1. Care Home Medicine Dr Rhian Simpson Consultant Community Geriatrician Cambridgeshire Community Services

2. Summary of presentation Background and general descriptives National UK guidelines Cambridgeshire care homes Pilot study data

3. Background in UK Marjorie Warren, long stay wards Health and social care 1980s efficiencies and hospital bed closures Growth of Care Homes (private) No specific policy that addressed how needs of frail elderly should be met or how it should be funded

4. Care Home 24 hour access to care Spectrum of care –Residential care –Nursing home –Dementia units Cost of care –75% of places funded by government –Range of cost (£300 - £1000)

5. UK population 61.4 million

6. Living arrangements of older people In 2001, 5 per cent of people aged 65 and over and 20 per cent of people aged 85 and over were living in communal establishments compared to 6 per cent and 26 per cent respectively in 1991. Older women are more likely than older men to live in communal establishments. In 2001, 6 per cent of women aged 65 and over in the UK were living in communal establishments, compared with 3 per cent of men in the same age group; and almost a quarter of women aged 85 and over (23 per cent) lived in communal establishments compared to 12 per cent of men of this age. http://www.statistics.gov.uk/cci/nugget.asp?id=1264

7. Disability in population Large study (N = 572) Community dwelling elderly aged ≥75 11.9% annual incidence of functional decline Doubles with every 5 year increase in age. Hébert R et al. Am J Epidemiol 1997

8. National UK census of care home residents N= 15,483 (25% residential) in 244 care homes 90% admitted due to medical morbidity or disability > 50% had dementia, CVA or PD 76% needed assistance with mobility 71% were incontinent 78% had mental impairment Bowman et al (2004) Age and Ageing 33:561

9. “Whilst the overall health and longevity of the population is improving, our census makes clear that there is an important group of older people greatly burdened by disabilities arising from long term medical conditions that are accompanied by high levels of care need. These people need continual care and support that can most practically be care provided in care homes. Whilst promoting various welcome community options, policy makers and commissioners must take careful notice of the needs of people for whom independent living is not possible” Dr. Clive Bowman

10. The health and care of older people in care homes Interdisciplinary approach to assessment, care planning and care delivery Development of the nurse as the lead practitioner Service delivery needs to engage general and specialist aspects of medical practice Practitioners should have appropriate education and training Report of a Joint Working Party. RCP, RCN, BGS (2000)

11. Resource implications Gerontological nurse specialist Specialist GP service Specialist pharmacist Increase input from professions allied to medicine Regular MDT consultant sessions and visits to homes Improve care planning Develop teaching nursing homes

12. National priorities Acute care Less time for geriatricians in community Frail elderly cared for by non-specialists Fragmented

13. Care home medicine in the UK - in from the cold Hallmark of caring society is how we care for weakest members Complex patients National guidelines (2000) Finding local model that meets criteria Donald IP et al Age and Ageing, 2008.

14. Summary Geriatricians have obligation to care for frailest in population Ageing population UK national guidelines universally applied Lessons from UK

15. Care Home Medicine in Cambridge (population 500,000) 2653 care home beds 1675 acute admissions (2008 -2009) –70% in residential –Cost £5.22 million Review of service model –Fragmented –Lack of integrated working –Lack of specialist geriatric input

16. Current Service East Cambridgeshire care homes – 7 homes: 2 NH 5 RH 320 patients 6 monthly medication review –Cost savings per annum £16,550 (5 homes) –Monthly visit being piloted in 1 NH Domiciliary Visits in care homes Hilton Park Care Centre Pilot

17. Care Home Pilot 2004 One residential care home (37 residents) Multidisciplinary team Review of medication, chronic disease management, support for local GPs

18. General descriptives

19. Diagnoses

20. Co-Morbidity

21. Medication review

22. Cardiac drugs Diuretics (N=16) Ace inhibitors (N=11) Aspirin (N=9) Clopidogrel (N=2) Digoxin (N=5) Warfarin (N=4) Simvastatin (N=3) Beta blocker (N=3)

23. Analgesics Paracetamol (N=9) Co-proxamol (N=6) NSAID (N=3) Celecoxib (N=3) Codeine phosphate (N=3) Gabapentin (N=3) Meptazinol (N=2)

24. Other most commonly prescribed medications Anti-depressants (N=16) Laxatives (N=14) Proton pump inhibitors (N=9)

25. Anti-psychotic drugs Haloperidol (N=1) Risperidone (N=5) Temazepam (N=2) Zopiclone (N=2) Donepezil (N=2)

26. ADR and Hospital Admissions BMJ (2004) Vol 329 15-19 Prevalence of ADR was 6.5% Associated with older patients (median age 75 years) 2% died 72% of all ADRs were avoidable GI bleed most common ADR Drugs most commonly implicated were NSAIDs (including low dose aspirin), diuretics and warfarin

27. Outcomes Simplify analgesia Reviewed need for primary and secondary prevention Reviewed anti depressant prescribing Guidelines for Vit D and Calcium use in care homes Chapuy et al NEJM 1992

28. Cost Savings Average annual cost saving per patient reviewed = £185 Total Saving for 37 beds = £8,140 annually Potential savings of £175,935 across East Cambridgeshire

29. New model of care in East Cambridgeshire Regular review (now every 6 months) which includes a medication review in 7 homes Improved integrated working Care Home pharmacist

30. Hilton Park Care Centre pilot 2009: Background Variations in GP input and knowledge of frail elderly My input was only every 6 months Pressure to reduce acute hospital admissions Lack of advance care planning

31. Hilton Park Care Centre Pilot January 2009 - December 2009 Nursing home with 80 beds (30 dementia) Dr Margaret Elliott (GP) weekly visits –Proactive care –Advanced care planning Support with monthly clinical visits

32. Major long term condition

33. Total number of deaths between Oct 2007 - Oct 2009 (N= 66)

34. Place of death

35. Cause of death

36. Deaths from end stage chronic disease Length of stay

37. Death vs length of stay

38. Summary of findings 35% of deaths occur within 3 months of admission All new admissions to HP who died came from the acute hospital 83% (N=55) of deaths were managed within the care home

39. Conclusions from pilot Early assessment important for new residents to discuss advanced care planning Care home and GP staff are providing end of life care New patients

40. Conclusions Guidelines underpinning best practice in care homes No evidence base to support a specific model of care Evidence that frailest elderly within our population –Local pilot suggests a hospice type function Recognition that there is a level of complexity that is difficult to manage in community Geriatricians should be involved in care home medicine due to their knowledge and use of CGA and end of life care