title: A systematic review of integrated working between care homes and health care services.
abstract: BACKGROUND
  In the UK there are almost three times as many beds in care homes as in National Health Service (NHS) hospitals. Care homes rely on primary health care for access to medical care and specialist services. Repeated policy documents and government reviews register concern about how health care works with independent providers, and the need to increase the equity, continuity and quality of medical care for care homes. Despite multiple initiatives, it is not known if some approaches to service delivery are more effective in promoting integrated working between the NHS and care homes. This study aims to evaluate the different integrated approaches to health care services supporting older people in care homes, and identify barriers and facilitators to integrated working.
  
  
  METHODS
  A systematic review was conducted using Medline (PubMed), CINAHL, BNI, EMBASE, PsycInfo, DH Data, Kings Fund, Web of Science (WoS incl. SCI, SSCI, HCI) and the Cochrane Library incl. DARE. Studies were included if they evaluated the effectiveness of integrated working between primary health care professionals and care homes, or identified barriers and facilitators to integrated working. Studies were quality assessed; data was extracted on health, service use, cost and process related outcomes. A modified narrative synthesis approach was used to compare and contrast integration using the principles of framework analysis.
  
  
  RESULTS
  Seventeen studies were included; 10 quantitative studies, two process evaluations, one mixed methods study and four qualitative. The majority were carried out in nursing homes. They were characterised by heterogeneity of topic, interventions, methodology and outcomes. Most quantitative studies reported limited effects of the intervention; there was insufficient information to evaluate cost. Facilitators to integrated working included care home managers' support and protected time for staff training. Studies with the potential for integrated working were longer in duration.
  
  
  CONCLUSIONS
  Despite evidence about what inhibits and facilitates integrated working there was limited evidence about what the outcomes of different approaches to integrated care between health service and care homes might be. The majority of studies only achieved integrated working at the patient level of care and the focus on health service defined problems and outcome measures did not incorporate the priorities of residents or acknowledge the skills of care home staff. There is a need for more research to understand how integrated working is achieved and to test the effect of different approaches on cost, staff satisfaction and resident outcomes.
authors: Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, AL10 9AB, UK.
authors: Sue L
authors: SL
authors: Davies
authors: Claire
authors: C
authors: Goodman
authors: Frances
authors: F
authors: Bunn
authors: Christina
authors: C
authors: Victor
authors: Angela
authors: A
authors: Dickinson
authors: Steve
authors: S
authors: Iliffe
authors: Heather
authors: H
authors: Gage
authors: Wendy
authors: W
authors: Martin
authors: Katherine
authors: K
authors: Froggatt
mesh_terms: D019033:Delivery of Health Care, Integrated / Q000379:methods*; D006302:Health Services Research; D006299:Health Services for the Aged; D006699:Home Care Services; D010348:Patient Care Team; D010353:Patient Education as Topic; D011787:Quality of Health Care