- In October 2022, NHSE outlined one its key objectives to reduce unwarranted variation in ambulance utilisation by care homes as part of the ‘Going Further for Winter Resilience’ plans
- In response, NHSE London region commissioned TN for an intensive programme. We worked with community providers, social care and the LAS to generate insights on care home utilisation and support effective decision-making on use of resources in winter 2022
- Co-developed metrics to quantify care home utilisation rates with system colleagues
- Agreed areas of focus, e.g., incidents per bed rate and conveyance rate (see Figure 1)
- Segmented care homes into seven ‘archetypes’ based on care home service type and specialisation
- Identified unwarranted variance in utilisation between similar care homes (see Figure 2A).This required extensive analysis to identify patterns in utilisation, including using box plots to compare the mean, medians, and interquartile range of the incident per bed rate for different care home specialisations and service types(see example for nursing homes in Figure 2B). We also compared the incident per bed rate with the size of care home specialisations and service types (in terms of total and average number of beds) to develop the archetypes (see Figure 2C).
- Identified drivers of variation in utilisation, for instance common reasons for calls, availability of alternative community services (e.g., falls services), and the frequent caller rate
- Engaged with community, social care and ambulance service colleagues to play back, and refine insights to support decision making going forwards
Demand for ambulance resources from care home residents is growing – yet many incidents could be treated using alternative pathways to avoid hospital conveyances and admissions
- Despite regional incidents falling by 12% over the past year, incidents from care homes have gone against this trend – rising by 9%
- Care home residents account 2% of regional ambulance service calls, 3% of incidents and 4% of conveyances, but residents have a disproportionately sized impact on the acute system – accounting for up to ~10% of hospital bed days (see Figure 3)
- Care homes incidents have increased by 9% since 2021, and in 2022 ~40% of care home incidents were due to conditions (e.g., falls, pandemic/outbreak) that could potentially be treated via alternative pathways such as Urgent Community Response (see Figure 4)
- More deprived places tended to have a higher average rate of incidents per care home bed
Viewing by care home provider group, we also found activity rates vary between provider groups (even those with similar archetypes), potentially driven by differences in provider policies
Viewing care homes by archetype (see Figures 5 and 6), we found:
- Nursing homes have higher incidents per bed rates than residential homes on average
- Care homes (nursing or residential) that provide dementia services have the highest average rates of incidents per bed, while homes that provide learning disability services have the lowest
- The call source and reason varies between archetypes. For example, 31% of non-conveyed incidents are due to falls in Residential Dementia homes, while all residential homes have low rates of incidents that come via HCPs
- The Nursing Dementia archetype has the largest absolute opportunity as this archetype accounts for the highest number of beds within the NHS region
- The Residential Learning Disability care home archetype has the highest proportional opportunity for improvement as 47% of incidents result from above average utilisation
We worked alongside experts (e.g., London Ambulance Service executives, NHS Improvement & Digital colleagues, ICB leads, care home directors) to co-develop drivers of unwarranted variance in care home utilisation and best practice initiatives for effective care provision in care homes. NHSE London region teams then took forward the recommendations by working closely with health and social colleagues across the five London ICBs.
Improvement initiatives
- Develop robust, regular training and induction processes for care home staff on care provision (e.g., fall management) and available services/ pathways, including when and how to utilise them
- Share best practice care home processes and practices across and within places, for instance:
- Provide shared clinical decision-making avenues to reduce risk aversion
- Expand the use of remote monitoring technologies for care home residents
- Incorporate regular preventative and anticipatory care practices for residents
- Engage with the resident’s family on care plans to manage expectations
Increasing service integration
- Establish closer links between primary care and care home providers, for instance hold weekly MDT meetings in care homes (e.g., care home staff, GPs, community service providers, social care workers, and voluntary, community & social enterprises) to identify the appropriate response to patient needs and update resident care plans
- Develop a single, accessible and comprehensive care plan for all residents, combining plans from GPs, palliative care teams etc. to create clarity for care providers by streamlining access to patient history and care plan updates
- Expand access and availability of alternative services, including
- ICBs provide a single point of access for care homes to contact urgent / ‘out of hours’ care, and specialist services (e.g., for palliative or mental health patients)
- ICBs expand availability of community services (e.g., UCR, fall services, frailty services, SDEC) to reduce unnecessary utilisation of 999 services
