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Abstract
Background Older people living in care homes are often frail and clinically complex. The Enhanced Health in Care Homes (EHCH) framework supports organisational and clinical strategies to deliver good care, promoting proactive person-centred care by whole system collaboration. We evaluate the impact of a new role, the Extensivist, in the delivery of EHCH for older people living in care homes.
Aims To evaluate implementation processes and the clinical utility of the Extensivist in older people care homes in the London borough of Southwark.
Methods The Extensivist (Band 8a Advanced Nurse Specialist skilled in frail older people) was embedded within the care home general practitioners (GP) service for a 2-year pilot (2019–2021). Implementation processes were evaluated. Impact of the Extensivist role was evaluated by the number of Comprehensive Geriatric Assessment (CGA) completed, interventions and other clinical activity performed as well as qualitative case studies and semistructured feedback from care home workers and professionals.
Results The Extensivist feasibly delivered CGA and implemented intervention plans. The role iteratively developed to support wider aspects of care including advance care planning (ACP) and training. Challenges included building trust, the time-consuming nature of CGA, ACP and coordinated communication. Case studies and semistructured feedback indicated the role was considered valuable in the delivery of clinical care, supporting residents, families, care homes and GPs and as a resource for education for care home workers.
Conclusions The Extensivist is a valuable resource and a linchpin in the delivery of EHCH framework in care homes for older adults in Southwark. Further evaluations to assess reproducibility in other areas of the UK are warranted.
- Geriatrics
- Long-Term Care
- Nursing homes
- Patient-centred care
- Quality improvement
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
There is a recognised need to improve the delivery of the Enhanced Health in Care Homes (EHCH) framework. Reflections thus far identified the need for skilled leadership to work alongside care homes.
WHAT THIS STUDY ADDS
The Extensivist is a linchpin in the clinical delivery of the EHCH framework in Southwark older people care homes.
The Extensivist enables personalised coordinated care plans using Comprehensive Geriatric Assessment (CGA), advance care planning and by coordinating and communicating across professionals and organisations.
The Extensivist needs to be agile to changing needs such as the COVID-19 pandemic but also to the individual needs of care homes.
Further studies evaluating this role in other areas of the UK are warranted.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This study highlights to clinicians and policy-makers that there are overlapping skillsets between doctors and advanced nurse practitioners; therefore, local systems can flex to use their workforce capacity to deliver components of EHCH. Critical aspects of care appear to be not only delivering the components of CGA but also providing the care homes with support, education, co-ordination and a pivotal personal contact point. Future research should evaluate this role in other geographical areas as well as evaluate cost-effectiveness.
Introduction
Life expectancy has increased significantly in recent decades with nearly 12 million people aged 65+ years in the UK of which 15 000 are centenarians.1 Care homes play a critical role in health and social care, with around 17 600 care homes and 30% nursing homes.2 In England alone, there were approximately 360 792 care home residents between 2021 and 2022 with 65.1% funded by the state.3
Older people living in care homes are often frail with complex clinical comorbidities. Accessing healthcare can be challenging, with demonstrated inequity of access across the UK from proactive general practitioner (GP) rounds, to planned medication reviews and access to other professionals such as physiotherapy.4 This inequity of access became more pronounced in the early phases of the COVID-19 pandemic5 and highlighted resident vulnerabilities and complexity.6
The need to support and provide better access and care to this group is becoming better recognised. National Health Service (NHS) England published The NHS Enhanced Health in Care Homes (EHCH) Framework in 2020,7 which was revised in November 2023: Providing Proactive Care to People Living in Care Homes.8 The framework outlines a minimum standard for care and health delivery with more proactive personalised care delivered in the community by integrated health and care systems. Primary care networks have a contractual obligation to deliver it. The elements included within the EHCH framework closely mirror components of Comprehensive Geriatric Assessment (CGA) and social care plans. It sets clear standards of what ‘good care’ should look like, leaving flexibility in how local systems achieve it.
King’s Fund reflections on lessons learnt so far in the delivery of EHCH in 2017 identified the need for skilled leadership and equal partnership with (not for) care homes.9 With a number of different providers contributing to different aspects of care, it can be challenging to provide integrated and coordinated care. We hypothesise that in order to deliver this in a consistent way, services require both the capacity to deliver EHCH but also requires an on-the-ground linchpin who understands and coordinates different areas of need/care. We developed a new role, the Extensivist, to deliver coordinated community-based EHCH support in older people care homes.
Extensivist roles originated in Southern California in the 1990s when the CareMore Health service was launched to manage complex and chronically ill older people.10 The Extensivist was a physician, who focused on integrating and personalising care across the community and with other services. Since then, other Extensivist roles in the UK have been mainly GP or physician based including several Vanguard programmes including the Symphony Complex Care in South Somerset and the Fylde Coast Extensivist model.11
The Extensivist in this pilot is a community-based advanced nurse practitioner (ANP), specifically skilled and experienced in older people care. This Extensivist aims to coordinate care, working collaboratively with care homes, primary care, community teams, social care, mental health teams, acute trusts, residents and their families. The role involves skill sets which overlap that of the GP and geriatrician, therefore, acting to complement and not replace the work of the GP and physician to enable better joined-up care.
