Table 3.

Studies included in the systematic review of integrated working between care homes and health care services:

First Author, Year Title Study design	Research Question/aims and objectives	Study population, setting and country of study	Sample size/number of participants: Include power calculation if available	Description of intervention/ Study design	Main outcome variable(s)/ Areas of focus for qualitative studies	Main findings/ Conclusions
1. King, 2001 Multidisciplinary case conference reviews: improving outcomes for nursing home residents, carers and health professionals Controlled study	To determine whether multidisciplinary case conference reviews improved outcomes for nursing home residents and its impact on care staff.	Population: Older people in nursing homes Setting: 3 nursing homes Country: Australia	245 older people But only 75 residents were reviewed	Weekly case conference reviews, one review per resident, over 8 months attended by GPs, clinical pharmacist, senior nursing staff and other health professionals. Multidisciplinary discussion of all aspects of a resident's care to make recommendations and devise a management plan for the resident. Reviews were led by GPs with data collection by the pharmacist. Baseline and endpoint comparisons were made between residents who were reviewed and those who were not.	Resident outcomes included: medication use, administered medications and weekly cost, health status and quality of life. Carer outcomes were based on resident interaction, workload or personal/professional satisfaction.	• There were no significant reductions in medications orders, cost and mortality. 40% of the recommendations benefited residents, measured through their health status and quality of life. 26% of the recommendations benefited care staff, but no details were given. Multidisciplinary case conferences were seen as beneficial to patients and carers. Their future use was recommended.
2. Llewellyn-Jones, 1999 Multifaceted shared care intervention for late life depression in residential care: randomised controlled trial. RCT	To evaluate the effectiveness of a population based multifaceted shared care intervention for late life depression in residential care.	Population: Older people 65 years + with depression and no or low cognitive impairment Setting: Residential facility living in self care units and hostels not nursing homes (equivalent to residential care in UK) Residents were stratified and randomised to intervention or control Country: Australia	220 older people No power calculation	The shared care intervention included: 1. Multidisciplinary consultation and collaboration 2. Training of gps and carers in detection and management of depression 3. Depression related health education and activity programmes for residents. The control group received routine care.	Geriatric Depression Scale	There was a significant reduction in adjusted depression scores for residents in the intervention group. Multidisciplinary collaboration, staff education, health education and activity programmes can improve depression in older people in residential care.
3. Opie, 2002 Challenging behaviours in nursing home residents with dementia: a randomised controlled trial of multidisciplinary interventions. RCT	To test whether individually tailored psychosocial, nursing and medical interventions to nursing home residents with dementia will reduce the frequency and severity of behavioural symptoms.	Population; Nursing home residents with severe dementia rated by staff as having frequent, severe behavioural disturbances. Setting: 42 Nursing homes Country: Australia	102 older people entered the study, (99 completed the 4 week trial, 2 RIPs 1 hospitalisation)	Residents selected on basis of CMAI scores and assigned to early or late intervention groups. Consultancy team with training in psychiatry, psychology and nursing met weekly for 30 minutes, to discuss referrals and formulate individualised care plans which were presented to nursing home staff to implement. Plans were reviewed at one week. 3 categories: medical, based on medication review, nursing, based on ADLs, and psychosocial including environment, sensory stimulation. The control was normal care, residents acted as their own controls by being in the early or late intervention groups.	Frequency and severity of disruptive behaviours and assessment of change by senior nursing staff. Tools included: Cohen-Mansfield Agitation Inventory (CMAI) which assesses frequency of 30 behaviours over previous 14 days Behaviour Assessment Graphical System (BAGS) which records a combined frequency and disruption score every hour for 24 hours.	There was a slight reduction in the daily observed counts of challenging behaviours. Individualised, multidisciplinary interventions appear to reduce the frequency and severity of challenging behaviours in nursing homes
4. Schmidt, 1998 The Impact of Regular Multidisciplinary Team Interventions on Psychotropic Prescribing in Swedish Nursing Homes RCT	To evaluate the impact of regular multidisciplinary team interventions on the quantity and quality of psychotropic drug prescribing in nursing homes Aim was to improve prescribing through better teamwork amongst physicians, pharmacists, nurses and nursing assistants	Population: Long term residents, 42% dementia, 5% psychotic disorder, 7% depression Setting: 33 Nursing homes Country: Sweden	1854 residents In 15 experimental homes and 18 control homes	Regular multidisciplinary team meetings over 12 months to discuss individual residents drug use. Training was provided for pharmacists but not for other staff. Control homes provided normal care.	Baseline and 12 month post resident medications	After 12 months the intervention group showed an improvement in the prescribing of hypnotics only. Prescribing practices can be improved through better teamwork between health care and nursing home staff using clinical guidelines.
