Nottingham City care home residents had 18% fewer emergency admissions and 27% fewer potentially avoidable admissions than a comparison group; and Wakefield residents had 27% fewer potentially avoidable admissions. In Sutton, however, the results were inconclusive.
• These initiatives included elements of the EHCH framework, which will be rolled out as part of the NHS Long Term Plan. Therefore, the work of the IAU shows that there is potential for the EHCH framework to reduce demand for emergency care from care homes, but it also points to some implementation challenges that need to be taken into consideration when rolling out the framework.
• Given the policy focus on improving care in care homes, both over the past few years and moving forward with the NHS Long Term Plan, understanding and monitoring the quality of health care provided to care home residents will be important, both to gauge the impact of national programmes and to help pinpoint areas of improvement, identify ‘active ingredients’ for a successful intervention and spread good practice.
• In this briefing, we synthesise learnings from our evaluations of the initiatives in Rushcliffe, Sutton, Wakefield and Nottingham City to pull out what seem to be key lessons for implementing the framework in care homes. These key lessons are that (i) there is greater potential to reduce emergency admissions and A&E attendance in residential care homes compared with nursing homes, (ii) co-production between health care professionals and care homes is key to developing effective interventions, (iii) access to additional clinical input by named GPs and primary care services and/or multidisciplinary teams (MDTs) may be a key element in reducing emergency hospital use, and finally (iv) our studies show that it is likely to take more than a year for changes to take effect – meaning it is important not to judge success too quickly.
• Finally, this briefing shows the importance of having access to linked administrative datasets to provide evidence to support policy making. It is important that these sorts of data are routinely and consistently collected and are easily accessible to both care providers and research teams if we are to understand residents’ health care needs and produce robust evaluations – and ultimately improve care for this vulnerable group.

Nearly 340,000 older people in England live in residential or nursing care homes; this includes long-term residents as well as people living in a care home temporarily for respite care, short breaks and recovery. Census data suggest that 274,000 residents have a residential or nursing home as their usual place of residence; we refer to these people as permanent care home residents. These people rely on the care home staff to provide care and support so that they can live their lives while having as much independence as possible. They also often have health care needs that require care from the NHS. Care homes either provide 24-hour nursing care (nursing homes) or personal care only (residential care homes). Although resident characteristics within the two care home types differ,,, with nursing home residents more often nearing end of life,,, both often have complex health care needs,, with residential care home residents often also having nursing needs. In such cases, nursing is provided in residential care homes by community nurses.

Providing health care to care home residents is complex and both health and care services are under pressure. The number of long-term conditions care home residents often have, including dementia, incontinence, poor mobility, circulatory problems and angina, present clinical challenges that are compounded by the need to ensure medications for multiple conditions work well in conjunction with one another.,, The differing support needs of individuals, as well as different treatment preferences and risk profiles present additional challenges when determining the best treatment for care home residents.

Admission rates are not the only metric of interest when assessing health care delivered for care home residents, but they are important for three reasons. Firstly, although emergency hospital admissions are often essential for delivering medical care, they can expose a patient to stress, loss of independence and risk of infection, reducing a patient’s health and wellbeing after leaving hospital., Care home residents may be particularly adversely affected by a hospital admission since many residents are frail and are susceptible to losing muscle strength when confined to a bed. About 70% of care home residents have dementia and can find the hospital environment stressful and disorienting., Secondly, many patients admitted to hospital would prefer to be treated at home or in a medical facility close to home – or to avoid the need to seek urgent treatment in the first place. Thirdly, emergency hospital care is also the most expensive element of the health service and in a cost-constrained system needs to be carefully managed. If some emergency admissions from care homes can be avoided this may be good for both the individuals concerned and the NHS.

Compared with other patient groups, there is less evidence on the quality of health care that is provided to residents in care homes, although this may be changing. One reason for the relative lack of rigorous quantitative evaluations of quality of care in care homes is that, while the NHS collects standardised data on patients, there is no readily available database of care home residents that can identify which of the patients in these hospital data are living in care homes. Local authorities collect some data on residents who are receiving public support, but these are not collated nationally at person level, and they lack information on residents who pay for their own care, who comprise 41% of the care home population. Records kept by care homes (sometimes on paper only) are not collated centrally.

