UK care homes house more than 400,000 people. These long-term care facilities provide 24-hour care for people with functional dependency. Nearly half of the beds (47%) are in homes that provide nursing care, while the rest are in residential homes. Social care staff are the most common care providers in both home categories. Many of them have extensive experience providing highly skilled care. Only 17% of homes offer care for people with learning disabilities, but most care is for older adults with frailty.
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Transfer to a care home
Senior citizens with frailty who move into a care home are usually there permanently, unless they need to be assessed or rehabilitated as part of an intermediate program. Care homes are often not the first choice for residents in British culture. The transition to a care home is often associated with a sudden or marked decline in physical function, cognition, or both. Over three quarters have dementia, more residents have mobility issues and as many as a third have incontinence. The average number and amount of medications used is 8.
Identifying the need
For care homes that do not provide nursing, the average UK life expectancy is 24 months and for those with nursing it is 12 months. Residents can enter care homes with rapidly deteriorating conditions, but this does not reflect the reality. This group often dies soon after being admitted, while others live longer in care homes. All residents of care homes in lytham should be considered for end-of-life care. However, it shouldn’t be assumed that everyone will require it immediately.
Planning for the future
New residents and their families can find moving into a care facility difficult. Many times, they have had to leave their home and families behind. They will likely be adapting to a significant decline in their health and functional status.
Evidence suggests that families and residents may be reluctant to talk about end-of-life care when dealing with many complex and overwhelming issues. It is crucial to assess the need for end-of-life care and present options for planning when admission to a care home. Advance care planning is proven to work in care homes. It can help reduce unnecessary escalations of care, and improve the quality of care for residents and their families.
The issue should not be brought up at admission for the aforementioned reasons. Long-term care offers the luxury of allowing for future discussions. Staff at care homes often form close relationships with residents. It is important to listen to their suggestions regarding advance care planning and follow-up.
End of life care in care homes is difficult because multidisciplinary teams are different than other care settings. Multidisciplinary teams are often split between multiple organizations, so members may have different work schedules. There may not be many opportunities to meet as a group. There is an advantage to this: time pressures in patient care are often less severe than in other settings. Different professionals can also add to the care plan at their times. This asynchronous assessment will require careful documentation (usually in a care home record), which will serve as the only document shared between all professionals, and close case management (usually by care home team members, who will need to keep all visiting professionals updated).
Care home staff must establish a structured approach for end-of-life care, given their importance on being care coordinators. The Gold Standards Framework is a popular approach that staff triage all residents.
- Blue (prognosis for more than a year)
- Green (prognosis of a few months)
- Amber (prognosis within the range of weeks);
- Red (prognosis within the range of days)
These meetings are held weekly and the triage categories help to plan and seek professional assistance. The challenge in a wide rollout of such models is the need for care home organizations to invest in training and registration. As part of the NHS Long-term Plan, the proposed roll-out of the NHS Enhanced Health in Care Homes model (EHCH), will allow for more integrated workforce planning between long-term and short-term care homes as well as training. It may also enable standardised methods of how these models are commissioned.
Good care in care homes is similar to good end-of-life care in other settings. This means that care must be based on the residents’ lives and prioritized needs. Care plans can be created by having structured conversations with residents and their family. These patient-centred conversations can help to reopen care planning dialogs that were perhaps difficult at the time of admission.
Medication and symptoms
If the care home staff, the general physician, and a representative of the resident are involved in medication reviews, they are considered gold-standard practice. Many medications can be stopped when an older person arrives in a care home. Staff at care homes will be able to monitor for withdrawal symptoms and cessation of medication if they are communicated to them.
Care homes can make it difficult to assess pain and determine the effectiveness of pain management. Care home staff without nurses are not licensed and need to have their pain recognition training adjusted. Many residents with advanced dementia don’t report pain as often and can experience pain in unusual ways. Even experienced dementia care staff can find it challenging to deal with this. Staff can use validated tools such as the Abbey Pain Scale and the Pain Assessment in Advanced Dementia(PAIN-AD), to help them take a structured approach.
Care home staff must be aware that plans made during work hours may be overridden by out-of-hours paramedics or doctors who have less knowledge about residents and are less familiar with the care home staff. These visiting staff may feel vulnerable when confronted with medical complexity. They may choose to admit the resident to hospital, even if it isn’t necessary, because they believe that they are doing the right thing. Care home staff are not always empowered to advocate for residents under traditional hierarchies.
It is important to consider how care home staff can be empowered and what clear messages and guidelines can go out to visiting health professionals so that they can follow working hours plans. This situation can be helped by a clearly written advance care plan.