Medical advances and the success of public health policies have increased longevity, resulting in a rapidly increasing ageing population. However, living longer in good health is not guaranteed, and age increases the possibility for developing frailty, putting older people at risk of adverse health outcomes, such as falls, delirium, long-term care and death (Fried et al, 2001; Clegg, 2013). The NHS Long Term Plan published in January 2019 set out priorities for funding over the next 10 years, with a promise to improve ‘out of hospital’ care, including urgent community response and recovery (NHS England, 2019). Most areas in England have well-established existing intermediate care and rapid response services. Despite this, the NHS Long Term Plan built on the Five Year Forward view policy platform (NHS England, 2014), with a £4.5 million funding budget to increase capacity and responsiveness (NHS England, 2019).
At present, one in seven individuals in the UK is aged 85 years and older and lives permanently in a care home (NHS England, 2019). It has long been recognised that many people living in care homes have unmet needs and inconsistency in access to NHS services despite often having complex long-term conditions (British Geriatric Society (BGS), 2011). NHS England reports 185 000 emergency admissions each year from older people living in care homes, with potentially 30–45% of these being avoidable (NHS England, 2019).
The Five Year Forward plan (NHS England, 2014) recognised that more NHS support was required for older people living with frailty in care homes. The Better Care Fund was established to allow local authorities and NHS organisations to collaborate in developing shared models of care with the aim of improving quality of life and reducing hospital admissions (NHS England, 2014). One such model is the Enhanced Health in Care Home (EHCH) framework, which was introduced into six vanguard sites in England in 2016 (NHS England, 2016). Version 2 of the framework, published this year, details much of the learning from the vanguard sites through a set of care elements and sub-elements to provide coordinated and quality personalised care in care homes (NHS England, 2020). The Ageing Well programme, within the NHS Long Term Plan, sets out ambitious plans for NHS support in care homes to be ‘guaranteed’, with the roll out of the framework across the country by 2024 (NHS England, 2020). This model includes the care element of ‘enhanced primary care support’, which describes residents being able to access an urgent community response within 2 hours of a health crisis where a hospital admission is a possibility (NHS England, 2020).
This article explores an existing rapid response and treatment (RRaT) service using the story of a patient and describes how urgent timely intervention allowed the patient, Sid, to receive hospital-level care in his care home. It also highlights particular challenges for the RRaT service during the COVID-19 pandemic and considers comparisons with guiding principles of a hospital at home (H@H) model, well established in Scotland, and other parts of the UK to foster a debate on the opportunities to consider such a service for older people living in their own homes.
Rapid response and treatment (RRaT) service
The RRaT service provided by the Berkshire Healthcare Foundation Trust (BHFT) is commissioned by the Berkshire West Clinical Commissioning Group and has been chosen as one of the seven ‘accelerator’ sites to receive additional funding to increase capacity and responsiveness to older people with complex health needs who require urgent care. Currently in the recruitment and planning stages, it is hoped that through standardising the urgent response, consistency in a standard framework will emerge before a national roll out across the country planned for 2021, which includes older people living in care homes. The service was launched in October 2015, using funding from the Better Care Fund originally targeted for a H@H service for older people living in their own homes. The RRaT service covers three localities in Berkshire West, 51 care homes with a total of 2400 beds. It has grown and developed since and, in 2018, became integrated with the already established multidisciplinary Care Home Support Team (CHST) to form the Integrated Care Home Service (ICHS) with two distinctive elements: a reactive one (RRaT) and proactive one (CHST).
The CHST works to improve the health, wellbeing and independence of care home residents by working closely with care home staff to build their knowledge, skills and confidence. Training is provided around key topics, such as falls, urinary tract infections (UTIs), dementia, dysphagia, healthy skin, nutrition and hydration. In addition, specific support can be offered to residents with more complex needs, particularly those with behavioural and psychological symptoms of dementia.
This large multidisciplinary team includes a consultant geriatrician, an RRaT GP, advanced nurse practitioners, specialist rapid response nurses, registered mental health nurses (RMN), specialist senior nurse practitioners, healthcare assistants (HCAs), assistant practitioners (APs), occupational therapists (OTs), physiotherapists (PTs), a speech and language therapist (SALT) and pharmacists, all of whom are supported by a service manager and an administrative team.
