Fundamental to realist approaches is the identification and refinement of a series of propositions about how a programme might work to achieve its outcomes . Stage 1 identified six potential candidate programme theories (later refined to three) of how health care services to care homes improved the health of residents and use of services. These considered that health outcomes for care home residents could be improved when:
Tailored education and support for care home staff provided by clinical experts and supported by the use of structured documentation and protocols will improve resident outcomes by prioritising specific assessment/care activities that trigger changes in how residents’ care is planned and how care home staff recognise and frame their need for training and support from visiting clinicians
Contracting and financial incentives paid to doctors (GPs) to provide dedicated services to care homes, with audit against pre-specified process and outcome measures will change the pattern and frequency of GP contact with residents and staff, increase the time and opportunities for screening and review of care, increase staff confidence that they can access a GP and reduce demand on emergency and secondary care services
Formalised recognition and ongoing facilitated support of care home staff to equip them to build relationships and work with health service providers will validate the expertise of care home staff, increase their confidence when working with visiting health care professionals, and lead to care home staff identifying priorities for residents’ health care with visiting health care professionals
Appointment of care home champions with specialist expertise in quality of care for older people and designated responsibility to work with care homes will provide expertise and continuity of support to the care home staff encourage skills acquisition that would cause staff to be more proactive in providing health care to residents
Commissioning and provision of services that focus on specific problems and health care needs frequently experienced by care home residents (for example, falls prevention, end-of-life care, continence management) changes the focus from care home residents to the individual needs of patients and triggers a service response that is equivalent to that received by people living in their own home
Building of inter-organisational and inter-sector networks (health/social/public/private sectors) will change how different services work together to highlight gaps and overlaps in service provision, this will trigger conversations and planning between services about resource use and who is responsible for providing health care.
In discussion with the advisory group, the research team focused on areas of overlap and fit with the preliminary scoping of the literature and review of service provision and likely configurations of enablers and barriers that might shape how these interventions work. This resulted in three broad programme areas that were the basis for the second stage of the synthesis, and focused on care home-specific evidence on ageing and frailty, system change and cross organisational working between care home and visiting health care staff (Table 1). These programme theories are each discussed in turn below.
The searches (Fig. 1) initially considered care home wide interventions and then topic led interventions that were linked to one or more of the five outcomes listed in Objective 2 (see above). This generated 687 records. Following screening and de-duplication, 86 full text articles were assessed for eligibility and 64 were included; 53 of which reported on at least one of the outcomes of interest. Papers were excluded for the following reasons: not care home specific; either did not include the outcomes of interest or provided no or insufficient detail about health care provision to care homes; or could not be linked to UK systems .
System based quality improvement mechanisms to improve health care outcomes: the use of incentives, sanctions and targets
The theoretical basis for the use of system-based incentives, targets and sanctions is that they prompt behavioural change through targeting particular professional groups or organisations (in this case, care homes), focus on the improvement of specific processes or outcomes, and thereby improve quality of care and reduce inequity of provision . The Quality Outcomes Framework (QOF), introduced for GPs in England in 2003, linked financial incentives to the quality of care that is provided by practices  and has been described as a lever to reduce health inequalities and reinforce evidence based practice .
Possible Context-Mechanism-Outcome configurations based on the different theoretical propositions were tested through the literature review, see below, (words in italics emphasise the suggested mechanisms). It makes explicit the differentiation between how we understood the intervention or the allocated resources used to provide care and the possible mechanisms that are the possible trigger for change (Context Intervention Mechanism Outcome).
The following possible C(I)MO configuration to explain how incentives and sanctions paid to primary care can improve health care in care homes were identified:
Context: Care home staff have intermittent contact with the residents’ GP; encounters with primary care are usually unplanned and in response to an urgent need and this affects the proactive identification of residents’ health care needs, access to and quality of care and frequency of acute episodes of ill health.
Resources/Intervention: GPs are provided with a range of incentives and sanctions to visit regularly and undertake resident assessments in key areas of care for example medication review, and provide the care home with support and advice in addition to individual patient visits.
Mechanisms: GPs are motivated to engage with the care home staff because of the incentives and sanctions that prompt them to complete regular reviews of care home residents and work with care home staff to plan care and
identify residents in need of additional support and care.
Outcomes: Care home staff are more confident working with GPs around particular areas of care, specifically medication management and reduced use of OOH and emergency services.
