On National Care Home Open Day (#NCHOD), Jacquetta Holder and David Jolley (PSSRU University of Kent and PSSRU University of Manchester) discuss their review of the evidence on residents’ health outcomes following nursing home closures.
Care homes play a crucial role in the range of health, housing and social care services available to older people. The risk that involuntary moves between care homes put residents’ health and lives at risk is a serious concern. It is frequently voiced in the national press, and has led to relatives making legal challenges and also been the focus of considerable research over the last 50 years. While there are moves to improve market oversight nationally and locally, closures are likely to continue to be a feature of the care home market as a result of service development, the market mechanism and regulatory action.
Outcomes of relocated residents: mortality, physical health and wellbeing
Our review of the recent (between 2000- 2012) literature about the impact of collective relocation on nursing home residents’ health confirmed that the evidence continues to be mixed.
Ill-planned or casually implemented closures and relocations are stressful and linked to adverse outcomes in terms of symptoms, health and survival. Yet when, carefully planned and managed, closures are linked to better outcomes than disorderly relocations. Moves to higher quality settings are also associated with improved outcomes.
Only 10 studies were found that reported health outcomes following the collective relocation of older people in long term care settings. The studies included a range of research designs and contexts, including planned and emergency moves, and moves due to relocation to newer facilities and moves due to a hurricane. The studies also included a variety of outcome measures and different follow-up periods.
Of the 10 studies reviewed in detail, six reported mortality, four physical health changes, and eight psychological changes. Negative outcomes were reported in nine studies, positive outcomes in five studies, and a mixture of both negative and positive changes in health was reported in four studies. Five studies found only negative outcomes and one study found only positive outcomes. Mortality rates following relocation ranged from 0 to 43%, with three of the six studies which reported mortality rates, reporting increased deaths. Other reported negative outcomes include increased falls, depression, pressure sores, hospital transfers, and prescription of antipsychotics, as well as reduced cognition, communication, and social engagement or functioning. Reported positive outcomes included no change in mortality rate, physical or mental health, or quality of life, reduced falls and use of restraint, and increased social contact, community access and psycho-social wellbeing.
What is known about good practice?
The review also looked at literature on managing the care home closure process, initial moves to long-term care and moves between care homes and hospitals. The Association of Adult Social Services (ADASS) and the Social Care Institute for Excellence (SCIE) have jointly published good practice recommendations (pdf) in 2011 for councils to support older people during residential care closures and the Social Care Association (2011) has also recently updated their guidance. Health and social care professionals involved in planning and implementing care home closures should draw on such guidance, alongside good practice knowledge about supporting individual transitions because much of it is likely to be relevant to mass moves. For example, the importance of effective communication and information transfer between professionals, and of providing older people and their families and representatives with information, support and advice on how to select an appropriate new provider irrespective of their funding, and recommendations to support adaptation after a move.
What should future work focus on?
The recent review of the literature suggests that more work is needed to communicate and develop guidance as well as good practice with care home providers so that closure plans are embedded, and not just sought out in response to a crisis that limits the time available for deliberation and joined up working. Older people and relatives moving to a care home should be made aware of the possibility of forced relocation and of the sort of support they can expect should it happen.
It would be timely to acknowledge that the question of whether forced relocation between nursing homes causes negative outcomes cannot be established in a way that overcomes all the methodological challenges involved. Instead, it would useful for future research to focus on what constitutes good relocation and transfer, what good practice should be trying to achieve in terms of process and outcome, and what elements of preparation work. There is a lack of research, for example, into outcomes tied to residents’ and relatives’ preferences, the effects of relocation on family and social networks, social life, social capital, participation in the community and social well-being.
Holder J, Jolley D (2012) Forced relocation between nursing homes: residents’ health outcomes and potential moderators, Reviews in Clinical Gerontology, 22, 301-319.
Glasby J, Robinson S, Allen K. (2011) Achieving Closure: Good practice in supporting older people during residential care closures, Health Services Management Centre, University of Birmingham and the Association of Directors of Adult Social Services, in association with the Social Care Institute for Excellence, Birmingham and London.
Social Care Association (2011) Managing Care Home Closure, Social Care Association, New Malden.