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Better Health in Residents in Care Homes


This study aims to develop and test a complex intervention to reduce rates of avoidable hospital admissions from nursing homes.

A lot of people go to hospital for conditions that could have been treated in the care home. These avoidable hospital admissions are often for:

  • Acute exacerbation of congestive heart failure
  • Respiratory infections
  • Urinary tract infection
  • Dehydration

Hospitalisation is costly to the NHS and can be distressing to the person, their family and nursing home staff. Nursing home residents are amongst the frailest and most vulnerable members of society. Most have complex health care needs and more than two thirds have dementia. Early identification of changes in residents’ health is essential to ensure active health care in nursing homes.

There are ways to improve health care in care homes:

  • Education for nurses and care assistants
  • Care protocols and pathways
  • Family involvement
  • Support for making change happen

Nursing home staff want their residents to get timely medical and health care. They don’t like to see their residents going to hospital for conditions that could have been cared for in the home, if detected and reported earlier. We want to develop and test a complex intervention to reduce rates of avoidable hospital admissions from nursing homes.

It is funded by a National Institute for Health Research programme grant. The study started on June 1 2015 and will last 3 years and 3 months. Information will be gathered in London and in West Yorkshire.

Patient and Public Involvement (PPI)

There are different levels of Patient and Public Involvement (PPI) in the project. They include:

Carer Reference Panels

Each PPI co-applicant, Shirley Nurock and Dr Barbara Woodward-Carlton, chairs one of two Carer Reference Panels for the project, in London and Yorkshire respectively. These panels are composed of people who have or have had family members living in care homes.

The Carer Reference Panels provide an additional level of oversight of the project and provide advice. The next meeting is of the London Panel in June 2018.

Residents’ advice

We will be consulting about our study with five residents currently living in care homes.

International Advisory Group

A PPI representative has joined the International Advisory Group for the project, providing a strategic project overview level. The addition of PPI representation has greatly strengthened the work of this group, which is composed primarily of academics and management-level healthcare/care home staff.

Pilot Trial launch events

Members of the Carer Reference Panels have been invited to attend launch events in the care homes which are participating in our Pilot Trial. These will create an opportunity for Panel members to help with recruitment and to answer any questions about the Trial, particularly from the perspective of family involvement. Panel members have provided invaluable input to the information sheets and briefing notes that we will use at these events.

Data analysis

Carer Reference Panel members have been invited to assist with analysing interview data at a later stage of the Pilot Trial.  We have held workshops at meetings in London (above) and Yorkshire where we presented an overview of qualitative data analysis and framework analysis, which is the approach being used in the BHiRCH project.

We are working with the Carer Reference Panels to evaluate the PPI involvement aspect of the BHiRCH study.  We will draw on Panel members' prior experiences and perspectives of PPI involvement and initial experiences of getting involved in the BHiRCH study.  We will complete two reviews across the life of the study: at the end of the Feasibility study and after the Pilot study.  The evaluation will form part of the final report to NIHR (study funder).

Key achievements

In the first year of the BHiRCH project we developed an intervention intended to improve the health of care home residents, and reduce avoidable hospital admissions.

We collected evidence to inform the intervention:

  • Feedback from academic and health care experts about the proposed Care Pathway
  • Interviews with key informants such as care home staff and care professionals, about the knowledge and skills that are required for care home staff to detect and manage changes in health conditions before any significant deterioration
  • Interviews with family carers about how they are involved in care homes
  • Literature reviews to inform each component of the intervention
  • Consensus workshops were held in August, October and December 2015. These involved family carers, care home professionals and primary care professionals.  We sought advice and reached consensus on each component of the intervention

Final development of the complex intervention

In the second year of the project the team finalised the intervention, which includes assessment and diagnostic tools for the four conditions that people are most likely to be admitted to hospitals when it was avoidable.

Feasibility Study

The Feasibility Study began in two care homes in October 2016 and ended in February 2017.  During the study we:

  • Tested study procedures in preparation for a Pilot Trial
  • Examined whether our approach to data collection was feasible
  • Identified refinements that were needed to the intervention and implementation support

Pilot Trial

We received full ethical approval for the Pilot Trial in October 2017 and began recruiting participants in 13 care homes in November 2017.  We finished recruitment in January 2018 and are delighted to have recruited 488 individuals across the 13 homes.

Above: Number of people recruited

We have completed the collection of baseline data and are now collecting on a monthly basis follow-up data in each of the 13 homes.

We have recruited two members of nursing staff - 'Practice Development Champions' - from each of the care homes allocated to receive the intervention, who will train, support and work alongside nurses and care staff to ensure effective introduction and embedding of the intervention. Members of the research team have begun monthly telephone calls to support the champions in the implementation of the intervention.

BHiRCH International Advisory Group

The International Advisory Group consists of academics and expert professionals in health and social care. We seek their advice at regular intervals throughout the project. 

The Group is chaired by Professor Finbarr Martin (Kings College London) and members comprise:

  • Jenny Adams, University of Bradford
  • Professor Barbara Bowers, University of Wisconsin
  • Professor Lynn Chenoweth, University of New South Wales
  • Professor John Gladman, University of Nottingham
  • Professor Claire Goodman, University of Hertfordshire
  • Professor Martin Green, Care England
  • Professor Raymond Koopmans, UMC St Radbound University
  • Professor Julienne Meyer, My Home Life / City University London
  • Professor Des O'Neill, Trinity College Dublin
  • Professor Joseph Ouslander, Florida Atlantic University
  • Dr Hilary Rhoden, PPI (Public and Patient Involvement)
  • Professor Graham Stokes, BUPA Care Services
  • Louise Taylor, Park Lodge Care Home
  • Gavin Terry, Alzheimer's Society
  • Stephen Williams, University of Bradford

Individual members of the IAG have visited us in person to offer advice and support including:

  • Professor Barbara Bowers of the University of Wisconsin at Madison, USA provided us with helpful advice about making sure that the care homes and staff who participated in the study were rewarded for their participation.  Professor Bowers has played a leading role in evaluation of the Green House model of long-term care and provides advice to the US government on its care home policy development
  • Professor Lynn Chenoweth, Professor of Nursing at the University of New South Wales in Australia, came to Bradford and advised us to consider the staff’s perspective on working with families as well as families’ perspective on working with care home staff.

Project team