Authors' objectives: Care home residents often lack access to end-of-life care from specialist palliative care providers. Palliative Care Needs Rounds, developed and tested in Australia, is a novel approach to addressing this. To co-design and implement a scalable UK model of Needs Rounds. Despite high levels of morbidity and mortality, care home (CH) residents do not always have adequate access to specialist palliative care (SPC). Residents can experience uncontrolled symptoms, poor-quality deaths and futile/burdensome hospitalisations. CH staff can feel unprepared and unsupported to look after residents at end of life. Although models exist for improving end-of-life care in CHs, these are primarily focused on education and do not adequately triage residents to focus on those most at risk of dying without a plan in place and rarely integrate clinical care. A clinical innovation in Australia called ‘Palliative Care Needs Rounds’ (hereafter ‘Needs Rounds’) combines triaging, with anticipatory person-centred planning, case-based learning and case conferencing. The approach has been synthesised into a checklist to provide guidance to clinicians running Needs Rounds. In Australia, Needs Rounds reduced length of stay in hospital and number of admissions, increased dying in preferred place, improved symptoms at end of life and normalised death/dying to CH staff. CH staff felt more confident looking after the residents. Preventing hospital admissions saved AUD$1.7 million over a year (nearly £1 million). The implementation objectives were to: co-design a UK version of Needs Rounds, which is responsive to different contextual characteristics of the UK CH sector (Phase 1) implement the adapted model of care, assess feasibility, acceptability and effectiveness and ultimately propose how the model of care can be further refined and adopted in the UK context, to reap the benefits demonstrated in the Australian work (Phase 2). The intervention objectives were to: determine the transferability of the core elements of the Australian Needs Rounds intervention in the UK context (Phase 1 and 2) delineate the mechanisms of action that enable more effective palliative and end-of-life care practices to be applied in UK CHs (Phase 2) identify the relationships between (1) the mechanisms of action embedded in Needs Rounds, (2) how these mechanisms function in different CH contexts and (3) the outcomes arising for different stakeholders and parts of the care system (Phase 2). The process evaluation objectives were to: document the outcomes of UK Needs Rounds on hospitalisations (including costs), quality of death/dying and CH staff capability (Phase 2) assess and report the perspectives of CH residents, relatives, CH staff and palliative care staff on using UK Needs Rounds (Phase 2).

Authors' results and conclusions: The programme theory: while care home staff experience workforce challenges such as high turnover, variable skills and confidence, Needs Rounds can provide care home and specialist palliative care staff the opportunity to collaborate during a protected time, to plan for residents’ last months of life. Needs Rounds build care home staff confidence and can strengthen relationships and trust, while harnessing services’ complementary expertise. Needs Rounds strengthen understandings of dying, symptom management, advance/anticipatory care planning and communication. This can improve resident care, enabling residents to be cared for and die in their preferred place, and may benefit relatives by increasing their confidence in care quality. Our work suggests that Needs Rounds can improve the quality of life and death for care home residents, by enhancing staff skills and confidence, including symptom management, communications with general practitioners and relatives, and strengthen relationships between care home and specialist palliative care staff. Phase 1: five theories were generated focusing on (1) Confidence and competence, (2) reducing hospitalisations, (3) interagency working and collaboration, (4) better-quality lives and deaths and (5) supporting families. These were integrated to produce one initial overarching initial programme theory to be tested during implementation. Needs Rounds improve palliative and end-of-life care for CH residents by enhancing staff skills and confidence, communication between CH staff and GPs and relationships with SPC clinicians. Needs Rounds result in more proactive support for residents and communications with families. These findings complement the robust evidence base on Needs Rounds in Australia. The facilitation approach was central to implementation. Needs Rounds worked well when SPC clinicians and CH staff adopted a collaborative, partnership approach and recognised and used complementary expertise to improve the quality of lives and deaths of residents.