Residents are referred with a new episode or sudden worsening of their condition, including:
- Delirium (hypo/hyperactive)
- Fluid retention
- Breathlessness
- Difficulty passing urine
- High temperature
- Cellulitis
- Reduced mobility
- Diarrhoea and/or vomiting
- Symptoms of chest infections, chronic obstructive pulmonary disorder (COPD) and asthma
- Falls
- Dehydration.
The service runs 365 days of the year between the hours of 9 am–7 pm, and referrals are made through a central point, the Health Hub. Any resident from a registered care home (nursing or residential) registered with a Berkshire West GP can access the service, and referrals can be made directly from the care home as well as GPs and the ambulance service. Where a resident has been admitted to the local acute hospital, frailty practitioners will encourage an early discharge and refer them to the RRaT team to continue treatment and for enhanced support in the care home. From Monday to Friday, the RRaT team also has access to an interface geriatrician at the acute hospital to discuss any resident whom they feel would benefit from a hospital admission, for which a comprehensive handover is provided.
Each locality also has a mobile number to allow care home staff to contact the team directly to clarify any concerns with a resident already on the service or discuss the suitability of a new referral. The ambulance team and GPs can also use this number to speak directly to a clinician for support and advice. Out-of-hours (OOH) medical support is provided through the GP OOH service, and the RRaT team liaises with the OOH service if there are concerns that may arise overnight or over weekends. Plans can be placed on Adastra, an electronic database that OOH GPs can view. The resident will remain on the caseload for up to 5 days, but this can be longer (or shorter) depending on their health needs and treatment plans, with residents being reviewed at least daily by RRaT nurses. There is a weekly multidisciplinary team (MDT) meeting with the consultant geriatrician, where residents on the caseload are discussed and further interventions from the PTs, OTs, pharmacists and SALTs are planned.
The service works very closely with the district nursing (DN) service (including OOH DNs), especially when a resident deteriorates and end-of-life care becomes a part of their health journey. Equally, other specialist services, such as the respiratory and heart function team, might be involved. The GPs continue to maintain overall medical responsibility for the resident and will be involved in important decisions and management plans. Discharge letters aim to be sent within 24 hours of the resident being discharged from the service; a copy is also sent to the care home, so staff are able to clearly see ongoing plans to maintain the health needs of the resident.
Box 1.What to expect from the RRaT service
- A detailed history will be taken using a Comprehensive Geriatric Assessment framework
- Physical examination will be performed
- Urgent bloods may be taken and analysed within 4 hours
- Cultures may be taken-blood, sputum, urine as well as swabs, etc.
- Other diagnostics such as echocardiography may be performed
- Provisional diagnosis will be made
- Treatment plan will be formulated with the resident, their family and care home staff, senior nurses will prescribe
- Management may include commencing oral treatments as well enhanced medical care (e.g. intravenous or subcutaneous therapy, nebulisers)
Case study: Sid's story
Sid is 90 years old and lives in a nursing home. Six years ago, he had been living at home but was admitted to the nursing home after suffering myocardial infarction (MI) followed closely by a middle cerebral artery stroke. Sid was described as a very busy and chatty man prior to the MI and stroke and was recognised as a ‘real character’ in the nursing home.
Sid was referred to the RRaT service due to an episode of vomiting in the night, with pyrexia and frank haematuria seen in his catheter bag. He had been assessed in the night via a telephone triage by the OOH GP service, and the staff contacted the RRaT team early in the morning for further support and assessment, as they were very concerned about him.
The RRaT arrived within 2 hours of the telephone triage on receipt of the referral via the health hub. The following information was provided by the care home, and the team also had access to electronic GP records, hospital records and recent blood results/investigations via laptops to further inform them of the patient's history.
In terms of his past medical history, Sid had COPD, middle cerebral artery stroke, brainstem syndrome, MI, a fracture in the neck of the femur with hemi-arthroplasty, chronic kidney disease and reduced left ventricular function. He was on the following medication:
- Phyllocontin forte Continus 350 mg BD
- Aspirin 75 mg OD
- Atorvastatin 80 mg OD
- Citalopram 20 mg OD
- Furosemide 40 mg OD
- Ramipril 5 mg OD
- Adcal-D3 one BD
- Fostair inhaler 100/6 two puffs BD
- Lansoprazole 15 mg OD
- Macrogol sachets OD
- Salbutamol 5 mg/2.5 ml nebuliser QDS
- Salamol 100 µg inhaler one–two puffs PRN
- Tiotropium 2.5 µg inhaler one capsule daily
- Paracetamol 500 mg two QDS PRN.
