Background: Care homes predominantly care for older people with complex health and care needs, who are at high risk of unplanned hospital admissions. While often necessary, such admissions can be distressing and provide an opportunity cost as well as a financial cost.
Objectives: Our objective was to update a 2014 evidence review of interventions to reduce unplanned admissions of care home residents. We carried out a systematic review of interventions used in the UK and other high-income countries by synthesising evidence of effects of these interventions on hospital admissions; feasibility and acceptability; costs and value for money; and factors affecting applicability of international evidence to UK settings.
Data sources: We searched the following databases in December 2021 for studies published since 2014 : Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews; Cumulative Index to Nursing and Allied Health Literature (CINAHL); Health Management Information Consortium (HMIC); Medline; PsycInfo; Science and Social Sciences Citation Indexes; Social Care Online; and Social Service Abstracts. ‘Grey’ literature searching (January 2022), reference list checking and citation searching were also carried out.
Methods: We included studies of any design reporting interventions delivered in care homes (with or without nursing) or hospitals to reduce unplanned hospital admissions. A taxonomy of interventions was developed from an initial scoping search. Outcomes of interest included measures of effect on unplanned admissions among care home residents; barriers/facilitators to implementation in a UK setting and acceptability to care home residents, their families and staff. Study selection, data extraction and risk of bias assessment were performed by two independent reviewers. We used published frameworks to extract data on intervention characteristics, implementation barriers/facilitators and applicability of international evidence. We performed a narrative synthesis grouped by intervention type and setting. Overall strength of evidence for admission reduction was assessed using a framework based on study design, study numbers and direction of effect.
Results: We included 124 publications/reports (30 from the UK). Integrated care and quality improvement (QI) programmes providing additional support to care homes (e.g. the English Care Homes Vanguard initiatives and hospital-based services in Australia) appeared to reduce unplanned admissions relative to usual care. Simpler training and staff development initiatives showed mixed results, as did interventions aimed at tackling specific problems (e.g. medication review). Advance care planning was key to success of most QI programmes but do-not-hospitalise orders were problematic. Qualitative research identified tensions affecting decision-making involving paramedics, care home staff and residents/family carers. The best way to reduce end-of-life admissions through access to palliative care was unclear in the face of inconsistent and generally low-quality evidence.
Conclusions: Effective implementation of interventions at various stages of residents’ care pathways may reduce unplanned admissions. Most interventions are complex and require adaptation to local contexts. Work at the interface between health and social care is key to successful implementation.
Limitations: Much of the evidence identified was of low quality because of factors such as uncontrolled study designs and small sample size. Meta-analysis was not possible.
Future work: We identified a need for improved economic evidence and the evaluation of integrated care models of the type delivered by hospital-based teams. Researchers should carefully consider what is realistic in terms of study design and data collection given the current context of extreme pressure on care homes.
Funding: NIHR Health Services & Delivery Research Programme (award number NIHR133884)
Registration: PROSPERO database (registration ID CRD42021289418)
CORE (COnnecting REpositories)
CORE (COnnecting REpositories)