Nursing home rehabilitation

This blog reviews a recent policy document from NHS England, which aims to introduce expert medical and rehabilitation services, including mental health and palliative care services, into all nursing and care homes. This blog reviews the proposal, showing how it could be simplified and used to provide accessible, expert rehabilitation services not only into care homes but also to people in the wider community.

NHS England and NHS Improvement have published a document which, if implemented as written, could transform rehabilitation (and healthcare in general) within the UK. It is “The Framework for Enhanced Health in Care Homes” (Version 2, March 2020) available here. The second and third elements (of seven) are “Multidisciplinary team support” and “Falls prevention, reablement, and rehabilitation including strength and balance”.

The totally artificial distinction between these two, and the third element which is “high-quality palliative and end-of-life care, mental health, and dementia care” shows that they need some clinical input and advice from people who work in the NHS and who understand rehabilitation. It shows a residual attachment to categorising patients, needs, and services artificially. Last, it also demonstrates the need to have a rehabilitation organisation in the UK, to get engaged with initiatives such as this. The framework proposal would benefit from an informed understanding of rehabilitation.

This initiative is, nevertheless, a brilliant opportunity to provide a holistic, whole-person service to patients with complex problems. We (rehabilitation clinicians) should get involved, help write a still better version 3 within the next year, and thereby ensure that when we need these services, they will help us properly! The NHS has also realised that this initiative could support any response to Covid-19 (here).

I will draw attention to some key points. The outline summary is at the end

Radical new ideas
(for an NHS document)

The Framework, when implemented, will provide England (and I hope other nations in the UK will follow suit) with an extensive network of potential community centres, that will allow people needing to see an expert multidisciplinary rehabilitation team easy access, both on an inpatient and on an out-patient/community basis. The suggested development would supplement the existing more specialised level I and level II inpatient rehabilitation services. Itt would also complement existing community rehabilitation services, which would probably be based in the care homes.

It emphasises, as its first “condition critical for success“, personalised care, a synonym for patient-centred care. I have already shown how patient-centred care is inextricably intertwined with the biopsychosocial model of illness and rehabilitation. (here). The second condition is ‘co-production’, which basically means ensuring collaboration and cooperation between services that are currently separate.

It lists the people with an interest in the proposal. This is done largely using acronyms but it seems to include many of the relevant services. To be more radical, it could and, I would argue, should include housing, employment, and social security departments. Perhaps it is accidental, but I was concerned to note that “individuals with care needs, carers, and families” were the last interested party to be mentioned. Not quite compatible with the earlier emphasis upon the centrality of the patient!

It suggests that every care home should have a review of all residents on a weekly basis by a multidisciplinary team to include a doctor to review medication. I attend a care home (50-60 residents) on a monthly basis and we manage such a review in three hours. Depending a bit on the nature of the care home, I wonder if weekly is not a bit too frequent.

It makes suggestions about the linkage between health and social care computer systems which is self-evidently good. However, it would be better to have a single record; alternatively, it could ensure that the data in any particular system can be accessed easily by any other system (just as the internet does). This must be one of the top priorities

Each care home is related to one healthcare commissioner and, I assume, will have a single GP practice providing medical input.

Importantly, the residents’ review is to be led by “a clinician with advanced assessment and clinical decision-making skills“. This role would be best met by a consultant in rehabilitation. This is a model that has been used in the Netherlands for several decades, where there is a medical speciality of ‘nursing home physicians’ who are basically trained in rehabilitation. This model succeeds in the Netherlands.

Each care home should have access to out-of-hours urgent care when needed. The care home where I work has access to a Rapid Response service based in the local hospital. It is excellent and provides occasional but much appreciated support when someone is acutely ill.

There is the expected emphasis of important issues such as reducing falls, proper nutrition and medical review. It is unfortunate that they seem to be separated into different Care Elements. They are all part of rehabilitation.

There is one very good suggestion, hidden in Care Element four, where it suggests “Developing community assets to support resilience and independence“. This basically means developing links between local communities, local volunteers and local care homes, to increase the social activities and social contacts available to a resident, and thereby reduce the loneliness that many residents probably experience. This would be a very good outcome.

It is not clear if this framework intends to develop some care homes as day centres, where individuals in the community could both be seen by a rehabilitation team if needed and participate in community activities. This would be an excellent and quite radical development.