Sid can transfer from his bed to a chair/wheelchair with assistance and using a wheeled zimmer frame. He does not mobilise around the home since his last fall and fracture of the right hip. He requires assistance for personal care and enjoys being with other residents in the home for activities and meals. He enjoys his food and has gained weight since his stroke in 2015, with a BMI of 34. He has normal-consistency fluids and soft, bite-sized food for his meals and had recently been assessed by the SALT team, as staff were concerned about his coughing when eating. He has a Rockwood score of 7, indicating severe frailty (Rockwood et al, 2005), a Waterlow score of 24 and a Malnutrition Universal Screening Tool (MUST) score of 0.
Sid can communicate well, although he is hard of hearing, and staff believe he may have some difficulty understanding his different conditions. He seems cheerful in the home, and his family visited regularly before the COVID-19 visiting restrictions were put in place. He has a ReSPECT form (Resuscitation Council UK, 2020), which states that he does not want to be admitted to hospital unless it is unavoidable, for example, a fall with a suspected fracture. It also states he has a rescue medication plan in place in the home with antibiotics and steroids for exacerbation of COPD. The staff report that he has had two admissions to hospital over the past 12 months, and he is very keen, as is his family, that he remains at the care home. These admissions have been due to a catheter-associated UTI and infective exacerbation of COPD, both of which necessitated intravenous antibiotics. Staff report that Sid had been well in recent months; he can be breathless and wheezy at times due to the COPD, with normal SpO2 ranging from 90% to 92%.
Examination
At examination by the RRaT nurse, Sid's temperature was 38.3 °C; SpO2, 88 %; pulse, 113 bpm; blood pressure, 90/60; and respiratory rate, 40 breaths per minute. His National Early Warning Score (NEWS2) (Royal College of Physicians, 2017) was 12, indicating that he was at high risk with possible sepsis.
His heart sounds were 1+2+0, and his calves were soft and non-tender. He had slight oedema in the feet and ankles, with no chest pain, and his capillary refill time was 3 seconds. His extremities were warm, but he had cyanosis of the lips.
Sid showed tachypnoea and was given salbutamol nebuliser during examination as he was distressed, but this treatment was not noticeably effective. He was able to use his accessory muscles, but was not able to complete sentences. Crackles were heard in the left mid- and lower lobe, as was an upper respiratory wheeze. Occasional coughing was noted, but it was no worse than his normal cough.
Sid had good bowel sounds, with no pain or tenderness in any of the four quadrants. He had had a large bowel movement the previous day, and had eaten and drunk well the previous day. He had experienced four episodes of vomiting overnight, with the vomit comprising partially digested food and fluids. He reported no loss of taste or smell. Frank haematuria of approximately 400 ml was observed in the catheter bag. There was evidence of oral thrush on the tongue.
Sid was able to talk and answer simple questions, but he was distressed and showed evidence of limited cognition and understanding of the situation; however, he expressed that he did not wish to go to the hospital when asked.
Impression/diagnosis
Sid was considered to have developed sepsis due to his catheter, but infective exacerbation of COPD with the possibility of aspiration pneumonia were also suspected. He had recently had his swallow assessed by the SALT, as staff were concerned he seemed to be coughing a lot when he swallowed. Oral thrush was also suspected, since white patches were seen on his tongue.
Treatment plan
Blood was withdrawn for routine tests as well as for culture, and a COVID-19 swab was taken (Sid had never previously tested positive in routine care home tests). He was given an IV fluid bolus of 500 ml sodium chloride 0.9% and then 1 litre sodium chloride 0.9% subcutaneously over 12–24 hours. Care home staff were asked to encourage Sid to drink something every hour and to record fluid input and output on a chart.
Sid was also administered IV gentamicin and IV co-amoxiclav in line with the local microguide. Dosing took into account his last renal function tests, with creatinine clearance calculated. This would be reviewed once the blood results became available later that day, including any early results from the blood culture tests. His catheter was replaced, and a specimen of urine from the catheter was sent for analysis.
The aspirin, furosemide and ramipril were stopped temporarily, and paracetamol 1 g QDS, nystatin oral suspension 1 ml QDS, cyclizine 50 mg TDS for nausea/vomiting and prednisolone 30 mg OD for 5 days were added to his medication regimen.
The probable cause of him being unwell and the need for treatment with IV antibiotics and additional fluids was explained to Sid. He appeared to agree with the treatment plan.
