Catherine Henderson

Background: This study explores how the service use and paid care costs of people with mild-to-moderate dementia in Britain change over a 7-year period, and which demographic and health characteristics were associated with variations in costs. Methods: We used data collected over six timepoints from the Improving the experience of Dementia and Enhancing Active Life (IDEAL) cohort study and applied regression analysis to estimate costs for sub-groups. Mean marginal effects were estimated to explore paid care cost trajectories following diagnosis. Results: Hospital and primary care service use remained stable or declined following diagnosis for most of the sample, while care home service use increased. Paid care cost trajectories increased gradually following a diagnosis. Costs varied by dementia sub-type, carer status, depressive symptoms, comorbidities, self-rated health, loneliness, falls, and health-related quality of life. Conclusion: Dementia sub-type, poor health, loneliness, comorbidities and living alone or being cared for by a non-spousal carer were associated with higher costs. Findings suggest the COVID-19 pandemic strained access to and demand for services.

Background: Residents of care homes for older people are at risk of illness and hospitalisation from respiratory infections. Care home industry pay and conditions may contribute to the risk that staff will transmit infection to residents at times when respiratory viruses are circulating. We sought to understand post-pandemic care home providers’ policies and practices on care home testing for COVID-19, sickness absence due to respiratory infections and consequent shift backfill in English care homes, and to explore the costs to providers of outbreaks of respiratory infections. Methods: In mid-2024, we interviewed 11 senior managers from 10 privately owned care homes or care home groups across England providing services to older people. The sample was diverse in terms of region, size of provider and Care Quality Commission rating. Interview transcripts were analysed using the framework approach and findings tabulated. Results: At the time of the interviews, none of the care homes conducted asymptomatic COVID-19 testing. A minority required staff with respiratory infection symptoms to test for COVID-19. Policy for most providers was to only pay Statutory Sick Pay (SSP) to symptomatic staff. Few offered enhanced sickness pay. Care homes backfilled vacant shifts by offering other employed staff the extra shifts, calling in internal bank staff, zero-hours contractors, or care agency staff. Outbreaks of respiratory illness could increase costs for providers in replacement staffing, personal protective equipment, cleaning hours and equipment, additional administrative duties, and loss of income from new residents due to home closure. Conclusions: Care homes’ COVID-19 testing and sickness pay policies were in line with current public health guidance on COVID-19 testing and SSP regulations. Pay and conditions have been linked to presenteeism in the social care sector and may contribute to the risks of staff transmission to residents at times when respiratory infections are highly prevalent. Although regular staff testing combined with self-isolation for those who test positive may be effective in reducing transmission of infection, such policies require careful design given the important financial implications for care workers, care home providers and for the wider public health and care sector.

Background: This scoping review explored theoretical frameworks that explain how assistive technology (AT), including assistive and electronic devices and home modifications, affects people with dementia and their unpaid caregivers. Objective: The review aimed to identify models linking home environments to themes of independence, sense of independence, social connectedness, safety and caregiver stress. Methods: We searched eight databases and Google Scholar, identifying 26 frameworks across 82 papers. The search strategy followed a structured procedure for identifying theory in eight databases and Google Scholar. Results: Twenty-six theoretical frameworks were identified across 82 papers describing development or application of models, theories or frameworks. Thirty-one theoretical papers described the development of models of disability, ‘ecological’ models of aging and systems and control theories. While only five models focused solely on AT, 16 included it as a component. Of 50 empirical studies, 13 models – predominantly ecological models of aging – were applied. Most examined a concept related to functional independence, while home safety was least addressed. Conclusions: A choice of theoretical frameworks is available to guide AT research and practice in dementia care. Choosing a suitable one depends on factors like stakeholders, model complexity, and centrality of AT to the study’s research objective.

Background: Credible and costed plans for managing future outbreaks of Covid-19 and other respiratory infections depend on the availability of good quality evidence. Methods: Three rapid reviews (RRs) examined evidence on: Bibliographic database searches for each RR and supplementary grey literature searches of Google for RR1 and RR3. Results: RR1 included 1 study, RR2 none, and RR3, 1 report. RR1: a study of testing undertaken during an outbreak of Covid-19 in one care home. RR3: a report briefly described recommended inputs of one local authority’s public health service into managing outbreaks of respiratory infections in settings including care homes. Conclusion: The reviews found little-to-no recent evidence on care home providers’ policy and practice on asymptomatic Covid-19 testing, care home sick pay and/or shift backfill, and the incidence of Covid-19 and other respiratory infections, nor on costs of public health teams’ outbreak management.