The available literature shows that, although the quality of care in care homes is mostly good, it can be variable,,,,, and is often reactive. There is also variability between care homes in their use of emergency services.,

There is also some variability between residential and nursing homes. For example, medication administration errors may be less likely among nursing homes. There is evidence that residential care home residents have higher ambulance call rates and higher emergency admission rates than nursing home residents. Furthermore, there are indications that GPs visit nursing homes more regularly than residential care homes, and that nursing homes are more likely to have an aligned GP and to pay a GP to provide services than residential care homes. Yet these differences seem to have gone largely unnoticed.

There has long been a recognition of the need to support and improve the quality of care for care home residents. The Five year forward view (2014) for the NHS in England included a commitment to support and stimulate the development of a new care model for enhanced health in care homes to improve the health care provided to care home residents and reduce hospital use. Subsequently, the Enhanced Health in Care Homes (EHCH) framework (2016), developed in collaboration with six NHS vanguards implementing the EHCH framework, set out three aims for the care model together to be delivered through seven core elements (see Box 1). The three aims for the model were:

• to ensure the provision of high-quality care within care homes

• to ensure that, wherever possible, individuals who require support to live independently have access to the right care and the right health services in the place of their choosing

• to ensure the best use of resources by reducing unnecessary conveyances to hospital, hospital admissions and bed days while ensuring the best care for residents.

In January 2019, the NHS published its 10-year Long Term Plan, which included a commitment to roll out the EHCH framework across England within the next decade, including stronger links between care homes and primary care services and more support by a consistent team of health professionals.

The IAU has to date evaluated four initiatives to improve health and care in care homes that were either EHCH vanguards or similar initiatives associated with the NHS’s New Care Models programme (Box 2 on page 23), one of which was quoted in the NHS Long Term Plan as a successful example of the EHCH framework. These evaluations have shown varying results across different outcome measures. These studies complement local evaluations of each EHCH vanguard that were undertaken as part of the NHS’s New Care Models programme. Overall, aggregate figures of EHCH vanguards indicate that emergency admission rates from care homes in vanguard areas remained broadly stable between 2014/15 and 2017/18, compared with higher rising rates for non-vanguard care homes over the same period. However, as in the case of the care home evaluations done by the IAU, there is likely to be variation within this group.

There is little robust comparative evidence of interventions in care homes that reduce emergency admissions, with much of the literature being based on case studies or of poor quality., Looking more broadly at patient outcomes, although evidence of the effect of interventions is often of poor quality,,, taken together potentially promising evidence is emerging on what combination of factors may be important for service development.

A common theme is multidisciplinary, partnership working and good relationships between care home staff and other professional groups.,,,,,,,,,,,,,,, This includes acknowledging care home staff’s knowledge and skills and working together to co-design changes;, the work being seen as legitimate and supported by contractual agreements;, and having protected time for training.,

Other elements showing encouraging signs are: training for care home staff;,,,,,,,,,,,,,, better preventative assessment and care management;,,,,,,, advance care plans; ,,,, end-of-life care planning; ,,,,, medicines management;,,, and data and monitoring. ,,,

Often evaluations either do not distinguish between residential and nursing homes, or are of only one type of care home. A 2011 systematic review of integrated care working between care homes and health care services pointed out that the majority of research was carried out in nursing homes, even though this was not where most older people in long-term care live. To our knowledge, other than some of the IAU studies,,, no studies have to date compared the impact of care home initiatives between residential and nursing homes, even though these differ in both staffing and resident characteristics.

The lack of good quality evidence on improvement initiatives in residential and nursing homes highlights the need for more robust evaluations in this field. Given the policy focus on improving care in care homes, both over the past few years and moving forward with the NHS Long Term Plan, understanding and monitoring the quality of health care provided to care home residents will be important, both to gauge the impact of national programmes and to help identify areas of improvement, identify ‘active ingredients’ for a successful intervention and spread good practice.

