Objective To evaluate the effect of specialist geriatric medical management on the outcomes of at risk older people discharged from acute medical assessment units.Design Individual patient randomised controlled trial comparing intervention with usual care. Setting Two hospitals in Nottingham and Leicester, UK.Participants 433 patients aged 70 or over who were discharged within 72 hours of attending an acute medical assessment unit and at risk of decline as indicated by a score of at least 2 on the Identification of Seniors At Risk tool.Intervention Assessment made on the acute medical assessment unit and further outpatient management by specialist physicians in geriatric medicine, including advice and support to primary care services. Main outcome measuresThe primary outcome was the number of days spent at home (for those admitted from home) or days spent in the same care home (if admitted from a care home) in the 90 days after randomisation. Secondary outcomes were determined at 90 days and included mortality, institutionalisation, dependency, mental wellbeing, quality of life, and health and social care resource use. ResultsThe two groups were well matched for baseline characteristics, and withdrawal rates were similar in both groups (5%). Mean days at home over 90 days' follow-up were 80.2 days in the control group and 79.7 in the intervention group. The 95% confidence interval for the difference in means was −4.6 to 3.6 days (P=0.31). No significant differences were found for any of the secondary outcomes.Conclusions This specialist geriatric medical intervention applied to an at risk population of older people attending and being discharged from acute medical units had no effect on patients' outcomes or subsequent use of secondary care or long term care.

Introductioncare home residents have high healthcare needs not fully met by prevailing healthcare models. This study explored how healthcare configuration influences resource use.Methodsa realist evaluation using qualitative and quantitative data from case studies of three UK health and social care economies selected for differing patterns of healthcare delivery to care homes. Four homes per area (12 in total) were recruited. A total of 239 residents were followed for 12 months to record resource-use. Overall, 181 participants completed 116 interviews and 13 focus groups including residents, relatives, care home staff, community nurses, allied health professionals and General Practitioners.Resultscontext-mechanism-outcome configurations were identified explaining what supported effective working between healthcare services and care home staff: (i) investment in care home-specific work that legitimises and values work with care homes; (ii) relational working which over time builds trust between practitioners; (iii) care which ‘wraps around’ care homes; and (iv) access to specialist care for older people with dementia. Resource use was similar between sites despite differing approaches to healthcare. There was greater utilisation of GP resource where this was specifically commissioned but no difference in costs between sites.Conclusionactivities generating opportunities and an interest in healthcare and care home staff working together are integral to optimal healthcare provision in care homes. Outcomes are likely to be better where: focus and activities legitimise ongoing contact between healthcare staff and care homes at an institutional level; link with a wider system of healthcare; and provide access to dementia-specific expertise.

Background: Care homes are the institutional providers of long-term care for older people. The OPTIMAL\ud study argued that it is probable that there are key activities within different models of health-care provision\ud that are important for residents’ health care.

Objectives: To understand ‘what works, for whom, why and in what circumstances?’. Study questions\ud focused on how different mechanisms within the various models of service delivery act as the ‘active\ud ingredients’ associated with positive health-related outcomes for care home residents.

Methods: Using realist methods we focused on five outcomes: (1) medication use and review; (2) use of\ud out-of-hours services; (3) hospital admissions, including emergency department attendances and length of\ud hospital stay; (4) resource use; and (5) user satisfaction. Phase 1: interviewed stakeholders and reviewed\ud the evidence to develop an explanatory theory of what supported good health-care provision for further\ud testing in phase 2. Phase 2 developed a minimum data set of resident characteristics and tracked their care\ud for 12 months. We also interviewed residents, family and staff receiving and providing health care to residents.\ud The 12 study care homes were located on the south coast, the Midlands and the east of England. Health-care\ud provision to care homes was distinctive in each site.

Findings: Phase 1 found that health-care provision to care homes is reactive and inequitable. The realist\ud review argued that incentives or sanctions, agreed protocols, clinical expertise and structured approaches to\ud assessment and care planning could support improved health-related outcomes; however, to achieve change NHS professionals and care home staff needed to work together from the outset to identify, co-design and\ud implement agreed approaches to health care. Phase 2 tested this further and found that, although there\ud were few differences between the sites in residents’ use of resources, the differences in service integration\ud between the NHS and care homes did reflect how these institutions approached activities that supported\ud relational working. Key to this was how much time NHS staff and care home staff had had to learn how to\ud work together and if the work was seen as legitimate, requiring ongoing investment by commissioners\ud and engagement from practitioners. Residents appreciated the general practitioner (GP) input and, when\ud supported by other care home-specific NHS services, GPs reported that it was sustainable and valued work.\ud Access to dementia expertise, ongoing training and support was essential to ensure that both NHS and care\ud home staff were equipped to provide appropriate care.