For General Practitioners (GPs) working with care homes, rewards linked to particular clinical activities are used as incentives to define and increase the length and frequency of their visits in order to achieve the desired outcomes of continuity of contact and proactive approaches to patient care . A focus of the evidence reviewed about the use of incentives and sanctions was around its role in the improvement of medication management . This literature suggests that additional payments to GPs and pharmacists to do specific activities can improve monitoring of medication use. However, the use of payments or sanctions alone to trigger GP involvement in resident assessment and review did not appear from the evidence reviewed to be sufficient to improve activities such as regular medication review, prescribing and related resident outcomes. Three further factors were also identified: the need for an accountability structure, named professionals used to deliver a specified intervention, and care home-sensitive protocols which took account of the high prevalence of dementia [32, 33]. Other contextual factors included the need to consider those residents at particular risk and also care home staff’s need for ongoing support and training.
Generally, the literature would appear to support the view that, whilst incentives can improve the process of care and productivity (for example, better adherence to protocols and care pathways), the evidence of their impact on patient outcomes is limited [34, 35]. Charlesworth and colleagues argued that:
“Incentive schemes can only work if the organisations and clinicians whose behaviour they are trying to change
understand what is required (
. Too often, the incentives are blurred or inconsistent. In part, this is a result of the complexity of the current system” p14
The main pay-for-performance approach in UK primary care (Quality Outcomes Framework) allows practices to exclude patients for reasons such as extreme frailty, or evidence of decline. This arguably creates an implicit expectation that payment is linked to a set of outcomes that are less relevant or irrelevant to care homes . Residents with dementia achieve lower quality indicators in the QOF pay-for-performance system than their community dwelling counterparts . Indicators focus on very specific aspects of disease management. Care home residents as a discrete population may not be recognised by GPs as a priority group in need of identification and active management. Payments alone may not be sufficient to change that view, make care home residents a GP priority or address issues of accessibility, appropriateness or system co-ordination . As Roland, observed when commenting on the evidence for pay for performance for GPs:
They (incentives) work best when all the ducks are lined up in a row: financial, organisational, and professional incentives, then the incentives are providing
(our emphasis) to do the things that doctors believe they should be doing anyway (Martin Roland When incentives go wrong http://www.cchsr.iph.cam.ac.uk/2107).
One small study audited cases of residents’ admission to hospital as a trigger to identify and discuss with GPs the factors influencing hospital admissions from care homes. The authors reported a change in GP behaviour, with an increase in care home visit rates and a reduction in overall hospital admissions  but the audit and review had no impact on the numbers of hospital admissions initiated by care home staff. The authors suggested that care home staff, particularly where there was no on-site nursing provision, needed further support from visiting health care professionals and involvement in anticipatory planning for residents at risk of hospital admission.
The Evans et al. (2010) study was the only study we found that explored and reported how the mechanism of providing feedback on GP performance could influence how GPs worked with care homes. Other studies suggested that formal notification to GPs of the need to improve care or guidance on good practice (prescribing), did not provoke change [39, 40]. A possible explanation is that feedback on medication management does not have the same impact as alerts about unplanned hospital admissions that are recognised as avoidable and costly. This suggests that it is the urgency of the issue to the health service, as opposed to its impact on individual residents or care home staff that influences when audit and feedback mechanisms trigger increased engagement with care homes by NHS services.
We found no evidence that targeted payments prompted an increase in health care professional visits or assessment of care home residents’ health care and medication needs. One US study found that financial payments, when paid directly to care homes as opposed to visiting health care professionals, improved resident outcomes but this was for specific projects identified by care home staff. The incentive was to introduce new approaches to care, not to ensure that health care was provided .
Age appropriate care can be accessed by older people resident in long term care
There is evidence that systematic approaches to the assessment and management of older people can reduce mortality and improve function [41–43]. These interventions rely on the involvement of clinicians with expertise in the care of frail older people and their ability to work with others to implement care plans. Box 2 illustrates a C(I)MO proposition outlining how services that focus on providing expertise in age appropriate care could work.
The following possible C(I)MO configuration explains how provision of expert practitioners in old age care can improve health care in care homes:
Context: Care homes have unpredictable access to health care services, the majority of staff are not clinically qualified, residents are frail and in the last years of life with complex health and social care needs.
Resources/Intervention: Experts in care of older people visit care homes regularly to compensate for known deficits in knowledge and skills.
Mechanisms: Care homes staff feel supported
trained in how to provide care to frail older people. They are motivated to learn new skills because of the facilitation and ongoing expert support they receive.
