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Case study: Conducting falls prevention research in a care home setting

Community settings such as care homes and pharmacies offer unique opportunities to deliver research.

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Clinical need

For research to be relevant it has to be representative of the target population. In the UK a significant per cent* of elderly people live in care homes so it’s important that care home residents are given opportunities to participate in research, and that researchers consider care homes in their recruitment strategies. This case study describes how the NIHR and the UK’s network of research-ready care homes helped deliver the FinCH study in a care home setting.

Falls are one of the leading causes of death and injury in people over the age of 65. Studies have shown that care home residents fall five times more often than elderly frail people living in their own homes. Of those residents who fall:

  • nearly 1 in 10 suffer a broken bone
  • 1 in 5 is admitted to hospital
  • 1 in 5 will die within the year as a result of this injury.

As well as these people suffering pain, immobility and fear of further falls, there are high financial costs for the NHS. For example, hip fractures cost the NHS approximately £1.4 billion per annum and the number of fractures is expected to double by 2050.
 
Pip Logan is Professor of Rehabilitation Research at the University of Nottingham and the Chief Investigator for the FinCH study, she summarises the wider impact that a fall can have on an elderly individual:
 
“A fall can often lead to sustaining a serious fracture, or develop a fear of falling, which is associated with activity restriction, increased hospital admissions and associated depressive symptoms. Therefore, having a fall, can severely affect the quality of people’s later life and we are keen to find ways to prevent this happening.
 
Professor Logan is also keen to emphasise the importance of conducting research in a care home setting:
 
“Care home research has been underrepresented in the past. Therefore, taking the opportunity to broaden our engagement with care homes to help understand the complexities they face on a day to day basis, often with limited support, was something we were very keen to embark on”.

About the FinCH study

The NHS provides falls prevention interventions, however the success of these traditional interventions is questionable in the care home setting. This is because 80% of residents are cognitively impaired and unable to engage fully, often due to reduced memory function. In response, the Guide to Action Care Home (GtACH) falls prevention programme was developed by University of Nottingham researchers in conjunction with care home and NHS staff.
 
GtACH is based on NICE clinical guidelines but offers a unique approach designed specifically for care homes. It involves falls prevention experts, usually employed by the NHS, training care home staff in small groups to systematically assess residents fall risk, and then provide actions to reduce falls risks.
 
The FinCH study is funded by the NIHR and it’s primary aim is to compare the number of falls in care homes where staff are trained to use the GtACH process with homes that are providing usual care. But FinCH also looks at a number of other outcomes over a longer 12 month period for each participant. Professor Logan explains:

“Our main outcome of interest is falls rates, but we are looking at fractures, quality of life, activities of daily living and mobility as these are areas our participants have highlighted they are important. A process evaluation alongside is exploring how the care home staff are trained and implementing the Guide to Action to Prevent Falls to help with implementation in the future.”
 
The  data is currently being analysed and will also be used to conduct a cost-effectiveness and utility analysis from both an NHS and a personal social service perspective. The results will be disseminated to care home practices, residents, their families and carers as well as at professional conferences and in journal articles.

NIHR impact: Clinical Research Network and ENRICH

The FinCH study originally set out to recruit 1308 care home residents at 66 care homes. However,  by the time the study closed in June 2018, more than 1800 participants had enrolled in the study at 87 sites. These were spread across Nottinghamshire, Lincolnshire, Norfolk, Yorkshire, Derbyshire, Leicestershire, Staffordshire, Hampshire, Norfolk and Northumberland and involved eleven different NHS trusts (sites) in total.

Six of the NHS trusts are within NIHR East Midlands Local Clinical Research Network’s (LCRN) region,  which is also where Professor Pip Logan is based. Karen Pearson is a Research Delivery Manager for East Midlands LCRN, she recalls supporting Professor Logan to engage a number of care homes in the study:

“I initially made contact with Professor Pip Logan prior FinCH opening to talk to her about ENRICH - an NIHR-funded initiative designed to ensure that care home residents have opportunities to take part in clinical health and social care research. It does this in a number of ways. For care homes it provides guidance on how to become involved with research, and how to prepare for it, including practical tools such as contract templates. For residents and family members it provides resources explaining why research is important and how to participate. For researchers it provides opportunities to collaborate and consult with care home staff on ideas or proposals  and a mechanism for disseminating research opportunities and findings to a network of over 850 research-ready care homes.

“I explained to Professor Logan how we had care homes across the region set up and ready to undertake research and suggested potential sites that could help deliver this study. At that point Professor Logan already had a number of sites lined up, however, we monitored performance of the study and an opportunity soon arose for us to work with Professor Logan to identify some new care homes to support the study. We then made sure the necessary resources were in place to deliver the study.”

In the case of the FinCH study,  ‘resources’ primarily meant research support staff to help set-up and facilitate the study. Clare Litherland is a Research Delivery Nurse at East Midlands LCRN. She helped to get the study up and running at two NHS sites in Nottinghamshire. Clare believes the ENRICH initiative played a key role in the recruitment success:

I helped to engaged 24 care homes to support the FinCH study.

“I helped to engaged 24 care homes to support the FinCH study. Twelve of these are in Nottinghamshire Healthcare NHS Foundation Trust which recruited 433 participants, and 12 of them come under Nottingham City NHS Clinical Commissioning Group (CCG), which recruited 76 patients. The 24 care homes included a mixture of sizes; from small private care homes to large corporate care homes.

“Getting the sites on board was made  easier because we have an ENRICH group spanning Nottinghamshire and Derbyshire  which holds an ENRICH Forum meeting four times a year. There are usually between 60 - 100 people from care homes in attendance and it is a great opportunity to talk about upcoming studies, share good practice from ongoing studies, and generally get feedback and ideas from care home staff.

“We have a good relationship with this group as we have done several studies in care homes already, including  OPTIMAL, MARQUE, and PEACH. I went along to talk about FinCH and people were keen to participate as preventing falls is such a big topic. We quickly collated expressions of interest and began following up with individual care homes.

“As with most studies there were a few challenges at the outset. FinCH is an ambitious study in that it is quite a large and complex study to set-up. In addition to organising the training sessions for staff, we had to factor in that we were enrolling participants from a vulnerable population. Sometimes consent had to be sought from next of kin, for example from family members of participants with dementia. However, we knew this from the beginning and we worked together with the study team to get all the procedures in place for each individual care home. All of this hard work was underpinned by our excellent working relationships with the care homes."

Professor Logan agrees and reflects on what was achieved:

Having the support from the East Midlands LCRN and ENRICH was essential to the success of this study

“Having the support from the East Midlands LCRN and ENRICH was essential to the success of this study, which is the largest care home study in the country. The expertise, access to groups of care homes, research trained staff who are keen to recruit hard to reach participants and work the extra mile has produced a study with over 90 per cent of completed data collected on time and to target. It has been a real pleasure to lead this trial. By having the NIHR Clinical Research Network and ENRICH teams working alongside the grant-funded research team, the benefits have been both ways - with real integration of ideas and satisfaction”

*https://www.gov.uk/government/publications/care-homes-market-study-summary-of-final-report/care-homes-market-study-summary-of-final-report - approx 6 per cent in 2017

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