title: Effective health care for older people living and dying in care homes: a realist review.
abstract: Care home residents in England have variable access to health care services. There is currently no coherent policy or consensus about the best arrangements to meet these needs. The purpose of this review was to explore the evidence for how different service delivery models for care home residents support and/or improve wellbeing and health-related outcomes in older people living and dying in care homes.
  
  
  
  We conceptualised models of health care provision to care homes as complex interventions. We used a realist review approach to develop a preliminary understanding of what supported good health care provision to care homes. We completed a scoping of the literature and interviewed National Health Service and Local Authority commissioners, providers of services to care homes, representatives from the Regulator, care home managers, residents and their families. We used these data to develop theoretical propositions to be tested in the literature to explain why an intervention may be effective in some situations and not others. We searched electronic databases and related grey literature. Finally the findings were reviewed with an external advisory group.
  
  
  
  Strategies that support and sustain relational working between care home staff and visiting health care professionals explained the observed differences in how health care interventions were accepted and embedded into care home practice. Actions that encouraged visiting health care professionals and care home staff jointly to identify, plan and implement care home appropriate protocols for care, when supported by ongoing facilitation from visiting clinicians, were important. Contextual factors such as financial incentives or sanctions, agreed protocols, clinical expertise and structured approaches to assessment and care planning could support relational working to occur, but of themselves appeared insufficient to achieve change.
  
  
  
  How relational working is structured between health and care home staff is key to whether health service interventions achieve health related outcomes for residents and their respective organisations. The belief that either paying clinicians to do more in care homes and/or investing in training of care home staff is sufficient for better outcomes was not supported.
authors.affiliation: Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, AL10 9AB, UK. c.goodman@herts.ac.uk.
authors.forename: Claire
authors.identifier: 0000-0002-8938-4893
authors.initials: C
authors.lastname: Goodman
authors.affiliation: Institute of Mental Health, University of Nottingham, Nottingham, UK.
authors.forename: Tom
authors.initials: T
authors.lastname: Dening
authors.affiliation: Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK.
authors.forename: Adam L
authors.initials: AL
authors.lastname: Gordon
authors.affiliation: Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, AL10 9AB, UK.
authors.forename: Susan L
authors.initials: SL
authors.lastname: Davies
authors.affiliation: School of Health Sciences, City University, London, UK.
authors.forename: Julienne
authors.initials: J
authors.lastname: Meyer
authors.affiliation: Division of Health and Social Care Research, Kings College London, London, UK.
authors.forename: Finbarr C
authors.initials: FC
authors.lastname: Martin
authors.affiliation: Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK.
authors.forename: John R F
authors.initials: JR
authors.lastname: Gladman
authors.affiliation: School of Health Sciences, City University, London, UK.
authors.forename: Clive
authors.initials: C
authors.lastname: Bowman
authors.affiliation: Department of Community Health Nursing and Health Studies, Brunel University, Uxbridge, UK.
authors.forename: Christina
authors.initials: C
authors.lastname: Victor
authors.affiliation: Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, AL10 9AB, UK.
authors.forename: Melanie
authors.initials: M
authors.lastname: Handley
authors.affiliation: School of Economics, University of Surrey, Guildford, UK.
authors.forename: Heather
authors.initials: H
authors.lastname: Gage
authors.affiliation: Department of Primary Care & Population Health, University College London, London, UK.
authors.forename: Steve
authors.initials: S
authors.lastname: Iliffe
authors.affiliation: School of Sociology and Social Policy & Centre for Dementia, Institute of Mental Health, University of Nottingham, Nottingham, UK.
authors.forename: Maria
authors.initials: M
authors.lastname: Zubair
mesh_terms: D000368:Aged; D004739:England; D005851:Geriatric Nursing; D006297:Health Services Accessibility; D006707:Homes for the Aged; D006801:Humans; D009313:National Health Programs; D010347:Patient Care Planning; D011787:Quality of Health Care; D013727:Terminal Care
keywords: Care home; Health outcomes; Long-term care; Older people; Realist review