What’s the problem?
Improving palliative and end of life care for care home residents is an urgent priority both in the UK and internationally. Whilst over half of care home residents die within the first year of admission, care home residents often experience poor care in their final weeks and months. Care home residents increasingly have multiple complex health needs and staff frequently report lacking confidence in providing end of life care. This often results in avoidable hospitalisations, sometimes leading to burdensome interventions, which can be distressing for care home residents and their relatives.
This study aims to improve palliative and end of life care by implementing an approach developed in Australia called ‘Palliative Care Needs Rounds’, or Needs Rounds for short. It aims to do this by reducing unnecessary hospitalisations, strengthening staff confidence and capability, and increasing advance care planning so that caring practices are aligned with resident needs, wishes, and preferences.
What are Needs Rounds?
Needs Rounds combined three things:
- monthly one-hour meetings where care home residents who are at risk of dying without a plan in place are discussed in turn to understand their needs as they approach the end of life. They are run by a senior clinician from a palliative care team (usually a nurse) and attended by several care home staff.
Needs Rounds involve discussing resident physical, psycho-social, and spiritual needs, and devising tailored action plans to address these. Needs Rounds often include education to help staff understand more about symptoms, deterioration, and how to look after people with life limiting conditions. - direct clinical care. This clinical work is triggered by discussions at the Needs Rounds meeting. Not all residents who are discussed will need to be seen by the specialist from the palliative care team, but it is part of the approach for those with complex needs.
- Multidisciplinary and family meetings. As with direct clinical work, sometimes it becomes clear in the Needs Rounds meeting that it would be helpful to have a broader group of people updated and involved in discussing next steps. A multidisciplinary meeting might include someone from primary care, or the hospital. A family meeting might be needed if there is disagreement or uncertainty from the person’s relatives about next steps.
The approach is always personalised, so the response will vary depending on the person’s needs.
Our Australian research involving 1700 care home residents showed a number of significant benefits. Using Needs Rounds resulted in a reduction in the number and length of hospitalisations which also led to substantial cost savings. Staff reported increased confidence and capability to provide end of life care leading to improved quality of death and dying for residents. Rates of advance care planning also increased. We aimed to replicate these positive outcomes by developing an adapted version of Needs Rounds that is responsive to care home settings in the UK.
About the study
The UK Needs Rounds study is funded by the National Institute of Health Research (NIHR). It aims to improve the lives and deaths of care home residents by creating a UK model of Needs Rounds.
The research team, led by Prof Liz Forbat at University of Stirling, is working with 6 hospices and 29 care homes across England and Scotland. In July 2021, the sites started implementation of the three components of the intervention:
- Monthly clinical meetings with a hospice nurse and care home staff, to discuss residents who they would not be surprised if they died in the next year. These meetings offer a chance to talk through physical and psychological symptoms, medications, and advance care plans. The hospice staff also weave in some education based around the residents that care homes are worried about.
- Clinical work with residents: after discussing residents in a Needs Rounds clinical meeting, the hospice nurse can conduct clinical assessments with the resident to help inform decisions about care.
- Supporting family meeting (with care home staff and relatives) to discuss care, or multidisciplinary team meetings with other health/social care professionals.
Study timeline
The study is split into two phases: in phase 1, we collected information to help us create a UK model of Needs Rounds and in phase 2 we introduced Needs Rounds. We are currently evaluating their impact.
Phase 1: data collection and designing the UK model of Needs Rounds
- Interviews conducted between February – April 2021 with care home staff, relatives, palliative care specialists, and other health care practitioners supporting palliative and end of life care;
- Workshops to co-design and refine a UK model of Needs Rounds held in April and June 2021, and May 2022. The model was developed in partnership with care homes, hospices, and our patient and public involvement and engagement representatives.
Phase 2: implementation and evaluation
Needs Rounds were implemented in 29 care homes for up to 12 months between July 2021 and June 2022.
Interventions routinely fail to change practice so we are using an implementation science approach to try and address this. We want to understand what elements of Needs Rounds work, for whom, in what circumstances and why, in the English and Scottish context.
Evaluation is ongoing and is based on the following methods:
- Interviews conducted at months 4, 8, and 12 of implementation;
- Questionnaires with staff and family members to measure staff capability, quality of death/dying, and family perceptions of care;
- An economic evaluation to understand the costs and benefits of Needs Rounds;
- Recordings of Needs Rounds to assess if they are being used in the way intended;
- Analysis of resident data on health service use and hospitalisations;
- An evaluation of Patient and Public Involvement to identify successes and challenges to inform future learning.
We are currently awaiting permission from the funder to circulate the final report.
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