5. Vu, 2007 Cost-effectiveness of multidisciplinary wound care in nursing homes: a pseudo-randomized pragmatic cluster trial Pseudo RCT	Trial to test the hypothesis that trained pharmacists and nurses working in collaboration with a wound treatment protocol would improve the wound healing and save costs.	Population: 176 residents with leg or pressure wounds Setting: 44 high care nursing homes Country: Australia	Based on an assumed improvement in the healing rate from 15% to 30%, 108 wounds per arm were required to have an 80% chance of detecting a two-fold increase in healing rates at a significance level of 5%. To adjust for clustering this number was increased to 151 in each group.	Residents in the intervention arm received standardised treatment from a wound care team comprised of trained community pharmacists and nurses. A standard treatment protocol was developed based on the colour, depth and exudate method for assessing wounds and the group's clinical and academic experience. They met weekly to discuss any new wounds and treatment options within the protocol. Both nurses and pharmacists received training on wound healing and management.	Treatment recommendations, frequency and detail of dressing changes, measurement and photos of wounds, SF36, Assessment of Quality of Life index, Brief Pain Inventory - measures wound pain, total estimated cost of treatment per wound including, staff time, training, wound care products and waste disposal.	During the trial more wounds healed in the intervention than in the control group but this was not significant. The mean treatment cost of wound healing was significantly less in the intervention group. Standardised treatment by a multidisciplinary wound care team cut costs and improved chronic wound healing in nursing homes.
6. Crotty 2004 An outreach geriatric medication advisory service in residential aged care: a randomised controlled trial of case conferencing. Cluster RCT	Evaluate the impact of multidisciplinary case conferences on the appropriateness of medications and on patient behaviours in residential care	Population: residents with medication problems/challenging behaviours Setting: 10 High-level aged care facilities Country: Australia	154 residents recruited with 54 in control, 50 in intervention, 50 in within facility control group 5 facilities randomised to the intervention and 5 to the control Staff nominated 20 residents for the intervention and 10 for the control, based on 2 criteria: Residents with a difficult behaviour they would like advice on, those prescribed 5+ medications An effect size based on patients aged 65 + with polypharmacy of 0.9 in the MAI between the intervention and control groups (power 0.9, type 1 error of 0.05) would be detected with 28 residents in each group	2 multidisciplinary case conferences chaired by the resident's GP, a geriatrician, pharmacist and residential care staff held at the nursing home for each resident. All facilities received a half day workshop on using the toolkit for challenging behaviour All residents had their medication chart reviewed pre and post intervention by an independent pharmacist using the MAI	Assessed at baseline and 3 months Primary outcome the Medication Appropriateness Index (MAI) Nursing Home Behaviour Problem Scale for each resident	There was a significant improvement in appropriate medication in the intervention group compared with the control group. Resident behaviours were unchanged after the intervention.
7. Joseph 1998 Managed Primary Care of Nursing Home Residents Cohort study	To measure the rates of hospital use and mortality of nursing home residents who received their primary care from practitioner-physician teams.	Population: older long term residents of nursing homes enrolled in Medicare HMO Setting: 30 nursing homes in Southern California Country: USA	307 nursing home residents	Primary care by accessible interdisciplinary team including physicians, nurse practitioners, and nursing home staff supported by clinical guidelines, continuous improvement techniques and increased availability of clinical services at the nursing homes.	Demographics, mortality, hospital days, minimum data sets	Integrated working between doctors, nurse practitioners and nursing home staff can reduce nursing home resident's hospital use.
8. Kane 2004 Effect of an Innovative Medicare Managed Care Program on the Quality of Care for Nursing Home Residents Controlled study	To assess the quality of care provided by Medicare HMO targeted specifically at nursing home residents, employing nurse practitioners to provide additional primary care to the physicians.	Population: Long stay nursing home residents Setting: Nursing homes Country: USA	44 Evercare homes 44 control homes 2 control groups a) other residents in same homes not enrolled in Evercare b) residents in homes in same geographical area that did not participate in Evercare	Evercare model of managed care using nurse practitioners to provide additional primary care over and above that provided by physicians.	4 aspects of quality: mortality, preventable hospitalisations, quality indicators, derived from the Minimum Data set and changes in functioning.	The Evercare mortality rate was significantly lower than the control-in group but not the control-out group. The Evercare residents had fewer preventable hospitalisation s the difference was significant for one of the control groups.
