An evaluation of the impact of the Gold Standards Framework on collaboration in end-of-life care in nursing homes. A qualitative and quantitative evaluation

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Abstract

Background

In the United Kingdom approaching 20% of people aged 85 years and over live in care homes and most will die there. Improving end-of-life care is a government health priority and homes may work with primary care staff and specialist palliative practitioners to provide comprehensive end-of-life care. Consequently effective collaboration between care home and health service practitioners is vital to ensure high quality end-of-life care.

Objectives

To evaluate the impact of a training programme to improve end-of-life care in nursing homes, on collaboration between nursing home staff and other health practitioners.

Design

Evaluation using survey methods and qualitative case studies.

Participants and setting

All 95 nursing homes in the first national ‘Gold Standards Framework in Care Homes’ programme in England were invited to participate in the evaluation.

Methods

A survey of homes’ characteristics, the approaches to end-of-life care, and liaison with other services, was completed pre and post programme implementation. Case studies were conducted in a sub-sample of 10 homes to provide important context and depth to the evaluation.

Results

Pre and post surveys were returned by 49 (52%) homes. Improved collaborations as a result of the programme were anticipated by 31% of managers. Challenges to collaboration included working with large numbers of general practitioners, out-of-hours services and access to specialist practitioners. Improved collaborations between home staff and health service practitioners were identified by 33% of managers as one of the main programme outcomes. Staff reported increased knowledge of end-of-life care, and enhanced confidence, which in turn resulted in improved communication and collaboration. Post-programme, staff felt more confident initiating contact and discussing residents’ end-of-life care with general practitioners and those working in specialist palliative care services.

Conclusions

The Gold Standards Framework in Care Homes programme can contribute towards end-of-life care by helping to improve the quality and quantity of communication and collaboration between nursing home staff and primary care and specialist practitioners. Further research is needed to determine why this was not consistent across all homes.

Section snippets

Background

In England over a third of people aged 85 and over will die in a care home (Seymour et al., 2005), and admissions may occur specifically for end-of-life care. Similar profiles of care home deaths are evident in the United States and Australasia (Teno, 2003, Marshall et al., 2011). However, until relatively recently, homes had a low profile in terms of their contribution to care for frail older people (Hockley and Clark, 2002, Bowman, 2011). Clearly though, they have significant roles in

Literature review

Practitioners working with nursing homes include general practitioners, district nurses and nursing and medical specialists in palliative care (SPC). However there is little research into collaboration between homes and these services (Katz, 2003, Goodman et al., 2005). This requires investigation, because the various health care sectors have different cultures which may impact upon care (Avis et al., 1999, Miller, 2010). Additionally homes vary in terms of resident type, size, management style

Setting and participants

Research sites were the nursing homes participating in the GSFCH programme, and evaluation participants included managers, staff, residents and family. The four one-day GSFCH workshops for nurse managers and senior nurses were held between June 2005 and February 2006. The research evaluation team and the GSFCH development team were separate. However, indicative outcomes were reported to the development team, to inform programme review. Nursing homes were recruited to the programme by local

Homes’ relationships with health services at baseline

At baseline, variations were revealed in nursing homes’ relationships with other services. There were structural differences, such as the number of GP practices which had patients in the home, and operational issues such as staff perceptions of GP support and knowledge of palliative care.

On average, homes worked with four GP practices. However, one third (35%) liaised with just one or two practices while almost one in five (17%) worked with 10 or more. Given the size of some group practices,

Discussion

The evaluation of the Gold Standards Framework in Care Homes indicated that the programme has the potential to improve collaborative end-of-life care delivery between home staff and other health professionals. The longitudinal survey response rate of 52% was encouraging, given that nursing home response rates are typically lower than this (Marshall et al., 2011). Liaison between homes and GP practices reflected earlier findings: only a minority of homes had contact with one practice, while the

Conclusion

The GSFCH programme offered nursing homes a systematic approach to end-of-life care which included training, support and opportunities for networking. Together these elements provided a tangible acknowledgement of the key role of nursing homes in providing end-of-life care. They also contributed to improvements in knowledge among the participants, empowered managers, and improved communication and collaboration between homes and other health services. While some problems endured, many staff

Acknowledgements

We are grateful to all participants for their involvement and to The Gold Standards Framework team for their cooperation. Chris Wright provided statistical advice. The study was supported by a grant from Macmillan Research and Education group.

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