• Optimal healthcare delivery to care homes in the UK: A realist evaluation of what supports effective working to improve healthcare outcomes

      Dening, Tom; Schneider, Justine (2018)
      Introduction: care home residents have high healthcare needs not fully met by prevailing healthcare models. This study explored how healthcare configuration influences resource use. Methods: a realist evaluation using qualitative and quantitative data from case studies of three UK health and social care economies selected for differing patterns of healthcare delivery to care homes. Four homes per area (12 in total) were recruited. A total of 239 residents were followed for 12 months to record resource-use. Overall, 181 participants completed 116 interviews and 13 focus groups including residents, relatives, care home staff, community nurses, allied health professionals and General Practitioners. Results: context-mechanism-outcome configurations were identified explaining what supported effective working between healthcare services and care home staff: (i) investment in care home-specific work that legitimises and values work with care homes; (ii) relational working which over time builds trust between practitioners; (iii) care which ‘wraps around’ care homes; and (iv) access to specialist care for older people with dementia. Resource use was similar between sites despite differing approaches to healthcare. There was greater utilisation of GP resource where this was specifically commissioned but no difference in costs between sites. Conclusion: activities generating opportunities and an interest in healthcare and care home staff working together are integral to optimal healthcare provision in care homes. Outcomes are likely to be better where: focus and activities legitimise ongoing contact between healthcare staff and care homes at an institutional level; link with a wider system of healthcare; and provide access to dementia-specific expertise.
    • Principles of service provision in old age psychiatry

      Dening, Tom (2013)
      The past decade has seen considerable changes in the shape of mental health services for older people. This has sometimes been so radical as to include the disappearance of the service as a separate entity, and yet this is at a time when the population of older people is growing and therefore it might be assumed that the demand for specialist services would also be increasing. How this can be so is the story of this chapter. There are two main strands to service provision to support mental health in older people. One is the general question of how mental health needs in this section of the population are to be met, and the other topic is the organization of specialist mental health services for older people. These strands are interwoven but also at risk of unwinding from each other. In this chapter, the focus is on the principles underlying services, rather than on much detail, partly because the situation will vary in different parts of the world but also partly because the way services are organized will continue to change, rendering anything too detailed obsolete in a short space of time. The chapter takes a largely UK, specifically England, focus. Many of the general issues are, however, global and also, as the UK has been one of the leaders in developing service models for old age psychiatry, it is likely that what happens there will be of interest to readers internationally. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
    • Severe and enduring mental illness

      Dening, Tom (2013)
      This chapter addresses the needs of people growing old with long-term, severe mental illness. These comprise mainly patients with schizophrenia and other psychotic mental illness, but also a smaller number with bipolar affective disorder and other diagnoses including obsessive compulsive disorder, personality disorders, and substance misuse. Much of the clinical research concerns patients with schizophrenia, but the service considerations also apply to those with other diagnoses. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
    • The optimal study: Describing the key components of optimal health care delivery to UK care home residents: a research protocol

      Dening, Tom; Zubair, Maria; Schneider, Justine (2014)
      Long-term institutional care in the United Kingdom is provided by care homes. Residents have prevalent cognitive impairment and disability, have multiple diagnoses, and are subject to polypharmacy. Prevailing models of health care provision (ad hoc, reactive, and coordinated by general practitioners) result in unacceptable variability of care. A number of innovative responses to improve health care for care homes have been commissioned. The organization of health and social care in the United Kingdom is such that it is unlikely that a single solution to the problem of providing quality health care for care homes will be identified that can be used nationwide. Realist evaluation is a methodology that uses both qualitative and quantitative data to establish an in-depth understanding of what works, for whom, and in what settings. In this article we describe a protocol for using realist evaluation to understand the context, mechanisms, and outcomes that shape effective health care delivery to care home residents in the United Kingdom. By describing this novel approach, we hope to inform international discourse about research methodologies in long-term care settings internationally. Copyright © 2014 AMDA - The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.
    • Using comprehensive geriatric assessment for quality improvements in healthcare of older people in UK care homes: protocol for realist review within Proactive Healthcare of Older People in Care Homes (PEACH) study

      Dening, Tom (2017)
      INTRODUCTIONCare home residents are relatively high users of healthcare resources and may have complex needs. Comprehensive geriatric assessment (CGA) may benefit care home residents and improve efficiency of care delivery. This is an approach to care in which there is a thorough multidisciplinary assessment (physical and mental health, functioning and physical and social environments) and a care plan based on this assessment, usually delivered by a multidisciplinary team. The CGA process is known to improve outcomes for community-dwelling older people and those in receipt of hospital care, but less is known about its efficacy in care home residents.METHODS AND ANALYSISRealist review was selected as the most appropriate method to explore the complex nature of the care home setting and multidisciplinary delivery of care. The aim of the realist review is to identify and characterise a programme theory that underpins the CGA intervention. The realist review will extract data from research articles which describe the causal mechanisms through which the practice of CGA generates outcomes. The focus of the intervention is care homes, and the outcomes of interest are health-related quality of life and satisfaction with services; for both residents and staff. Further outcomes may include appropriate use of National Health Service services and resources of older care home residents. The review will proceed through three stages: (1) identifying the candidate programme theories that underpin CGA through interviews with key stakeholders, systematic search of the peer-reviewed and non-peer-reviewed evidence, (2) identifying the evidence relevant to CGA in UK care homes and refining the programme theories through refining and iterating the systematic search, lateral searches and seeking further information from study authors and (3) analysis and synthesis of evidence, involving the testing of the programme theories.ETHICS AND DISSEMINATIONThe PEACH project was identified as service development following submission to the UK Health Research Authority and subsequent review by the University of Nottingham Research Ethics Committee. The study protocols have been reviewed as part of good governance by the Nottinghamshire Healthcare Foundation Trust. We aim to publish this realist review in a peer-reviewed journal with international readership. We will disseminate findings to public and stakeholders using knowledge mobilisation techniques. Stakeholders will include the Quality Improvement Collaboratives within PEACH study. National networks, such as British Society of Gerontology and National Care Association will be approached for wider dissemination.TRIAL REGISTRATION NUMBERThe realist review has been registered on International Prospective Register of Systematic Reviews (PROSPERO 2017: CRD42017062601).