9. Goodman 2007 Controlled study	To assess whether clinical benchmarking can be incorporated into care homes for older people with the support of NHS primary care nursing staff	Population Older people in residential care homes Setting: 7 residential care homes (6 +1 pilot home) Country: UK	46 Care home staff and 154 older people from 6 residential care homes 12 district nurses from 6 district nursing teams in 3 PCTs.	3 intervention care homes used Essence of Care benchmarking in relation to resident's bowel care, joint implementation for all residents by care home staff working together with senior district nursing staff over six months. Regular benchmarking meetings to discuss, plan and implement specific aspects of bowel related health promotion and continence care that would be suitable for residents. DN led bowel care training sessions for other care staff in the care homes. Non-intervention care homes received usual care from their district nursing teams	Main outcome variables were bowel related problems captured in a bowel diary recorded for residents pre and post intervention and related hospital admissions, medication and continence product use, time spent on bowel related activities, staff satisfaction and turnover.	Clinical benchmarking could be utilised in care homes as part of everyday working with district nurses and used few resources. However, commitment by both parties and mutual trust was necessary for the process to be successful. Bowel care was complex and challenging for care staff especially where older people were cognitively impaired. There was no significant reduction in bowel related problems but some evidence of improved documentation and appropriate prescribing.
10. Szczepura, 2008 In-reach specialist nursing teams for residential care homes: uptake of services, impact on care provision and cost-effectiveness. Economic evaluation	Evaluation of a dedicated nursing and physiotherapy in-reach team (IRT)	Population: older people in care homes Setting; 4 residential care homes Country: UK	131 residents	IRT gives 24 hour cover 7 days a week - a specialist team offers support and onsite care for up to 15 beds for specialist nursing care to prevent transfer to hospital or nursing home. It also supports care home staff through health training up to NVQ level 3.	Cost of the service Number of referrals to the service Reasons for referral/visits by team Hospitalisations and nursing home transers avoided	IRT resulted in savings through reduced hospitalisations, early discharges, delayed transfers to nursing homes and illness recognition. Introduction of an in-reach team was at least cost neutral. It also benefited the care home staff through training which enhanced the quality of care and reduced the transfer of residents to other care facilities.
11. Proctor, 1998 An observational study to evaluate the impact of a specialist outreach team on the quality of care in nursing and residential homes Quantitative - non-participant observation	To assess the applicability of a training and support programme for care staff in nursing and residential homes on the quality of staff-resident interaction	Population: Older people considered by staff to have problems in terms of behaviour, social functioning or psychiatric symptoms Setting: 5 residential homes, 1 nursing home Country: UK	12 residents - 2 from each home 51 care home staff	1. Staff training over 6 months included Seminars provided by a multidisciplinary team including old age psychiatrists, nurses, doctors and OTs. A behavioural approach to care planning to help staff plan and implement care plans for individual residents. Training was given by a psychiatric nurse with weekly visits to staff	Resident behaviour and staff contact was recorded through non-participant observation prior to the training, 3 and 6 months post Activities recorded were based on QUIS - Quality of Interactions Schedule (Dean et al, 1993)	There was a significant increase in the proportion of time that staff spent in positive interactions with residents (direct care p < 0.002, social contact p < 0.05) and levels of resident activity increased (p < 0.001).
12. Knight, 2007 All-Wales integrated care pathway project for care homes Process evaluation/audit	To facilitate the implementation of ICP into care homes through negotiation with local palliative care providers to improve the care for dying patients	Population: Older people in nursing homes Setting: 29 nursing homes in Wales Country: UK	130 older people pre-intervention, 133 post intervention	Introduction of an integrated care pathway for dying patients in care homes. Other support: • Education subgroup • ICP education pack • Teaching sessions • Syringe driver training • Matron forums • Informal training/support	Pre and post ICP audit of dying patient's notes to measure their quality. Pre-audit highlighted poor communication, symptom control, and lack of staff end of life care education.	The re-audit indicated an improvement in recording end of life care. ICP use in the care homes had increased from 3 to 31% in one year. Recording of events and documentation remained poor.
13. Mathews, 2006 Using the Liverpool Care Pathway in a nursing home Process evaluation/ Audit	Aim to illustrate how collaborative working in a nursing home using the Liverpool Care Pathway(LCP) can enhance end of life patient care and improve palliative care education	Population: Older people resident in a nursing home Setting: 1 nursing home Country: UK	150 residents with 50 bed contracted out to the NHS for end of life care	Pilot study to introduce LCP into a nursing home. LCP discussed with GPs, pharmacist and ambulance service. Trained nursing staff received 3 hours of palliative care training including using LCP. Followed by implementation of the LCP for patients.	Focus on improving documentation and symptom control of patients	An audit of the first 10 patients on the LCP showed an improvement in documentation and assessment of symptoms. Staff felt that the training should be extended to health care assistants. A steering group was also set up to discuss the pathway and training needs.
