|A systematic review of integrated working between care homes and health care services
|Davies SL, Goodman C, Bunn F, Victor C, Dickinson A, Iliffe S, Gage H, Martin W, Froggatt K
This review evaluated different integrated approaches to health care services supporting older people in care homes. Most studies showed mixed results and the authors concluded appropriately that there was limited evidence about the outcomes of different approaches to integrated working. It was unclear whether integration at a strategic level significantly reduced unnecessary hospital admissions.
To evaluate the different integrated approaches to health care services supporting older people in care homes and identify barriers and facilitators to integrated working.
Nine electronic databases including MEDLINE, EMBASE and The Cochrane Library were searched to February 2009; search terms were reported. Reference lists were checked and care home related interest groups were contacted. Only papers in English were included.
Studies of interventions to develop, promote or facilitate integrated working between care home or nursing home staff and health care practitioners were eligible for inclusion. Included studies could be of any design and had to demonstrate at least one of the following: clear evidence of joint working; joint goals or care planning; joint arrangements covering operational and strategic issues; shared or single management arrangements; or joint commissioning at macro and micro levels. Studies also had to report one of the outcomes: health and well being of older people; service use; cost savings; or process-related outcomes. Studies where project staff were employed for a short time to deliver a specific intervention were excluded.
Study participants were care home or nursing home residents, relatives and staff, and health professionals including general practitioners, district nurses, nurse specialists, pharmacists, psychiatrists and psychologists. Interventions were focused on individual care (for example dementia, end-of-life or wound care), group needs (for example detection and treatment of depression) or supporting care home staff through training and prescribing improvements. Service evaluations of an in-reach team for care homes, a care home support team and nurse practitioners were included. Studies were conducted in the UK (nine studies), Australia (five studies), USA (two studies) and Sweden (one study).
Two reviewers independently selected studies for inclusion. Any disagreements were resolved by consensus or discussion with a third reviewer.
Assessment of study quality
Checklists informed by the Cochrane risk of bias tool and the quality assessment checklist for qualitative studies by Spencer et al (2003) were used. Quality assessment criteria used for randomised controlled trials, controlled studies (without randomisation) and qualitative studies were reported.
The authors did not state explicitly but it seemed that quality assessment of individual studies was done by two reviewers independently.
Data on health outcomes, service use, process-related outcomes and costs were extracted. Qualitative studies were used to identify possible facilitators and barriers to integrated working.
Two reviewers independently extracted data using a standardised form. Any disagreements were resolved by consensus or discussion with a third reviewer.
Methods of synthesis
Narrative synthesis was presented due to substantial heterogeneity in study design, interventions, participants and outcomes. The effects of the interventions were categorised as positive, negative or no significant effect.
Framework analysis was used to compare the level of integration between care or nursing home staff and health professionals in the studies. The level of integration was categorised as patient level, organisational level or strategic level. The amount of contact, support and training given by the health professionals to the care or nursing home staff in each of the studies was assessed.
Results of the review
Seventeen studies (approximately 3,635 care/nursing home residents and 198 care/nursing home staff) were included: four randomised controlled trials, six controlled studies, one economic evaluation, two process evaluations and four qualitative studies.
Effectiveness and level of integration: Most studies had mixed results, with positive effects of integrated working on one outcome and negative or no effects on other outcomes. Most studies achieved integrated working at the patient level. More positive outcomes, such as avoiding hospital admissions, were found in a small number of studies where care homes were supported by a dedicated health service team, health service funded beds or managed care (integration was judged to be at a strategic level in these studies).
Facilitators and barriers to integrated working: Facilitators included care home manager support for the integrated working intervention and protected time for training and support for all care home staff from health care professionals. Barriers included a failure to acknowledge expertise of care home staff, care home staff's lack of access to health care services and a high turnover of care home staff.
There was insufficient evidence to evaluate the cost of integrated working.
There was some evidence about facilitators and barriers to integrated working between care homes and health services but limited evidence about the outcomes of different approaches to integrated working.
The review question and inclusion criteria were clear. Several databases and other relevant sources were searched. The restriction to studies in English may have resulted in the exclusion of other relevant studies. Methods for study selection and data extraction were adequate. The authors noted that owing to a lack of evidence in the area, all study types were included and acknowledged that uncontrolled studies are open to bias. Both the controlled and uncontrolled studies were considered to be at high risk of bias. The qualitative studies were considered to be low quality. The authors noted that although the included studies involved integrated working, it was not the main focus for most of the studies (only two studies referred to "partnership working"); it was possible that the study reports did not capture the extent of integrated working achieved.
Differences in study design, intervention, populations and outcomes mean that a narrative synthesis was appropriate. However, as the authors acknowledged, this made it difficult to make any comparisons between the studies when assessing effectiveness of the various approaches to integrated working.
Three studies suggested that integration at the strategic level reduced unnecessary hospital admissions. The quality of the studies and the clinical significance of the finding were unclear. The authors' overall conclusions appropriately reflect the low quality of the evidence about a variety of approaches to integrated working between care home and health care staff.
Implications of the review for practice and research
Practice: The authors stated that more effective working between the NHS and care home providers was essential given increasing demand for residential and nursing home care.
Research: There was a need for more research to evaluate the effectiveness of integrated working, identify how integration can best be achieved and indicate how quality of care can be improved for the care home population as a whole. Outcomes needed to be meaningful to care home residents and staff.
Service Delivery and Organisation programme, National Institute for Health Research, UK.
Davies SL, Goodman C, Bunn F, Victor C, Dickinson A, Iliffe S, Gage H, Martin W, Froggatt K. A systematic review of integrated working between care homes and health care services. BMC Health Services Research 2011; 11: 320
Other publications of related interest
Goodman C, Davies SL, Dickinson A, Gage H, Froggatt K, Morbey H. Victor C, Masey H, Martin W, Ilife S. A study to develop integrated working between primary health care services and care homes. NIHR Service Delivery and Organisation programme; 2013.
Subject indexing assigned by NLM
Delivery of Health Care, Integrated /methods; Health Services Research; Health Services for the Aged; Home Care Services; Patient Care Team; Patient Education as Topic; Quality of Health Care
Date bibliographic record published
Date abstract record published
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.