The GP surgery was contacted and a message was left for the matron responsible for GP support to the care home, so they were aware of the situation.
The treatment plan was discussed with the care home staff, and they were provided information on assessment details and the written plan. A referral was made to the OOH DN service to administer IV antibiotics overnight.
Advance care planning
The RRaT team called Sid's family to discuss his condition and to gauge its opinion on any ceilings of care in terms of active treatments and priorities-advance care planning (ACP), in essence. His daughter was in agreement with the proposed plan; she felt that, although Sid may not have been able to fully understand the situation, he would not wish to go to hospital, based on previous discussions when he has been well. The family was informed that, due to his level of frailty, he may not respond to the treatment and could further deteriorate. Managing any distressing symptoms with medications, which would improve his comfort, was discussed, and it was agreed that this would be prioritised over any life-sustaining treatments. Although his daughter was upset, she also recalled how unwell he had been in hospital the previous year, and they had prepared themselves for Sid not recovering. Ultimately, she felt his comfort was the priority, and, if the treatment failed to improve his condition, then managing his end-of-life needs at the care home was what she felt he would want.
Follow-up and review
The following day, Sid was reviewed by the RRaT geriatrician. His blood pressure, SpO2 and temperature were improving, but he remained tachycardic, the tachypnoea persisted, and he still looked very unwell. The catheter bag was still draining frank haematuria, with some clots evident; he experienced pain over the suprapubic region on palpation, and the urine output was low. The geriatrician replaced the catheter over concerns it was blocked. This was successful, as it then drained clearer rose haematuria, and his discomfort reduced. The geriatrician was contacted by the microbiologist to report Gram-negative rods seen in the blood culture. Escherichia coli bacteraemia was suspected, and further discussion was held to agree on the ongoing IV antibiotic treatment. His blood tests revealed stage 2 acute kidney injury, and a further 500 ml IV fluid bolus was given.
Sid had eaten some breakfast, and staff were encouraging a good hourly intake of oral fluids; there had been no further vomiting. His subcutaneous fluids were continued, and his oral medications were reviewed daily depending on his observations and blood test results. His family was updated most days by the team, who documented the ongoing plan in his notes at the home as well as in his electronic record.
Sid was discharged a week later from the RRaT service. His road to recovery had not been straightforward, but was supported with input from the MDT and the diligence of the care home staff. The care home staff and the RRaT team knew he was getting better when he was able to laugh and joke again during visits to his room.
Further discussions were held with the family and Sid with regard to the ACP, and a plan was put in place with his goals should he deteriorate again in the following weeks. The understanding that he remains at high risk for infection due to the COPD and indwelling catheter was shared, as this was the third episode of sepsis and the need for IV antibiotics in the past year. Each time he recovered, it was not quite to his previous state of health, and it was recognised that this was impacting on his quality of life in the home. His ReSPECT form was updated to reflect the discussions, which remains in his notes at the care home. This information was also shared with the OOH GP, his GP and the ambulance service.
RRaT service and COVID-19
The RRaT team has first-hand experience of the unprecedented impact of the COVID-19 pandemic on care home residents, the staff and their families. Nearly 20 000 care home residents have died during the pandemic (Office of National Statistics, 2020), a shocking statistic that does not reveal the true distress and anguish of each and every one of those deaths for their loved ones and those who looked after them day in and day out. Even now, for those who have survived the first wave of the pandemic, the impact continues as residents are missing close contact from family and loved ones and many other health and wellbeing activities that constituted normal care home life. Dementia charities have raised the issue with the Health Secretary, calling for relatives to be considered as essential workers due to the reported physical and mental deterioration of many residents resulting from the enforced separation (BBC News, 2020).
The referral rate to the RRaT service tripled in April 2020. Many residents were referred with COVID-19 symptoms, but a similar number had atypical presentations, including extreme sleepiness associated with reduced oral intake. Hypoactive delirium was a common symptom, which seemed to fit with the emerging clinical data globally that delirium was more prevalent with increasing age (seen in over 40% of those aged >80 years) (International Severe Acute Respiratory and Emerging Infections Consortium (ISAREIC), 2020).