Background: Regular severe acute respiratory syndrome coronavirus 2 testing of care home staff was introduced to reduce transmission following significant morbidity, mortality and disruption for residents early in the pandemic. However, evidence was lacking on benefits relative to disadvantages. Objectives: The VIVALDI-Clinical Trial aimed to investigate whether regular asymptomatic staff testing for severe acute respiratory syndrome coronavirus 2, alongside funding for sick pay and agency backfill, was feasible and effective in reducing severe coronavirus disease discovered in 2019-related outcomes in residents. Design and methods: VIVALDI-Clinical Trial comprised five interlinking work packages. A cluster randomised controlled trial was conducted from January to August 2023. The ‘Test to Care’ intervention was coproduced with the care sector. Settings and participants: Eighty-one residential/nursing homes in England providing care to adults aged ≥ 65 years. Forty-one homes were randomised to intervention and 40 to control. Interventions: Care homes were randomised 1 : 1 to intervention (twice weekly staff testing, staff sick pay and agency backfill) or control arm (national testing guidance at time of trial). Main outcome measure: Primary outcome was incidence of coronavirus disease discovered in 2019-related hospital admissions in residents. Data sources: Health data from routine national data sets were used alongside aggregate data from participating homes. Health economic and modelling analyses evaluated costs and cost-effectiveness of staff testing. Interviews with care home managers explored post-pandemic policies on staff testing, sickness pay and absence. A process evaluation was conducted to understand intervention roll-out. A mixed-study design investigated the impact of coronavirus disease discovered in 2019 outbreaks on care home residents’ quality of life. Stakeholder engagement was undertaken to enable the sector to coproduce recommendations for policy-makers. Results: The trial stopped early for futility due to site recruitment and primary outcome incidence being lower than expected. There was no significant difference in resident coronavirus disease discovered in 2019-linked hospital admission incidence between intervention and control arms (incidence rate ratio 1.19, 95% confidence interval 0.55 to 2.58; p = 0.66). The process evaluation found that changing epidemiology, policy and social norms around coronavirus disease discovered in 2019 shaped the uptake and maintenance of testing. Interviews with care home managers suggested most homes no longer test staff, even when symptomatic, and do not pay for sickness absence outside of statutory sick pay. Modelling concluded that regular staff testing, when combined with non-pharmaceutical interventions preventing transmission among residents, is an effective strategy to reduce cases and deaths among care home residents that could also lead to significant cost savings. There was lower-than-expected quality of life for 43 residents from 9 care homes without outbreak and 1 home with recent coronavirus disease discovered in 2019 outbreak, with older residents experiencing greater benefits from social care support. Limitations: Intervention acceptability was initially high, but waned because of the changing epidemiological, policy and social context. Conclusions: Contextual changes undermined our ability to evaluate the intervention’s impact. However, trial set-up was achieved in < 3 months, and we present findings on the feasibility and economic implications of routine testing and impact of disease control measures on residents’ quality of life. Costs associated with severe acute respiratory syndrome coronavirus 2 testing including support payments for care home staff and for care homes to fund agency staff backfill were funded by the United Kingdom Health Security Agency. Future work: Our approach provides a model for agile interventional studies in care homes. Research training and capacity building for care home staff are important to ensure that future trials can be delivered efficiently in this setting. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR154310.

Introduction Despite significant social and financial investment, evidence suggests that technology-enabled care services (TECS) for older adults with assisted living needs fail to meet their potential. Simultaneously, an increasingly diverse range of care and consumer technologies are entering the market with the potential to deliver innovative, effective, cost-effective, and scalable social care services. However, there is limited evidence illustrating how novel digital technologies are currently being deployed across social care. Before high-quality evidence can be generated, we need a clearer sense of delivery, what outcomes are being achieved, and the factors influencing their implementation and adoption at scale. Methods DIALOGUE identifies the novel digital care technologies being implemented for social care services for community-dwelling older adults with assisted living needs that have the greatest potential for future social care research. Working with two local authorities and an Integrated Care Board, DIALOGUE adopted a mixed methods approach, including a rapid review of academic and professional literature regarding technology implementation in social care, three co-production partnerships with older people with assisted living needs using digital technologies in social care services, a process evaluation of social care TEC delivery, and an e-Delphi survey of TECS staff. Results Older adults using social care services identified priorities in relation to signposting and information seeking, safety, security and trust, and costs and financing technologies as key priorities. Local authorities highlighted building awareness and training in person-centred approaches to TECS, building the evidence base for TECS, and ensuring that commissioning and implementation of TECS is aligned with service user priorities. Conclusion Project findings are being used to build a programme for future research regarding effective person-centred implementation of Social Care TECS. Initial work in building this agenda includes applications for NIHR research Health Technology Assessment and Research Programme for Social Care funding during 2024–2025.