The IAU has to date evaluated four care home interventions as part of or similar to the EHCH framework. There were some mixed results on emergency hospital use but collectively these studies provide evidence that it is possible to improve health care in care homes. Our aim in this report is to provide a national analysis of emergency hospital use by care homes and synthesise what this is showing in order to inform the implementation of the NHS Long Term Plan.

This briefing consists of two parts. The first part presents the results of a national analysis of emergency hospital admissions from care homes across England, to provide insight into how often care home residents are being admitted to hospital and the types of conditions that are causing their admissions. We use a novel technique of identifying care home residents at national level developed by the IAU that is more robust than other methods such as postcode matching, or surveys. We present figures for care home residents across England broken down by residential and nursing homes. We focus on emergency admissions for people aged 65 or older who are living permanently in care homes in England (excluding younger people and those moving to care homes for short periods of time). We included residents regardless of whether their stay was funded by the local authority, privately, or through NHS continuing care, but could not identify residents who were in the care home temporarily for respite care, rehabilitation, short breaks or other purposes.

The second part of the briefing draws on evaluations conducted by the IAU of four enhanced care packages provided to care home residents in Rushcliffe, Sutton, Nottingham City and Wakefield. By comparing and contrasting the different elements and contexts of these sites and bringing in other local evaluations of these sites, we explore the factors that may be most influential in reducing hospital admissions.

Lastly, our analysis points to the next steps for local health and social care providers and commissioners looking to better understand the quality of care being provided in order that they may improve care further.

Descriptive analysis of emergency admissions from care homes nationally

The IAU developed a linked dataset that allowed us to look at A&E attendances and hospital admissions for permanent residential and nursing home residents across England for the first time. This dataset is based on data from 17 April 2016 to 15 April 2017.

Our method relied on accessing data on addresses that were collected by general practices in England. These were cross-referenced with a list of the addresses of care homes from the Care Quality Commission (CQC). Once care home residents were identified in this way, we linked this information to data on hospital admissions obtained from the Secondary User Services which is a national, person-level database that is closely related to the widely used Hospital Episode Statistics.

All processing of address information, and subsequent linkage of patient information was carried out by Arden & Greater East Midlands Data Services for Commissioners Regional Office (Arden & GEM DSCRO). The IAU subsequently carried out the analysis of the linked dataset using ‘pseudonymised’ information in a secure environment hosted by the Health Foundation. All data accessed by the IAU are anonymised in line with the Information Commissioner’s Office’s code of practice on anonymisation. Arden & GEM DSCRO and the Health Foundation are Data Processors on behalf of NHS England.

One limitation of our method is that it relies on patients updating their address information with their general practice after they move to a care home. As a result, we are likely to have identified only people who move to a care home on a permanent basis, and assume that we have excluded people who move to a care home temporarily for respite care, rehabilitation, short stays or other purposes. We will also have missed the early parts of care home stays if individuals did not update their address with their general practice immediately after moving to the care home.

Correction

Our method identified 195,296 permanent care home residents aged 65 or older in England at any point in time in 2016/17, compared with 274,040 according to Census 2011. Validation work has shown this is underestimated due to the method used to automate the cleaning of address information, but we found no evidence this underestimate varies across different age bands or geographies. To correct for this difference, all estimates on the number of emergency admissions have been multiplied by a factor of 1.403. Note, this correction does not affect our estimates of admissions rates.

Although the number of permanent care home residents in England, according to the census, dates back to 2011, we think it is still appropriate. We compared the distribution of age and gender at national level as well as patients aged 65 or older at regional level and found no substantial differences in variation between our linked dataset and census data. Data on all care home residents (including people living in a care home temporarily for respite care, short breaks or other purposes) shows little increase in the total number of residents, going from 328,600 in 2011 to 337,500 residents in 2016 (a 2.7% increase in five years).