Authors' recommendations: Enhancing the UK evidence for Needs Rounds would involve calculating the cost–benefit analysis and treatment effect. Future research could examine how Needs Rounds run alongside primary care. Semistructured interviews exploring families’ and residents’ perspectives of UK Needs Rounds would provide a fully rounded account of the impact of the approach to care, which was not possible given the limitations of COVID-19 during this study. A follow-up study evaluating how much knowledge and learning is retained and applied by those attending Needs Rounds would provide evidence regarding the long-term impact on staff, including staff moving to different CH providers.

Authors' methods: A pragmatic implementation study using the integrated Promoting Action on Research Implementation in Health Services framework. Implementation was conducted in six case study sites (England, n = 4, and Scotland, n = 2) encompassing specialist palliative care service working with three to six care homes each. Phase 1: interviews (n = 28 care home staff, specialist palliative care staff, relatives, primary care, acute care and allied health practitioners) and four workshops (n = 43 care home staff, clinicians and managers from specialist palliative care teams and patient and public involvement and engagement representatives). Phase 2: interviews (n = 58 care home and specialist palliative care staff); family questionnaire (n = 13 relatives); staff questionnaire (n = 171 care home staff); quality of death/dying questionnaire (n = 81); patient and public involvement and engagement evaluation interviews (n = 11); fidelity assessment (n = 14 Needs Rounds recordings). (1) Monthly hour-long discussions of residents’ physical, psychosocial and spiritual needs, alongside case-based learning, (2) clinical work and (3) relative/multidisciplinary team meetings. A programme theory describing what works for whom under what circumstances with UK Needs Rounds. Secondary outcomes focus on health service use and cost effectiveness, quality of death and dying, care home staff confidence and capability, and the use of patient and public involvement and engagement. Semistructured interviews and workshops with key stakeholders from the six sites; capability of adopting a palliative approach, quality of death and dying index, and Canadian Health Care Evaluation Project Lite questionnaires; recordings of Needs Rounds; care home data on resident demographics/health service use; assessments and interventions triggered by Needs Rounds; semistructured interviews with academic and patient and public involvement and engagement members. COVID-19 restricted intervention and data collection. Due to an insufficient sample size, it was not possible to conduct a cost–benefit analysis of Needs Rounds or calculate the treatment effect or family perceptions of care. A pragmatic critical-realist implementation study using the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. We determined what works, for whom and in what circumstances for the UK Needs Rounds model. Implementation was conducted in six case studies, where a case is defined as a SPC service working with three to six CHs each. Phase 1: development of an initial programme theory Inclusion criteria: SPC or CH staff in one of the six sites; residents or relatives of someone residing in one of the CHs; worked in a role supporting CHs (acute care, the ambulance service or primary care); and had capacity to consent. Participants and methods: stakeholder interviews (n = 28) across the six cases were used to develop an initial programme theory. Subsequently, we ran four online workshops to co-design UK Needs Rounds with key stakeholders (n = 43). Analysis: Inductive thematic analysis was applied to the interview data, using NVivo for coding. Integrated Promoting Action on Research Implementation in Health Services informed subsequent deductive analysis, categorising the data into contexts, mechanisms, outcomes and innovation components. Chains of inference were identified, and context, mechanism, outcome configurations generated. Outputs: Five theories and an initial programme theory to be tested during implementation. Key contextual factors impacted implementation of Needs Rounds and data collection. Needs Rounds delivery took place during 2021–2 when COVID-19 lockdowns continued to occur both locally and nationally, which significantly impaired implementation. This resulted in core parts of the intervention not working, namely the case conferences with family members and multidisciplinary team meetings. COVID-19 also reduced the amount of data returned for analysis; the resulting small sample sizes limited the power of claims we can draw from the data.

Project Status: Completed

URL for project: https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/NIHR128799

Year Published: 2024

URL for published report: https://www.journalslibrary.nihr.ac.uk/hsdr/KRWQ5829

URL for additional information: English

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: England, United Kingdom

DOI: 10.3310/KRWQ5829

Organisation Name: NIHR Health Services and Delivery Research programme

Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK

Contact Name: journals.library@nihr.ac.uk

Contact Email: journals.library@nihr.ac.uk