Purpose: To describe the development of an intervention (‘ Test to Care’ ) maintaining biweekly asymptomatic SARS-CoV-2 testing amongst care home staff. Methods: Diverse inputs were sequentially integrated: 1 ) A behaviour change wheel (BCW) analysis of the results from a systematic review of barriers and facilitators to staff testing for SARS-CoV-2 from 14 international studies to generate initial intervention content ideas; 2 ) A series of eight stakeholder events with UK care home staff and policy makers (N=∼70) to iteratively operationalise emerging intervention content; 3 ) Confirmatory thematic analysis of barriers and facilitators to biweekly asymptomatic SARS-CoV-2 testing from four focus groups (N=15) to check temporal relevance of the intervention; 4) Intervention specification via programme theory and a logic model. Results: Narrative programme theory and a simple logic model described ‘ Test to Care ’. It showed the primary intervention function was ‘ incentivisation’, addressing agency backfill and sick pay. Secondary intervention functions included: ‘ education ’ and ‘ persuasion ’ to staff through communications and social marketing (i.e., posters and emails with embedded short videos); and ‘ environmental/social restructuring ’ and ‘ enablement ’ which invited managers to initiate and support implementation (i.e., the location of testing, management support and poster locations). Conclusions: Our integrative approach to intervention development produced an evidence-based, theoretically-informed intervention tailored to its specific implementation context. The diversity of included inputs were essential to overcome the relative weaknesses and strengths of each input source (e.g., the historical timeframe of published studies in the review, and the sampling biases associated with focus group participation). What is already known on this subject?: During the global COVID-19 pandemic, compliance with SARS-CoV-2 testing and other non-pharmaceutical interventions amongst care home staff was enforced through intervention functions such as ‘coercion’ and ‘restriction’ (e.g., mandatory routine testing). However, little is known about how to maintain testing when these intervention functions are removed. Intervention development guidance suggests optimal processes should combine the published literature, stakeholder engagement, and programme theory. However, few examples illustrate this process in detail. What does this study add?: We present a worked example of using diverse inputs to systematically develop an intervention within a compressed time frame: a typical behaviour change wheel analysis of findings (i.e., barriers and facilitators) from international published studies, novel iterative stakeholder input to add/remove and operationalise intervention content, and sense-checking the emerging intervention’s relevance within the context in which the intervention will be used. Uniquely, the study also shows how narrative programme theory and logic models can be used to illustrate an intervention and its purported functions: numerous intervention functions are required (i.e., ‘incentivisation’, ‘education’, ‘persuasion’, ‘environmental/social restructuring’ and ‘enablement’), as are varied behaviour change techniques addressing a range of important mechanisms of action (i.e., ‘knowledge’, ‘beliefs about consequences’, ‘professional role and identity’, ‘social influence’, ‘environmental context and resource’, ‘behavioural regulation’ and ‘memory attention and decision-making’).

Background Care home residents are at high risk of severe outcomes following respiratory infection due to age, co-morbidities, and close contact with staff and other residents. Frequent staff testing could potentially reduce respiratory infection cases in residents, but evidence is limited. This study uses historical COVID-19 data in England to assess the impact of varying staff testing rates under different transmission scenarios to inform response during future pandemics. Methods We developed a compartmental model of SARS-CoV-2 transmission in England, with three population strata: general population, care home staff, and residents. The model was calibrated using prevalence data from January 2021 to March 2022 and testing rates from the VIVALDI Study (ISRCTN14447421). We conducted a scenario analysis projecting resident cases and deaths over 12 months under varying staff testing frequencies (monthly, twice-monthly, weekly, twice-weekly, daily) assuming a new dominant strain. We also explored the impact of testing when combined with a hypothetical low-cost highly-effective public health and social measures. Findings Staff testing alone has little impact on reducing cases and deaths in the resident population. Daily testing could avert only 3.8% (95%UI: 3.1-4.4%) cases and 3.5% (95%UI: 2.3-4.4%) deaths compared to a baseline testing of less than one test per month. When combined with public health and social measures, however, the effect is large. Daily staff testing, combined with public health and social measures, can reduce resident cases by 54% (95%UI: 50-58%) and deaths by 50% (95%UI: 26-59%). Additionally, if testing frequency is reduced but there is still a public health and social measure, the effect size decreases, however there are potential cost savings (£0.7 to £3.4 million). Interpretation Increasing staff testing alone is insufficient to significantly reduce SARS-CoV-2 cases and deaths in care home residents. However, combining testing with some form of a public health and social measure aimed at reducing transmission among residents, is epidemiologically effective and cost-effective in most scenarios and possibly cost saving.