14. Doherty, 2008 Examining the impact of a specialist care homes support team Qualitative	To examine the work the work and perceived impact of a dedicated care homes support team Aim of the care homes support team was to enable staff to manage the health and social care needs of residents to avoid unnecessary admission to hospital	Population: Older people in care homes Setting: 29 Care homes? residential Country: UK	19 care home managers, 13 CHST including specialist older peoples nurse, pharmacist, GP, and Senior managers in PCT interviewed 32+ participants interviewed	Intensive component:: 5 care homes CHST promoted practice development through action plans focusing on staff identified needs Extensive component: 29 homes where CHST acted as a resource in terms of information sharing and networking but no development working	Processes, working methods and outcomes of the care home support team	Statistical analysis did not support the effectiveness of the care homes support team, but the qualitative data showed the impact of the team through empowering staff, increased quality of life and access to services for residents and professional development for staff.
15. Hasson, 2008 The palliative care link nurse role in nursing homes: barriers and facilitators Qualitative	To explore link nurses' views and experiences regarding the development, barriers and facilitators to the implementation of the role in palliative care in the nursing home	Population: Older people in nursing homes Setting: 33 nursing homes Country: UK	33 nursing homes 14 link nurses in 3 focus groups	Link nurse initiative - 3 phases over 3 years: 1. Training needs or nurses and nursing assistants assessed 2. Palliative care educational programme for staff and identification of link nurses identified in nursing homes 3. Evaluation of link nurses by nursing home staff	Topics in focus groups included; link nurse preparation, barriers and facilitators to delivery of education in the home	The link nurse system had the potential to improve palliative care in nursing homes. Facilitators included external and peer support, monthly meetings and access to information. Barriers included the transient workforce and a lack of preparation for the role.
16. Avis 1999 Evaluation of a project providing community palliative care support to nursing homes Qualitative	Evaluation of project to extend 'hospice standards' of palliative care to nursing homes	Population: 231 Nursing home residents Setting: Nursing homes with registered palliative care beds Country: UK	2 Questionnaire surveys of 39 & 43 matrons of nursing homes, at 6 months and at the end of the project 35 Interviews with local stakeholders	Project was implemented by a nurse advisor and a peer support group of 6 district nurses who delivered the service to nursing homes. Nursing home staff made referrals to the team who responded by visiting and assisting in assessments and care plans for residents. 1st phase involved assessment of services required by nursing homes identified by matrons. Focus on 3 areas: advice on individual care problems, training and support on palliative care, pain, symptom control, accessing specialist advice and offering support to relatives and residents including bereavement counselling.	Interviews explored participant's understanding of the project, their perceptions of issued involved in providing palliative care, benefits, limitations for staff and residents. Questionnaires were used to rate project performance, access, response time, liaison, benefits and limitations of the project. Services were also rated in order of their importance for care homes and residents.	The project helped to overcome the barriers to care between NHS services and the independent sector. Care home isolation was decreased through assistance with individual care and better access to specialist advice and training.
17. Hockley 2005 (primary) Promoting end of life care in nursing homes using an integrated care pathway for the last days of life 18. Watson 2006 (secondary) Barriers to implementing an integrated care pathway for the last days of life in nursing homes Action research	To promote quality end of life care in nursing homes using an integrated care pathway document. Explores the barriers that needed to be overcome during the implementation of an integrated care pathway for eol care	Population: Older people in nursing homes Setting: 8 independent nursing homes Country: UK		Use of action research to promote collaboration between staff in nursing homes and the research team, empower staff in practice of eol care and promote sustainable eol care once study complete. - Core research team of 3 nurses with palliative care and action research experience, + 2 champions were identified in each care home Facilitation to implement ICP: - Monthly action learning sets for champions, monthly collaborative learning groups for all staff to reflect on eol care and ICP documents of residents who had died, clinical support from nurse specialist researcher.	Interviews to explore the respondents' understanding of the project, their perceptions of the issues in providing palliative nursing care and the benefits and limitations of the project for staff and residents Questionnaires focussed on: their use of the project, access, response time and liaison, perceptions of the benefits and limitations and the difficulties experienced in providing palliative. Data was also collected through field notes, action learning sets, monthly collaborative learning groups.	Dying became more central to nursing home work. Five main themes emerged, a greater openness to death, recognition of dying, better teamwork, using palliative care knowledge to influence practice and better communication.