Overview

This project aims to evaluate and improve a Digital Care Homes app to support decision-making by care home and community staff when a care home resident becomes unwell. This process will allow the community NHS team to make an action plan and hopes to reduce unnecessary hospital attendances, allowing residents to be cared for in their own environment where appropriate.

The Challenge

Around 430,000 older people in England live in care homes. Many have frailty, dementia, poor mobility and are near the end of life, which adds complexity to managing their preferences. When residents become more unwell, care staff often feel they would be better looked after in hospital. However, hospital admissions carry big risks including infection, increased confusion, poor mobility, and falls. Furthermore, residents often prefer to be treated where they live. Determining the most appropriate management for individual patients is a significant challenge.

The Solution

The team aims to enhance development of a process to support care home staff when a resident becomes unwell. They will evaluate the Digital Care Homes (DCH) app, which they have already set up in 60 care homes. The app allows staff to provide a structured referral (SBAR, Situation, Background, Assessment, Recommendation) and resident observations, and then transmits the data instantly to the community NHS team who also see the resident’s GP record, allowing them to make an informed action plan.

The team will evaluate this referral process by analysing what happens to residents when the referral system is used, and specifically whether it leads to fewer hospital admissions. Linked data from routine care will be analysed to identify how care homes use the DCH App and will quantify any changes in service use, clinical outcomes and costs to the NHS. They will also test how residents, their families, care home staff and the community NHS team feel about this new referral process and how it could be improved as a continuous ‘learning loop’. The findings will allow the process to be refined and rolled out on a larger national scale.

Impact and Outcomes

By implementing the DCH app in a wider ‘learning systems’ framework, the project aims to improve structured referrals, supporting care home and community staff in making decisions and optimising the management of individual care home residents.

Avoiding unnecessary referrals of care home residents to urgent care services could reduce A&E attendances and hospital admissions by 25%, based on pilot data, and allow more appropriate care to be delivered to residents in the care home, improving patient satisfaction and outcomes.

Project Leads

Graham King, Chief Information Officer, Newcastle Hospitals

Suzanne Mason, Professor of Emergency Medicine, University of Sheffield and Barnsley Hospitals NHS Foundation Trust