Outcomes: Care home staff are more confident and skilled in looking after care home residents and specific areas of care. Residents' function is improved or maintained and staff have higher levels of job satisfaction and the care homes are less likely to use emergency and out of hours services,
An increasing body of work has developed interventions for care home residents that have focused on specific processes such as assessment, targeted interventions and protocol-based care. Examples include comprehensive assessment , depression [45–47], dementia , falls prevention , nutrition [49–52], recovery from stroke , medication , end of life care [55–57], tissue viability , oral hygiene , and occupational therapy interventions [60, 61]. Most of these interventions were multicomponent but had in common the detailed assessment of residents’ functional abilities and the teaching of new skills to care home staff to improve residents’ health and wellbeing.
Most but not all interventions were appreciated by care home staff, often with reports of increased staff confidence that could have acted as a feedback loop and potential additional mechanism to influence improved residents’ health. However, the positive response of staff was as likely to have been a reflection of care home staff’s previously limited experience of professional support and encouragement. Where there was a comparative study, the control was invariably usual care or provision of written materials. This suggests that the mechanism that triggered a change in staff (or not) was the process of working together and receiving clinical support. The underlying assumption of many of the studies reviewed, that the allocation of professional (biomedical) expertise, education and training of staff and identification of people at risk would lead to improved health outcomes, was not supported.
These were important contextual factors necessary for change. They were not, however, the mechanisms that provided the generative force to achieve the resident outcomes.
Several contextual factors have been suggested that may inhibit care homes and/or residents ability to engage with interventions, but these remain largely untested. Putative factors include care home size and ownership, staff turnover, percentage of residents who have been resident in the care home for less than 12 months, and the absence of additional triggers or mechanisms such as the involvement of care home leadership, staff qualifications and the duration of programmes . Two studies on end-of-life training programmes found that use of advanced care planning documentation, improved staff satisfaction and reduced hospital deaths were positively associated with how long the care home manager had been in place, prior training in end of life care and low staff turnover [55, 62].
One study with a positive outcome appears to have been successful because of particular contextual factors. Researchers  tested the effectiveness of an influenza vaccine programme for care home staff (not residents) to prevent death, morbidity and health service use. The mechanisms of interest within the programme were the identification of a key link-worker within the care home and the development of tailored processes to encourage vaccination uptake by care home staff. These were supported by a care home policy for immunisation. It achieved significantly lower mortality of residents in intervention homes compared with control homes. The key differences between the intervention process described in this study and that of the others reviewed was that it was a single, time-specific intervention that could be co-ordinated by one member of staff per care home. It was, in comparison to the other studies, a simple intervention with a quantifiable outcome where the proposed health benefits to both staff and residents were clear for staff and residents . An expert practitioner was important as a resource that enabled the link worker in the care home to implement the immunisation process that generated the positive outcomes.
Relational approaches to promote integrated working between visiting health care and care home staff that emphasise interpersonal skills and shared decision making
The competing priorities of health and social care staff, inherent power imbalances between qualified and unqualified staff, staff turnover and the difficulties health care professionals have in understanding the predominantly private care home environment are well documented barriers to effective collaboration between health and care home staff [50, 64–67]. Relational working draws on theories that emphasise strategies that coordinate and support shared problem solving (and not blaming) and working relationships that are grounded in common goals, shared knowledge and mutual respect [22, 68, 69]. In the extraction of data in this stage of the review (based on the stakeholder interviews and the preliminary scoping) relational working was characterised as those activities and processes which emphasise shared-decision making, planning and learning and continuity of contact between staff from different sectors.
The following possible C(I)MO configuration explains how an intervention designed to improve relational working achieve improved outcomes for care home residents and staff involved:
Context: The expertise of care home staff in providing care for older people with frailty and/or dementia is seldom recognised by visiting health care professionals. Health care interventions, emphasising physical health, do not fit well with care home priorities of providing a homely setting and working practices that seek to balance positive risk taking with patient safety. Working patterns to facilitate in reach from numerous health professionals are difficult to accommodate by care home staff with limited resources who want to achieve a more personalised environment for residents.
Resources/Intervention: Models of care that introduce opportunities for joint priority setting and processes that support ongoing discussion and review of residents’ health care needs between care home and visiting health care professionals.
Mechanisms: Identification of key personnel in the care home to work with visiting health care professionals trigger a response where staff are motivated to develop shared priorities for care and a sense of common purpose because their views are valued, they develop approaches that fit with the care home working patterns, incorporate care home staff knowledge and priorities are jointly agreed, enacted and reviewed.
Outcomes: Care home staff and visiting health care professionals are motivated to work together and improve care for residents in agreed areas of practice. Residents’ function is improved or maintained; staff have higher levels of job satisfaction; and the care homes are less likely to use emergency and out of hours services.
