Integrating rehabilitation and palliative care to optimise function for older people: The Dunhill Medical Trust – Saunders PhD Programme

Context and overview Globally, more people are living into old age, with increasing disease, multimorbidity and/or frailty, and a trajectory of prolonged, unpredictable functional decline (32, 33).

Rehabilitation, nursing and palliative care needs will escalate over the next decades, driven by population changes (34). Health and social care needs among older people are diverse and complex.

Services must work together and support people to live as well as possible, maximizing function and preventing complications, but also adapt successfully to gradual deterioration (26).

The healthy ageing agenda spans the care continuum, starting with initial primary prevention of illness functional decline, and continuing throughout periods where of functional loss, including towards the end of life (35). Healthy ageing also extends beyond longevity and care must strive towards best possible quality of life and well-being.

This can be realised through timely recognition and management of symptoms, adjusting to loss, and reducing any care requirements caused by advanced illness and/or frailty (26, 27).

Building research capacity in this area is vital to achieve the system-level changes needed to improve the lives of older people.

This will require training and upskilling individuals across disciplines and professions, with investment beyond traditional disease-focussed research to address the major issues that people face later in life.

We will deliver three PhD studentships to boost the number and calibre of people researching in rehabilitation, nursing and palliative care for ageing-populations.

They will ensure that skilled leaders are trained and equipped to lead research that addresses future societal challenges of ageing.

Our partnership with Cicely Saunders International affords dedicated support to help co-ordinate the programme and maximise dissemination and routes to impact.

Development work Our programme has been carefully developed through our recent NIHR Research Partnership on Functional Loss and Rehabilitation Towards the End of Life (2021-22), which brought together a community of over 35 experts with relevant clinical, research and personal experience.

Through a structured research question generation exercise with researchers, clinicians, patients and public members, we identified high priority topics that align with what is important to older people affected by functional loss, as well pressing clinical practice challenges.

Research questions and methodological approaches were further strengthened with input from this expert group through multidisciplinary workshops.

As a result, our proposed studentships span multiple disciplines, from applied health and psychology to technology and economics, to unlock innovations in the holistic support of functional independence in older people.

Going forwards, this established wider community of experts with an active interest in the proposed projects will also provide an additional source of support for the PhD students (e.g. as external advisors and collaborators).

Areas to be investigated The novel research to be undertaken is shaped by the priorities of older people and their families, and aligned to future health and social care challenges.

Our projects fall under two broad area: 1) optimising mobility and social participation, including economic evaluation; and 2) management of restricting or limiting symptoms, especially breathlessness. A-list of related projects, with aims and outline methods, is shown in the appended Table.

As described below, we will advertise a list of opportunities, to gain the greatest interest and allow a match between the best candidates and their preferred project.

The projects share a focus on: • development and evaluations of solutions to issues important to older people • supported self-management and community-oriented approaches that make use of existing resources, and the strengths and assets of older people • use of high-value technology, including embracing low-tech ‘frugal’ innovations to provide high quality care without high costs • personalisation of care, through judicious and comprehensive assessment, tailoring based on each individual’s presentation and preferences, and adapting to change (e.g. illness progression, change of living arrangements, etc) Fit to The Dunhill Medical Trust strategic priorities The PhD programme directly responds to “preventing, delaying or reducing future health and social care requirements, in particular, improving the ability to maintain functional independence for older adults.” We focus on advanced illness and multimorbidity in older adults where loss of functional capacity is common (35), with exponential rise in health and social care requirements (42, 43).

Timely access to community care is a priority for older adults to maintain function and wellbeing.

At points of decline, skilled care can enable adults to remain in their usual place of care and prevent burdensome transition to hospital.

We will develop, test, and implement interventions that take account of visual, hearing or mobility limitations, and new delivery models to efficiently meet increasing population needs.

The work also aligns to the priority “Improving the quality of life for older people, in particular; in developing and delivering suitable living environments…”.

We extend our work in rehabilitation services and interventions, into assistive devices and technologies that may help tackle aspects of life that matter for older people but are often overlooked. Throughout, we consider social determinants of health and social care requirements and outcomes. Importance and impact The CSI has a strong track-record in leading and supervising impactful research.

The interventional focus of the projects will inform the collective understanding of “what works” and lead to the development of improved, innovative, and data-driven ways of delivering services, care and support for older people.

The findings will provide high-quality evidence to inform commissioners and policymakers on options to improve care, including around value and costs. Several projects will deliver co-designed interventions ready for evaluation in efficacy and effectiveness trials.

The interventions look to harness technology to empower patients and families, to both support their own independence and reduce health and social care requirements.