The RRaT service has always been driven by being able to offer personalisation through the principle of the right care at the right place at the right time. Older people living in care homes, often with significant levels of frailty, face additional risks when admitted to hospitals with exposure to hospital-acquired infection as well as a loss of further independence and functionality (Healthcare Improvement Scotland,, 2020). Additional driving forces, such as systemic factors, including an increasing pressure on acute hospital beds. This was emphasised heavily at the start of the pandemic in the UK as part of the COVID-19 action plan (Department of Health and Social Care (DHSC), 2020). All rapid response services prepared for an increase in referrals to support early discharge from hospital and prevent admissions to ensure capacity remained within the hospitals to manage the expected increase in COVID-19 patients. The media reporting of the use of blanket Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders for care home residents (The Guardian, 2020) presented additional challenges to the difficult and emotional conversations at that time. The RRaT team continued to have open, honest and sensitive discussions with individual residents and their families that would inform their ACP, detailing wishes for resuscitation, hospital admission and any ceilings of active treatment (Royal College of Physicians et al, 2009). The Care Quality Commission (CQC) has been asked by the DHSC to carry out an inquiry into the reports of such blanket policies being used during the pandemic, and it issued a statement condemning this practice (CQC, 2020). In it, they highlighted the importance of individual discussions, as well as access to acute hospital care should care home residents need and want it.
Challenges and the future
The ongoing increasing demand for the RRaT support among the care homes continues to challenge the capacity within the service. The additional funding recently announced though the Ageing Well programme has opened up positive opportunities to review existing services. The H@H model has demonstrated its value for residents in Berkshire West care homes and could offer similar benefits to older people living with frailty in their own homes. The H@H model has existed in other countries around the world for 25 years, and, with more H@H services being developed and delivered in the UK, unequivocal evidence is emerging demonstrating its benefits (Healthcare Improvement Scotland, 2020). With the recently launched Hospital At Home (HaH) UK Society (www.hospitalathome.org.uk), it appears interest is growing exponentially, perhaps also driven by the pandemic, to consider how NHS organisations can deliver more acute-level care for older people in their own homes. The society states that its purpose is to raise awareness of the model through the sharing of information from existing services and highlighting important research and policy that supports NHS organisations to implement the model (HaH UK Society, 2020). The first virtual HaH conference brought together HaH experts from around the world, including the UK, to share key insights of setting up services as well as the multidisciplinary professionals who have been instrumental in their success. The key themes that emerged reflected many of the challenges and opportunities critical to implementing and sustaining the RRaT service, such as leadership, governance, stakeholder engagement and key performance indicators to measure impact and outcome. A H@H service offers a short-term targeted intervention that can provide truly person-centred care, reducing many of the adverse effects of hospital admission for older people living with frailty and allowing them to remain in the comfort of their homes (Healthcare Improvement Scotland, 2020).
Conclusion
This article describes a RRaT service for older people living in care homes in Berkshire West. Sid's story discussed here demonstrates how such a service can support acutely unwell care home residents in avoiding hospital admission and reflects many of the principles that underpin a H@H model. With additional funding through the Ageing Well programme to support and develop rapid response services, there are opportunities to consider how such a model could be considered for older people living with frailty in their own homes. Research on H@H services continues, and this will contribute significantly to the H@H movement. Fundamentally, there has to be a shift in the cultural landscape of what acute care looks like for older people living with frailty in community settings. It should start with understanding what matters most to an older person experiencing health deterioration and, perhaps, some pioneers.
KEY POINTS
- Rapid response services provide opportunities for older people living with frailty to remain in their own homes during an episode of health deterioration
- Additional funding has been announced through the Ageing Well programme to support and develop rapid response services, including enhanced primary care support for care home residents to access an urgent community response within 2 hours of a health crisis, where a hospital admission is a possibility
- A hospital at home service offers a short-term targeted intervention that can provide truly person-centred care, reducing many of the adverse effects of hospital admission for older people living with frailty and allowing them to remain at home
- A shift in the cultural landscape of what acute care looks like for older people living with frailty is fundamental
CPD REFLECTIVE QUESTIONS
- How often do you start an assessment by asking the patient ‘what matters to you most’ and use that information to support shared decisions and goals?
- How much do you understand about your local rapid response services?
- Reflect on older patients living with frailty who have been admitted to hospital due to a frailty syndrome (falls, immobility, delirium) that, given a choice, would have preferred to receive acute level care in their own home
- Do you regularly see advance care plans being discussed with patients and their families? Does your organisations provide training for senior clinicians to complete Recommended Summary Plan for Emergency Treatment and Care forms with patients and families?