The care older people receive is an area of increasing concern to policy makers and the public, and there is a growing interest in the quality of social care – especially that provided in residential and nursing homes. However, beyond the results of inspections published periodically by the Care Quality Commission (CQC), there is very little comprehensive information available. There are no full routine national datasets on the well-being or health status of residents, and we are limited in our ability to monitor outcomes for this potentially vulnerable group.
In the US, there is a large body of research that looks at the use of health services by care home residents, particularly around the rates, causes and costs of hospital admissions. The CQC has also done some work looking into these types of measures. We were interested in extending some of these ideas by examining the patterns of hospital use by care home residents in England, and exploring whether rates of hospital admission could be used as markers of the quality of social care.
More emergency admissions, less planned care
Initially, we looked to see if we could detect any differences in hospital use between care home residents and the remainder of the older population. Owing to concerns around data confidentiality, we were not able to access information about individual care home residents, but we were able to estimate hospital activity from areas containing a care home.
Though not perfect, this approximate method highlighted significant differences in hospital use associated with people in care homes. In areas containing care homes we found much higher rates of emergency hospital use (A&E attendances and emergency admissions) and much lower rates of elective hospital use (outpatient appointments and planned admissions) compared to older people living in areas which did not contain care homes. However, this trend appeared to reverse in the last few months of life, when we found some evidence that care homes may help prevent emergency hospital admissions.
We also found differences in the types of conditions people were being admitted for. Care home areas were associated with more admissions for conditions such as hip fracture, pneumonia, and mental health problems, and fewer admissions for heart failure and diseases of the circulatory system.
Examining organisational variation
One potential practical application for this type of data is as a quality assurance tool – to assess whether the standard of care being received by residents in a particular home is in line with what would be expected from similar homes. To this end, we examined emergency admission rates between areas containing care homes and found significant variation. Clearly, some emergency admissions are necessary and appropriate. The question is whether some homes are reducing the need for admission through better preventive care or better management of crises.
In some instances, the level of admissions may be indicative of local systemic problems across institutions. Indeed, the quality of care residents receive could be considered a microcosm of how well care is integrated in a particular area. Poor coordination across care settings can have adverse impacts on residents like Alan, whose story is told here, and their families.
A foundation for further research
While we did find significant variation in emergency admission rates, it is important to emphasise that these indicators require careful handling. The measures are not simple and, given the limited data available, must be used with caution. We have shown, however, that techniques already established for monitoring other areas of care can be extended to residential and nursing care. Ultimately, these measures can only be improved with better data, but we hope to have provided a good starting point.