Effective health care for older people living and dying in care homes: a realist review

Stage 2: Theory refinement and testing

Stage 2 tested the relevance and rigour of emerging findings from Stage 1. Using the tabulated findings from this stage, the research team developed a series of statements that captured the emergent programme theories of how health care services worked with care homes. This resulted in a series of statements about possible context, mechanism and outcome configurations [17]. These informed how the academic and professional/practice based literature was identified and data extracted. More detailed searches of the literature then revisited and expanded the searches from Stage 1 and considered interventions that drew on theories that focused on: the assessment of frail older people in the last years of life [3, 18, 19]; system driven quality improvement schemes in primary care [20]; and theories of integrated working that emphasise relational, participatory, and context sensitive approaches in care home settings [21, 22] (Tables 1, 2 and Fig. 1).

Preliminary Programme theories developed from Stage 1

Health care for older people resident in care homes achieves optimal outcomes if

How expressed in service delivery models/intervention research

System based quality improvement approaches incentivise health care staff (GPs and care home staff) regularly to visit and review residents’ health status then care home staff will prioritise the aspects of care activities that are being monitored, review of patient care and avoid inappropriate and avoidable use of urgent and emergency services

Interventions that use financial payments, sanctions and audit to improve particular health care outcomes and adherence to protocols and guidance

Age-appropriate care can be accessed by older people resident in long term care. Then residents will not have to wait to have symptoms treated and then they will experience fewer episodes of avoidable ill health

Interventions that focus on assessment maintenance and improvement of function, management of diseases and symptoms associated with old age through education, training of care home staff and access to visiting clinical experts and care home specialist teams

Interventions are predicated on establishing relational approaches that promote integrated working between visiting health care and care home staff. Staff will become less risk averse, trust each other’s opinions and be willing to engage with activities that promote residents’ health and support them to stay in the care home.

Emphasis on strategies that support co-design and joint priority setting to achieve improved outcomes for residents, e.g. shared education and training, continuity of contact with particular clinical experts, shared learning, feedback on achievements between health and care home staff

bold type denotes the working title of each programme theory

In keeping with realist inquiry methods, equal consideration was given to negative and positive outcomes and inconsistencies in accounts of what works, when and with what outcomes.

Relevant literature was requested through primary care and care home networks comprising: the MyHomeLife Network, National Care Home Research and Development Forum, Dementia and Neurodegenerative Diseases Research Network (DeNDRoN), Clinical Research Networks and care home provider organisations and associations including Care England and the National Care Forum and the Residents and Relatives Association.

The following electronic databases were searched: Pubmed, CINAHL (Cumulative Index to Nursing Allied Health Literature), The Cochrane Library (including the Cochrane Database of Systematic Reviews), DARE (Database of Abstracts of Reviews of Effects), the HTA Database, NHS EED (NHS Economic Evaluation Database), Scopus, SocAbs (Sociological Abstracts), ASSIA (Applied Social Sciences Abstract Indexes), BiblioMap (The EPPI-Centre register of health promotion and public health research), Sirius, OpenGrey, Social Care Online, the National Research Register Archive, the National Institute of Health Research portfolio database, Google and Google Scholar. Search terms used were organised to capture the range of possible interventions that health care services provide (e.g. falls prevention, wound care, end of life care) and included studies that focused on achieving change in one or more of the outcomes of interest (for example prevention of hospital admission, resident satisfaction). These searches were complemented by lateral searches of reference lists from primary studies and relevant systematic reviews.

Initial searches excluded publications prior to 2006, because the later period has seen social care and independent care providers take responsibility for long term care of older people. It has also coincided with a rapid growth in care home research outputs [23].

We included studies of any research design, unpublished and grey literature, policy documents and information reported in specialist conferences.

Studies reviewed had to be relevant to UK systems of health care. We treated with caution or excluded studies where the care home medical support would be in-house (as in the Netherlands) or the level of care would be closer to hospital level provision (as can be the case in the US). Relevant studies therefore described health care provision to care homes that were similar or could be applied to UK working patterns. Included studies focused on health care to care homes provided by visiting health care professionals or services. Studies that were not UK-based and where there was transferable learning were included. These tended to be those that had been identified from iterative searches and that reinforced or challenged something identified in the UK literature.

Four reviewers (CG, SLD, MZ, MH) independently screened titles and abstracts to identify potentially relevant documents, which were then retrieved and assessed according to one or more of the following inclusion criteria:

• Studies which considered residents in a care home with specific health needs/problems and focused on one or more of the outcomes of interest

• Studies of any intervention designed to improve the health status of care home residents that involved visiting health care professionals and offered opportunities for transferable learning to a UK setting

• Studies that provided context relevant evidence on the implementation and uptake of interventions in care homes generally (not confined to health care), that also helped build our programme theories and logic.

Data extraction proceeded as follows. In order to identify key elements of importance to the success or failure of an intervention or models of service delivery in particular contexts, information was gathered on how health care was organised, funded, provided and delivered. Particular attention was given to the detail or thick description of the process, how the underlying assumptions and theoretical framework (if identified) were articulated, and whether this fitted with the focus of our review in terms of the underlying theory and the impact of the intervention on the outcomes of interest. Our approach drew on Rycroft-Malone et al.’s [24] approach to data extraction in realist synthesis that questions the integrity of each theory, considers the competing theories as explanations to why certain outcomes are achieved in similar and different settings and compares the stated theory with observed practice.