Previously, face-to-face CGA was not systematically completed for all care home residents in Southwark. North Southwark had monthly Multi-Disciplinary Meetings (MDMs). All residents in the 3 North Southwark homes (240 beds) had regularly MDM-delivered CGA (hereafter referred to as MDM-CGA) with only the most complex receiving geriatrician-delivered face-to-face CGA. MDMs were a discussion process with team members including a geriatrician, care home staff, GPs and other allied health professionals (AHPs). South Southwark had not yet systematically implemented MDM-CGA and was at an earlier stage in its MDM development journey. Prior data from North Southwark residential homes demonstrated that MDM-CGA was feasible and several intervention plans were made from this.12 It also identified, however, that face-to-face CGA (ie, a clinical assessment as opposed to a discussion process) generated more interventions. This suggested face-to-face assessment added value in identifying needs that are not apparent without individual in-person CGA. The Extensivist role aimed to fill this gap by delivering CGA as a face-to-face clinical intervention within the community to facilitate identification of needs and coordination of multidisciplinary team (MDT) support. The gap this filled differed in the North and South of the borough. In the North, all 240 residents had regular MDM-CGA, the Extensivist delivered additional quality of identifying further needs that face-to-face brings as well as performing critical tasks related to MDM decisions as well as delivering crucial discussions/support for families. In the South, MDM-CGA was less developed, and therefore, all 227 residents had not necessarily received MDM-CGA although were all receiving GP-delivered care planning on moving into the home. The Extensivist in these homes was able to complete the first full CGA assessment in person. All residents in all homes, whether North or South, are frail, mostly Clinical Frailty Scale (CFS) 6–8. Those seen by the Extensivist were mostly severely frail or terminal (CFS 7–9, 87.9%). All but two of the remainder were moderately frail (CFS 6).
Aims
To evaluate implementation processes and the clinical utility of the Extensivist role in completing CGA and EHCH components in older people care homes in the London borough of Southwark.
Methods
The Extensivist role was piloted during October 2019–September 2021 in Southwark older people care homes and was funded by South East London CCG. The responsibilities of the role were designed through stakeholder engagement and informed by other Extensivist roles in America and England as well as roles performed by Band 8A ANP, clinical fellows and Community Matrons. The pilot was led jointly by the primary care enhanced care home provider (Quay Health Solutions (QHS)) and the community provider (Guy’s & St Thomas’ NHS Foundation Trust). Older people care homes in Southwark have a total bed capacity of 467 beds, comprising 5 residential homes (240 beds) and 2 nursing homes (227 beds). The homes are supported by a single GP provider who routinely provides two GP-led face-to-face rounds per week for nursing home residents, once weekly for residential patients. The Extensivist worked within this GP provider team. MDT meetings were in place and included the linked geriatrician. For emergency GP support, the service is provided Monday–Friday 8:00–18.30 hours on call service for queries with access to same day face-to-face/virtual input as needed. During the COVID-19 pandemic acute phase, the on call availability increased to 7 days per week for several months. The intensity of needs and workload during the COVID-19 pandemic meant the GPs were still equally involved. The Extensivist was able to share this workload with their overlapping skillset.
Partnership delivery of EHCH has been and continues to be a journey of delivering integrated care. The introduction of the Extensivist role was one part of this journey in Southwark. Developments over the prior 3 years included delivery of geriatrician liaison, both with face-to-face reviews and through MDMs. This has already identified incremental improvements to delivery of CGA in care homes. Given the evolving change in the 3 years prior, a formal ‘before-and-after’ comparison was not possible.
Data were collected on permanent residents only. As the new role was an evaluation of service delivery, this evaluation was managed as a quality improvement project as no new interventions were being evaluated. Standards for Quality Improvement Reporting Excellence framework was used to evaluate quality improvement from the new role.
The clinical utility of the role, and its development, was assessed using both quantitative and qualitative data. Quantitative data included CGA performed, interventions undertaken, specific day-to-day activities of the Extensivist (eg, falls assessment, acute reviews and MDM discussions) to better understand the gaps in need that the role needed to fill. Qualitative data included case studies where the Extensivist was of particular value and feedback from care home staff and professionals.
Outcome data related to hospital attendance/admission/readmission and length of stay was planned, however, due to the impact of the COVID-19 pandemic, this evaluation was not viable. Process measures reported (eg, the number of interventions completed by the Extensivist) were recorded prospectively in an intervention database from EMIS GP records and completed at the time of assessment. We can, therefore, be clear that the interventions reported were directly completed by the Extensivist rather than the wider primary care team.
Process evaluation was descriptive and included
The iterative development of the role and responsibilities as well as how needs evolved in the COVID-19 pandemic.