Background: Hip fracture has a substantial impact on the health, well-being and independence of patients and their families. In the 12 months after fracture, patients are at increased risk of cognitive and functional decline, admission to long-term care institutions and higher mortality. People with cognitive impairment are among the most vulnerable in acute hospital settings. They have lower short-term survival, with 24% mortality during admission. They are susceptible to suboptimal and inconsistent care standards that contribute to cognitive deterioration, increase risk of postoperative complications, prolong their length of stay and cause loss of independence. Objectives: Establish best-practice from a systematic review of literature, observations of practice, perspectives of service users, carers, healthcare professionals, health service managers and experts in the field. Design the care pathway. Determine cultural/organisational changes necessary to implement and maximise adherence to the enhanced recovery pathway in hospital settings. Develop staff training and a training manual. Undertake a feasibility randomised controlled trial and collect outcomes to identify potential clinical and cost-effectiveness of the enhanced recovery pathway. Disseminate the findings and develop a definitive trial bid. Design: A programme to develop an enhanced recovery pathway for people with hip fracture and cognitive impairment, tested for implementation and refined in the clinical environment. This refined enhanced recovery pathway was then tested in a feasibility study in 10 hospitals across the UK. Setting: Acute care. Participants: Hospital staff, people with cognitive impairment and hip fracture, carers and national and international experts in hip fracture or dementia. Interventions: An enhanced recovery care pathway with checklist and an implementation process. Main outcome measures: Mortality, patient and carer quality of life, cognition, activities of daily living. Data sources: Clinical trial. Results: A total of 284 participants were recruited, 132 to the PEFECT-ER intervention arm and 150 to the control arm, had good retention in the study and provided data for analysis. There was no evidence of any systematic between group difference at either the point of discharge from hospital or at 1-month follow-up. However, at 3 months, a relatively small effect of around one quarter of a standard deviation (0.071 units), was evidenced with respect to the health-related quality of life of the patient based on the EuroQol-5 Dimensions, five-level version by proxy in the intervention group (95% confidence interval 0.018 to 0.124; p = 0.009). A difference of 0.099 units in favour of the intervention group was also seen at the 6-month follow-up (95% confidence interval 0.001 to 0.198; p = 0.047). ‘Timed Up and Go’ and the Suitable Informant EuroQol-5 Dimensions, five-level version showed a no statistically significant difference except the model for length of stay. Those individuals in the intervention group had significantly longer lengths of stay, on average 1.22 times longer (95% confidence interval 1.02 to 1.45; p = 0.028). Mortality was similar in both groups, with a 6.1% mortality rate by 30 days post surgery. The process evaluation found that patients and carers were unable to comment on receiving the intervention. Limitations: This was a feasibility study and was not designed as a definitive evaluation of the intervention. Lack of direct access to patient notes meant that researchers were unable to verify the Perioperative Enhanced Recovery hip FracturE Care of paTiEnts with Dementia-Enhanced Recovery check listing results. The relationship between changes in documentation of practices and changes in care practices is also unclear. Patient and suitable informants did not assist understandings of implementation, mechanisms of action or experiences of interacting with the intervention. Client Services Receipt Inventory data collection burden was an issue. Conclusions: The Perioperative Enhanced Recovery hip FracturE Care of paTiEnts with Dementia-Enhanced Recovery feasibility trial demonstrated mean recruitment of 1.87 participant per centre per month. Retention at 1 month was over 80% and at 6 months approximately 50%. This information is useful for those wishing to design a definitive clinical trial. Although 30-day mortality was the same in both groups, the potential for reduction, by Perioperative Enhanced Recovery hip FracturE Care of paTiEnts with Dementia-Enhanced Recovery being implemented, exists from cumulatively increased good practices across a range of care domains. To compare longer-term survival of patients who received the intervention, we would recommend measuring 3-month (110-day) mortality in addition to 30-day mortality. These data are readily available from National Hip Fracture Database and are thus ideal for efficient trial design. Client Services Receipt Inventory can be reduced for a definitive trial, removing equipment questions and some community health use questions. Qualitative interviews with Perioperative Enhanced Recovery hip FracturE Care of paTiEnts with Dementia-Enhanced Recovery trial patient and carer should not take place. Future work: Work to date shows that the intervention pathway for Perioperative Enhanced Recovery hip FracturE Care of paTiEnts with Dementia-Enhanced Recovery required considerable input from champions for delivery. We are exploring further funding options to facilitate work to understand these mechanisms and further test, pilot and produce the Perioperative Enhanced Recovery hip FracturE Care of paTiEnts with Dementia-Enhanced Recovery manual. Trial registration: This trial is registered as Current Controlled Trials ISRCTN99336264. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research Programme (NIHR award ref: DTC-RP-PG-0311-12004) and is published in full in Programme Grants for Applied Research; Vol. 13, No. 1. See the NIHR Funding and Awards website for further award information.