Measuring emergency hospital admissions for care home residents

An emergency admission is one where a patient is admitted to hospital urgently and unexpectedly (that is, the admission is unplanned). Emergency admissions often occur via A&E departments but can also occur directly via GPs or consultants in ambulatory clinics. We identified these admissions from the hospital data linked to information about care home residents.

We also examined a subset of emergency admissions for specific conditions that were potentially manageable, treatable or preventable outside a hospital setting (so-called ‘potentially avoidable’), namely:

• acute lower respiratory tract infections, such as acute bronchitis
• chronic lower respiratory tract infections, such as emphysema
• diabetes
• food and drink issues, such as abnormal weight loss and poor intake of food and water, possibly due to neglect
• fractures and sprains
• intestinal infections
• pneumonia
• pneumonitis (inflammation of lung tissue) caused by inhaled food or liquid
• pressure sores
• urinary tract infections

The list of conditions was originally developed by the CQC, as part of its analysis of older people receiving health and social care. These were unplanned admissions for conditions that were potentially manageable, treatable or preventable outside of a hospital setting, or for conditions that could be caused by poor care or neglect. For example, some fractures may be avoidable with appropriate risk assessment and falls prevention, and urinary tract infections may be treatable within the community or care home. However, the complexity of the patient group means that ‘potentially avoidable’ admissions are not, when they become acute, necessarily avoidable. Context is also a factor in determining whether a ‘potentially avoidable’ admission could in fact have been avoided. For example, if a residential care home resident had pneumonia, hospital admission may be the most effective way of eliminating the infection quickly, whereas the available nursing support in a nursing home may have been able to oversee treatment of the same condition within the nursing home. Admissions for these conditions cannot always be avoided, especially given the complex and interacting health needs of care home residents. However, the enhanced support available in care homes could be expected to have greater impact on admissions for these conditions than others.

Further research is needed to validate the appropriateness of these conditions as a marker of avoidable admissions for the care home population. In the meantime, the data presented can only be taken as an illustration of the range of health conditions for which care home residents are admitted to hospital, some of which are potentially avoidable.

We expressed the number of admissions as rates per person per year. The rates were calculated as the total number of hospital admissions for all care home residents during 2016/17 divided by the number of days spent in the care home across all residents. That was then multiplied by 365 to provide a rate per person per year. Thus, two care home residents who stay in the care home for six months each would have counted towards one year in the rate.

In addition to looking at how often care home residents are admitted to hospital, we also examined the average length of hospital stay. For patients who stayed in hospital overnight, we calculated the length of their hospital stay as the number of nights spent in hospital. Patients who were admitted and discharged from hospital on the same day were counted as having spent half a day in hospital.

Long-term conditions

To investigate the level of complexity of the health needs of the care home population, we calculated the prevalence of certain long-term conditions and markers of frailty. Using the International Classification of Diseases (ICD) diagnosis codes recorded in either primary or secondary diagnosis fields in inpatient hospital data, we calculated the Charlson Index,, as an aggregate measure of the burden of disease, and the long-term conditions listed by Elixhauser, , as well as conditions related to frailty. To calculate these, we used inpatient data from the three years prior to 2016/17 (or prior to the date a patient moved into a care home if in 2016/17). If a resident did not have an inpatient admission, it is not possible to determine if they had any of these conditions; therefore, these were only calculated for the subset of residents who had a prior hospital admission.

Review of four case studies

The IAU has to date evaluated four initiatives to improve health and care in care homes that were either EHCH vanguards or similar initiatives associated with the NHS’s New Care Models programme. A review was conducted to identify key themes and learnings from the evaluation reports related to these four initiatives. The aim of this analysis was to identify patterns in relation to the ‘inputs’ each site invested (that is, ‘what was done’ locally) with a view to identifying any common themes that may prove useful in understanding impact, as measured by the IAU in terms of secondary hospital use.

