Understanding and addressing variation in Emergency Department attendances and inpatient admissions from care homes: a mixed methods study.

Background Older care home residents are at risk of harm during Emergency Department (ED) attendances and inpatient admissions. Around 40% of emergency admissions from care homes may be avoidable. Admissions from care homes are six-times higher in some parts of England.

The NHS Enhanced Health in Care Homes programme has recommended a broad range of enhanced services to support treatment of residents in the community and reduce hospital admissions. There are differences in how enhanced services have been implemented. This may contribute to variation. Aims Measure variation in ED attendances, inpatient admissions and place of death between care homes.

Identify differences in implementation of the Enhanced Health for Care Homes programme which contribute to variation. Identify replicable models of enhanced care provision that safely reduce attendances and admissions. Develop statistical tools to help monitor and plan services for care homes.

Phase 1 (Year 1: 12 months) I will create a nationally representative cohort of care home residents (10% all care home residents England for 2022-2024).

Individual level routinely collected GP data will be linked to death registrations, Hospital Episode Statistics and the Care Quality Commission (CQC) register. I will develop a multi-level regression model estimating ED attendances, inpatient admissions and place of death.

I will describe national variation by reporting the difference between observed and predicted rates of attendance/admission for each care home.

Phase 2 (Years 1-3: 18 months) Using the results of Phase 1 I will identify six care homes with high/medium/low adjusted rates of attendance/admission for in-depth qualitative case study research.

I will interview GPs, commissioners and professionals providing specialist services to characterise how services are implemented and deepen the broad proposed taxonomy of enhanced care elements. Specific models of enhanced care which effectively reduce attendances/admissions will be identified.

I will explore care home staff, family members and residents' experiences and consider secondary outcomes including place of death to assess whether low observed rates reflect appropriate care.

Phase 3 (Years 2-3: 13 months) Using the findings of Phase 2, the care home leads for each integrated care system in England will be surveyed to map where identified effective models of enhanced care are available.

The multi-level regression modelling in Phase 1 will be revisited to incorporate predictors for specific models of enhanced care for each care home area. This will provide some evidence of the effect of different models of enhanced care on outcomes.

Working with integrated care system level commissioners, GPs and other stakeholders funnel plots will be developed to help monitor and prioritise development of the Enhanced Health in Care Homes programme.

Impact and dissemination The study will identify replicable enhanced care models within the Enhanced Health for Care Home programme which safely reduce hospital attendances and admissions. The statistical methods will develop funnel plots that can be used to monitor and plan services.

By working with integrated care system level commissioners, the CQC data insights team and other stakeholders, findings will be disseminated in a way which can be used by commissioners and regulators.