Limitations: Findings were constrained by the numbers of residents recruited and retained in phase 2 for\ud the 12 months of data collection.

Conclusions: NHS services work well with care homes when payments and role specification endorse the\ud im...

Background: older people are at an increased risk of adverse outcomes following attendance at acute hospitals. Screening tools may help identify those most at risk. The objective of this study was to compare the predictive properties of five frailty-rating scales. Method: this was a secondary analysis of a cohort study involving participants aged 70 years and above attending two acute medical units in the East Midlands, UK. Participants were classified at baseline as frail or non-frail using five different frailty-rating scales. The ability of each scale to predict outcomes at 90 days (mortality, readmissions, institutionalisation, functional decline and a composite adverse outcome) was assessed using area under a receiver-operating characteristic curve (AUC). Results: six hundred and sixty-seven participants were studied. Frail participants according to all scales were associated with a significant increased risk of mortality [relative risk (RR) range 1.6-3.1], readmission (RR range 1.1-1.6), functional decline (RR range 1.2-2.1) and the composite adverse outcome (RR range 1.2-1.6). However, the predictive properties of the frailty-rating scales were poor, at best, for all outcomes assessed (AUC ranging from 0.44 to 0.69). Conclusion: frailty-rating scales alone are of limited use in risk stratifying older people being discharged from acute medical units.

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Background sarcopenia is the loss of muscle mass and quality and is diagnosed using measures of muscle strength, size and mass. We evaluated the literature on whether sarcopenia measures are predictive of motor outcomes in older people in clinical settings. Methods electronic databases (MEDLINE Ovid, EMBASE, CINAHL and Web of Science) were searched for articles on measures of muscle mass, volume, thickness or strength, in older people in clinical settings, which reported cross-sectional or longitudinal associations with motor outcomes. Clinical cohorts included geriatric medical inpatients and outpatients, patients with hip fracture, geriatric rehabilitation and care home residents. Motor outcomes were mobility, falls, balance and activities of daily living (ADL). Due to high study heterogeneity, standardised mean differences were used to compare strength of associations. Results in total, 83 articles were identified. The most frequently studied measures were grip strength (47 studies), knee extension strength (21 studies) and bioelectrical impedance analysis (18 studies). Handgrip strength (HGS) had evidence for cross-sectional associations with mobility (14 of 16 studies, 2,088 participants), balance (6 of 6 studies, 1,177 participants) and ADL independence (10 of 11 studies, 3,228 participants), and evidence of longitudinal associations with mobility (3 of 3 studies, 883 participants) and ADL independence (7 of 10 studies, 1,511 participants). There was no conclusive evidence for association with falls. Conclusions HS was the most studied measure and was associated with mobility, balance and ADL outcomes. There was a paucity of studies, particularly with longitudinal follow-up, measuring muscle mass, volume or thickness using gold-standard approaches.

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IntroductionThis protocol describes a study of a quality improvement collaborative (QIC) to support implementation and delivery of comprehensive geriatric assessment (CGA) in UK care homes. The QIC will be formed of health and social care professionals working in and with care homes and will be supported by clinical, quality improvement and research specialists. QIC participants will receive quality improvement training using the Model for Improvement. An appreciative approach to working with care homes will be encouraged through facilitated shared learning events, quality improvement coaching and assistance with project evaluation.Methods and analysisThe QIC will be delivered across a range of partnering organisations which plan, deliver and evaluate health services for care home residents in four local areas of one geographical region. A realist evaluation framework will be used to develop a programme theory informing how QICs are thought to work, for whom and in what ways when used to implement and deliver CGA in care homes. Data collection will involve participant observations of the QIC over 18 months, and interviews/focus groups with QIC participants to iteratively define, refine, test or refute the programme theory. Two researchers will analyse field notes, and interview/focus group transcripts, coding data using inductive and deductive analysis. The key findings and linked programme theory will be summarised as context-mechanism-outcome configurations describing what needs to be in place to use QICs to implement service improvements in care homes.Ethics and disseminationThe study protocol was reviewed by the National Health Service Health Research Authority (London Bromley research ethics committee reference: 205840) and the University of Nottingham (reference: LT07092016) ethics committees. Both determined that the Proactive HEAlthcare of Older People in Care Homes study was a service and quality improvement initiative. Findings will be shared nationally and internationally through conference presentations, publication in peer-reviewed journals, a graphical illustration and a dissemination video.