We examined the five IAU reports evaluating the impact of the four care home initiatives:

• Two reports on Principia enhanced support in Rushcliffe between August 2014 and August 2016,
• Sutton Homes of Care between January 2016 and April 2017
• Wakefield Clinical Commissioning Group (CCG) between February 2016 and March 2017
• Nottingham City CCG between September 2014 and April 2017.

In addition to the five studies carried out by the IAU, this briefing, where applicable, also draws on local evaluation reports for each of the sites and the EHCH framework itself to assess to what extent the elements of the EHCH framework were implemented. These reports were:

• Cordis Bright (2018) NHS Nottingham City CCG. Enhanced Health in Care Homes vanguard evaluation: final report (available upon request from NHS Nottingham City CCG)
• SQW (2018) Evaluation of Sutton Homes of Care Vanguard report
• Wakefield Public Health Intelligence Team 2018 report on the evaluation of a holistic assessment approach to: supporting care home and independent living schemes
• The NHS’s New Care Models framework for Enhanced Health in Care Homes.

All documents were examined using a thematic analysis approach with the pre-existing EHCH framework used to identify and code key themes. In addition to the pre-existing framework, the researchers familiarised themselves with the studies and local evaluation reports with a view to identifying additional factors and themes that could assist in understanding. The documents were coded into key themes to better enable the identification of patterns.

The NHS in England is already working with care homes to improve the care provided to residents, most notably through the roll-out of the Enhanced Health in Care Homes framework and ongoing efforts to foster greater integration between health and social care.

These initiatives will be helped by a better understanding of the quality of health care provided in care homes, for which emergency admissions, especially rates of potentially avoidable admission, can be seen as a proxy. Ongoing robust evaluation of local care home initiatives is needed to identify those schemes that are having a positive impact on emergency admissions and to identify the active ingredients driving improvement. Identifying and spreading the use of these active ingredients are likely to bring benefits to people living in care homes and to the wider NHS.

Our analysis of national rates of emergency care found that 7.9% of the total number of emergency admissions for older people in England are for care home residents. This shows that reducing emergency admissions from care homes has the potential to reduce pressure on hospitals.

Furthermore, our evaluations of four care home initiatives show that there is potential for the roll-out of the EHCH framework to benefit individuals and reduce demand for emergency hospital use, and provide some hypotheses regarding how best to do so.

In particular, we found that there is potential to reduce A&E attendances and emergency hospital admissions in residential care homes. Both the national analysis and the evaluations point towards residential care home residents having unmet needs and that an improvement programme such as the EHCH framework has significant scope to improve their care and outcomes. This review therefore suggests that nationally we should perhaps re-evaluate the perceived risk and clinical support needs of residential care home residents.

This does not mean that there is not scope for improvement in nursing homes too, especially as there are aspects to quality of care in addition to reducing emergency hospital admissions, such as quality of life. It may be that ‘usual care’ in nursing homes already encompasses some of the elements of the enhanced support, making further reductions in overall emergency hospital admissions more challenging. However, our evaluation of Wakefield indicated that there is potential to reduce emergency hospital admissions related to specific conditions that are potentially manageable, treatable or preventable outside of a hospital setting. Therefore, a more targeted approach, for example including regular reviews of residents’ hospital admissions to help identify and track reasons for unnecessary A&E attendances and emergency hospital admissions along with residents of particular concern, may be required.,, To be able do this effectively, staff caring for residents need access to these data as an important step towards further improving care. Furthermore, although good working relationships between health care professionals and care home staff are important for the successful implementation of improvement programmes in both types of care home, more engagement and greater focus on establishing good working relationships may be required in nursing homes.

To gain a better understanding, further studies that evaluate changes in residential and nursing homes separately are needed, both robust quantitative evaluations of other improvement programmes to provide stronger evidence that the findings from this study are generalisable, and qualitative evidence to understand the mechanisms of change in each care home setting and identify the ‘active ingredients’. In order to support this, it is important to have access to routinely and consistently collected dataset that can be linked and are easily accessible by both care providers, evaluators and researchers.