Community care for severely frail older people: Developing explanations of how, why and for whom it works

Abstract

Background A Community Wellness Team was implemented in North East England in 2014, in line with national policy directives to support frail older people in the community. The service provides a comprehensive and integrated care package, which aims to reduce avoidable admissions, inappropriate service use and enable patients to stay at home. Design A realist design combining a review of the literature and primary data collection from service providers and patients was used to develop programme theories explaining the links between the Team interventions and expected outcomes. Results Five programme theories were developed, detailing: trust development and relationship building; risk minimisation in the home environment; advice on self‐management; referral to preventative services; and coordination of services. Discussion The programme theories explain the role and impact of the Community Wellness Team. These programme theories are interrelated and impact one another; a hypothesised progression of programme theories indicating how the Community Wellness Team “works” is discussed. Of particular importance was the comprehensive initial assessment, which leads to the alteration of the social and physical environment within which older people live. Conclusion Severely frail older people present cases that are complex socially, medically, financially and environmentally. In order to meet these needs, the Team coordinators are adopting a complex and flexible person‐centred approach. Implications for Practice This study paves the way for further research into the care networks surrounding severely frail older people living in the community, and how they can most effectively be implemented.

Rapid evidence review to understand effective frailty care pathways and their components in primary and community care

“…They evaluated either pathway processes (whether pathways are carried out as planned), pathway determinants (barriers to and enablers of pathway implementation) and/ or pathway implementation (reach, adoption, adaptions to, maintenance and sustainability of pathways). Three of these studies had an overall low-EPPI weight (Bryce et al, 2018;Lhussier et al, 2019;Stoop et al, 2019) and one had a medium weight (Berntsen et al, 2019). Berntsen et al's (2019) literature review described how literature on whole system transformations of frailty pathways reflects (1) operationalisation of interventions, (2) maturity, (3) evaluation methodology and (4) effect on outcomes.…”

“…PACT consists of guidance for primary-care services regarding screening, CGA, person-centred care planning and medication review. Lhussier et al's (2019) study aimed to develop a theory explaining the links between outcomes and a community wellness team (CWT) pathway consisting of referral to the CWT via screening, care coordination, management plans, MDT input, referral to preventative services, advice on selfmanagement and risk minimisation in the home. Stoop et al's (2019) study explored the improvement plans of the 14 European sustainable tailored integrated care for older people in Europe (SUSTAIN) sites.…”

“…(2018) used a mixed-methods evaluation using normalisation process theory to explore determinants and implementation barriers and enablers. Using a realist evaluation approach, Lhussier et al (2019) used a literature review and focus group to explore determinants of CWT success. Stoop et al (2019) explored determinants by using content analysis of baseline reports, projects plans, project flow charts; interviews with older people, carers and professionals using the SUSTAIN services; researcher field notes; workshop meeting minutes and templates for site and improvement plan descriptions.…”

“…The studies identified processes, determinants and implementation requirements to support successful pathway operation. These were all stakeholders including patients need to be clear about the aims of the pathway (Bryce et al, 2018); policies and procedures are required to support implementation of pathways (Stoop et al, 2019); workforce development is required to ensure staff's competency and capacity to effectively implement pathways (Bryce et al, 2018;Stoop et al, 2019); development of rapport and trusting therapeutic relationships between professionals and patients are required to support pathway delivery (Lhussier et al, 2019); pathways need to be championed by effective leaders and early adopters (Berntsen et al, 2019;Bryce et al, 2018); information sharing across professions, organisations and sectors is essential (Berntsen et al, 2019;Stoop et al, 2019) and adequate funding is required to resource pathways (Stoop et al, 2019). However, Berntsen et al's (2019) Frailty care pathways in care services literature review concludes that with regard to championing pathways and information sharing, there is a lack of hard evidence underpinning these results due to weaknesses in process evaluation.…”

The Over 75 Service: Continuity of Integrated Care for Older People in a United Kingdom Primary Care Setting

“…Home visits were conducted as part of initial assessments by the practice matrons, in response to a crisis or on a more impromptu basis. A comprehensive initial assessment, has been judged of particular importance in other studies on integrated primary care for older people [29]. This care setting was important in establishing and maintaining relational continuity both from a user and professional perspective as it was felt that the environment led to the relationship being less hierarchical and medically-dominated.…”