The organisation of care between the resident, their relatives, care home staff and visiting health care professionals requires more than the one-on-one encounter between clinician and patient. It is a negotiated process within a changing environment. Over time, there may be individual and organisational changes in who has responsibility for providing and/or paying for care, and changes in the arrangements for commissioning health and social elements of care. Roles and responsibilities for a resident’s care can shift as a consequence of an acute health event and/or a gradual shift in need from “social” to “health” care as complex long-term conditions progress and predominate, and/or as part of a transition to end-of-life care [70, 71]. These observations highlight the importance of understanding how the arrangements for health service involvement support, or inhibit, the development of networks of interprofessional collaboration and care, specifically how they impact on relational working. In the extraction of data in this stage of the review (based on the stakeholder interviews and the preliminary scoping) relational working was characterised as those activities and processes which emphasise shared-decision making, planning and learning, and continuity of contact between staff from different sectors.
Three contextual factors reflecting aspects of relational working were identified as important for triggering activities and processes that were likely to lead to improved outcomes. These were important whether the intervention being reported had an explicit focus on working with care homes collaboratively or not.
Shared priority that fitted with care home workflow
Most of the health care interventions reviewed were multi-component. Interventions were more likely to have positive uptake and promising outcomes (completion of education and training programmes, improved documentation of residents’ care) where they focussed on a concern of mutual interest to care home and healthcare staff and/or residents and family. For example, end of life care that avoided unplanned hospital admissions and enabled the person to die in the care home fitted with care home staff views that they were the person’s proxy family, that the care home was the person’s home and that it was distressing to be with strangers (hospital staff) at the end of life [56, 72].
Where the initiative was identified as a priority based on a review of resident need, but not recognised by staff as such (particularly where it added to their workload), it was unlikely to be implemented or sustained [47, 73]. As one study that introduced a therapy-led intervention to reduce depression observed:
At times it was difficult to explain our remit to staff. We had little time to change attitudes of some staff to issues of mobility; making it hard to facilitate a change in practice Underwood et al.  (p 2013)
This relates to who the health care professionals worked with and their role in care delivery. Studies showed that interventions were more likely to be acceptable and effective when there was a nominated person in the care home to liaise with, particularly where this person could play a collaborative role in reviewing, planning and supporting care .
Fit with the care home workplace
There was evidence of improved outcomes where care home staff had flexibility in how an intervention was implemented [39, 63, 74]. This was particularly the case where there was access to expert facilitation and support. Emphasis on preparatory work, structured assessment of a care home’s readiness to participate, collaborative and bottom-up approaches, shared learning and the development of a common understanding between care home staff and health care providers were key mechanisms for improvement and involvement of care home staff in the intervention [58, 67, 75]. In one study this involved developing an intervention with care home managers that built on previous staff learning in end of life care, it was an iterative and reflective process that involved day and night staff and sought to address care home specific issues such as supporting people with dementia:
“We think this success (reduction in hospital deaths, improvement in quality of life for residents with dementia) is related to the training
addressing staff fears and problems
(our emphasis) as well as increasing knowledge” Livingston, et al. 2013 (p1587)
The involvement of care home staff, particularly senior staff, and other psychological and contextual factors that could be characterized collectively as a care home’s readiness for change positively impacted upon the uptake of innovation [50, 76].
Bamford and colleagues found that whilst some changes could be achieved in staff understanding of nutrition the implementation of nutrition guidelines in care homes foundered because:
It proved difficult to build collective understanding of and commitment to the study resulting in inconsistent implementation…Managers’ commitment to the nutrition guidelines did not extend to using scarce resources to facilitate implementation (p10)
This finding was resonant with multiple references in the reviewed texts to the probable influence of the leadership and culture of particular care homes on health care outcomes and staff satisfaction.
Access to ongoing support and facilitation
We were unable to find any evidence to support the widely expressed belief that attachment of one GP practice per care home improved resident outcomes. In fact there was evidence that GP allocation did not lead automatically to continuity of support and could have the unintended consequences of rationing care because GPs set regular but fixed times for their availability . There was also evidence that one practice per care home arrangements could effectively trap providers in dysfunctional relationships, providing an adverse context for appropriate health care delivery .
Ongoing support from a clinician or team with relevant expertise was nevertheless important, and especially so, was how this was delivered. Where the facilitator or lead clinician was able to be present and responsive to the needs of particular residents as they arose and engage staff in action learning that focused on issues of interest to staff, this was linked to higher levels of staff engagement and fidelity with training [11, 26, 39, 74, 78] when compared to interventions where the clinician input was episodic or task focused [54, 79]. The mechanism within the facilitation process was when the health care professional worked with staff as the “bridge” to connect between interventions to improve health care of residents over time in a way that could be modified or be incorporated into existing patterns of working.