Care Element four puts together, on no very logical basis, access to Mental Health services, Palliative Care and end-of-life services, and dementia care services. The idea that these three expert services should be freely and routinely available to all care home residents – as they are in principle to all other people needing them – is again very important and, unfortunately, radical.

It is similar to my suggestion in relation to long-covid (here) and illustrated here. The Framework document emphasises that mental health conditions are common in nursing homes. It notes that mental health “conditions are often under-identified, under-diagnosed, and under-treated in residential care.” It outlines what a high quality service should aspire to.

The emphasis on dementia is fully justified. The document records that 76% of nursing home residents have dementia. I am not surprised but did not realise it was quite so high. It is also growing as a percentage, being 56% in 2002; this may reflect an increasing reluctance of anyone without dementia to move into a care home.

Care Element five is Joined-up commissioning and collaboration between health and social care. Maybe the authors know something we do not. This is far from radical as a suggestion. If the document contributes towards achieving this, it will be quite radical.

Care Element six is Workforce Development. Again the suggestion is not radical. The suggestion of “Joint workforce planning across all sectors” may be relatively radical but, as planning the workforce up to this point has been, in reality, “planning to spend what the government allows us”, it will require a radical change in the culture of the Department of Health and Social Care to achieve proper, needs-based planning whether jointly or singly.

In the same vein, the suggestions concerning Information Technology are scarcely radical. They require adequate funding (capital and revenue) and, to an extent, clarity about the freedom to choose between different IT platforms. Easy interoperability so that anyone (permitted) can gain access to information is required. Currently, my local hospital has many systems that cannot work seamlessly, so I am not optimistic about this care element.

In summary, the document repeats many long-established, sensible but never achieved ideas for service improvement. However, there are also some quite radical suggestions. The proposed development of care homes will form a network of community rehabilitation centres. The framework will ensure that all care home residents have sufficient, and sufficiently expert. health input to ensure the best care and social life possible. It will also enable most disabled people in the community to have easy access to rehabilitation expertise.

Integration of components

The framework also has one weakness, which can easily be remedied. The weakness arises from an inadequate understanding of rehabilitation and a failure to use the biopsychosocial model of illness as a framework for the proposed development.

The irony is that, given the commendable emphasis on integrating care (see Integrated Care Systems here), the proposal still refers to multiple separate services.

For example, the document seems to consider hydration and nutrition support, oral healthcare, and multidisciplinary team support as three separate matters. Any proper multidisciplinary rehabilitation (or ‘reablement’) team would, or certainly should, consider both feeding and oral health as an integral part of its concerns. It also separates out mental health services, despite the increasing recognition that there should be integration between mental health and all other services.

There are many possible explanations for this, but I suspect one is a conflation of ‘being expert‘ with ‘being separate‘. They assume that to be expert, a service also has to be separate from other services. A moment’s reflection shows this is untrue. A neurology department would contain experts in, for example, multiple sclerosis, muscle diseases, and auto-immune encephalitis but they are all within the expert neurology service.

Therefore, as I have argued elsewhere (e.g. here and here), it is quite possible within a rehabilitation service to have expertise in particular problems, such as feeding and oral health, or in specific conditions, such as dementia or Huntington’s disease.

The proposal can be easily simplified. The principles are:

All care homes within a commissioning area (e.g. a Clinical Commissioning Group area) will be provided with health services by that commissioning group;
* and each individual care home will be covered by one general practice group.
All care homes will have input from a multi-disciplinary rehabilitation team;
* each care home will have a regular review of all residents by the team, including a consultant doctor and members of the mental health and palliative care teams.
All care homes will also have:
* similar input from an expert mental health team;
* similar input from an expert palliative care and end-of-life team.
Centred on one or more care homes in a locality, groups of volunteers and others will support and develop links between the care home(s) and the local community;
* this may extend to other disabled people in the community coming to the care home for rehabilitation assessment, advice, and treatment and also to participate in social activities with residents.
The services will all be commissioned jointly by health and social services.
The Department of Health and Social Care will ensure adequate numbers of appropriately trained staff are trained, and that ongoing training for staff is available.
The electronic record systems will be made inter-operable to allow seamless shared use across all boundaries.

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