Implementation processes and strategies.
Reflection of the challenges.
Impact of the Extensivist was evaluated by
Reviewing CGA and interventions performed.
Advance care planning (ACP) and resuscitation discussion activity.
Qualitative case studies.
Qualitative semistructured feedback from care home workers and GPs.
Patient and public involvement
Patients and public were involved in the design of the Extensitivist role. Local Care Network Ethnographic Engagement (2017) identified some of the priorities of living with long-term conditions by conducting in-depth interviews with residents with long-term health conditions in the borough of Southwark and Lambeth. Further scoping literature reviews of patients’ experiences of health and social needs were also taken into consideration. The Extensivist project worked with local residents to further prioritise the recurrent themes that are of most concern to them and codesign solutions to address these challenges.
Results
The Extensivist role and responsibilities
Through literature review, project team steering and stakeholder consultation, the key aspects of the role were initially set as:
Delivering CGA in care homes, working with staff and the wider MDT.
Developing action plans, including (but not limited to):
Management of acute or chronic conditions.
Medication reviews.
Identifying need for input from AHPs, initiate and coordinate referrals.
Identifying need for acute support from hospital@home or the acute frailty unit.
Iterative development of the roles and responsibilities
As the role embedded, it became clear the Extensivist filled a role beyond delivering CGA alone. It played a crucial role in:
Using CGA to better inform MDM discussions with new clinical information being provided consistently.
Delivered decisions made during MDM, especially with regard to ACP.
Improve ACP delivery and communication.
Improve patient, families and care home staff experience and quality of care.
Supporting families.
Supporting care homes in delivering care through the pandemic.
Supporting homes with training/education including those related to the pandemic.
Implementation approach
The Extensivist started their role by attending GP rounds in care homes working alongside them as a way of introduction to familiarise themselves with the setup and nuances of the different homes. This process enabled a soft launch approach to introduce them to care home managers and staff, explain the Extensivist role and foster a collaborative approach. The Extensivist initially spent greater time in the largest nursing home in Southwark to develop and test embedding the role within the team. From there, then gradually spreading across the other older people care homes in the borough with the learning. The role evolved from developing close collaborative relationships with the care home GPs and care home staff while building trust and confidence in the role building autonomy.
The Extensivist initially prioritised seeing new admissions or those returning following an ED attendance or hospital admission. As the role became embedded, close working relationships with GPs, other health providers and the care homes developed. Residents were then additionally identified/referred as appropriate for Extensivist assessment and interventions, whether full CGA or for a specific assessment need, for example, falls assessment, complex ACP discussions, complex nursing needs, challenging behaviour.
Cases were not selected by CFS. Most care home residents did not have a coded CFS before Extensivist role and the electronic Frailty Index was felt not useful in the care home setting for discriminating frailty levels. CFS was coded from the assessment. The Extensivist did not see all residents due to capacity as a single practitioner, particularly in the context of the COVID-19 pandemic, where activities needed to pivot to acute COVID-19 care, more rapid ACP as well as supporting care workers and families with emotional support and training.
Extensivist evolution during the COVID-19 pandemic
The role and responsibilities of the Extensivist adjusted dynamically in response to the pandemic meeting new challenges including:
Acute clinical support: supporting assessment and delivery of acute and palliative care including accessing Hospital@Home COVID-19 treatment pathways for care home residents.
Proactive care: supporting GPs in delivery of complex care management.
Infection control support: supporting outbreak prevention including supporting the homes with personal protective equipment training.
RESTORE2 training: training and supporting the implementation of RESTORE 2—an acute assessment tool for care home workers.
Family support: keeping families up to date with the clinical progress of residents with COVID-19.
Care workers support: supporting staff morale.
COVID-19 vaccination delivery: for both care home residents and staff.
Strategic support: informed COVID-19 Care Home health partnerships of escalating issues on the ground and collaborating with partners for solutions.
Embedding the role: process evaluation
Several challenges were identified through process reflection:
Building trust and confidence, embedding into a new culture, colleagues, care home staff and wider community-based workers took time.
Completing CGAs was time-consuming. It generated numerous interventions including liaison/referrals to multiple professionals which took time to deliver and co-ordinate.
ACP took time and was not a task and finished activity. Ongoing support in implementing the plan including multiple family discussions, especially during acute exacerbations, was needed.
Despite a London-wide ACP electronic documentation system, ensuring visibility of ACP across the system was challenging.
CGAs were recorded in the primary care system which was not accessible to other relevant clinicians, particularly the community staff.
Challenging to collate education opportunities for staff across the system.
Different care home providers and GPs worked differently and had differing priorities, different care workers had different strengths and weaknesses. Extensivist needed to work with care homes not for care homes to personalise support to their needs and priorities.
Family expectations would not always reflect where the residents were in their life’s trajectory. Support was required during these periods.
Quantitative data
CGA assessments
The Extensivist completed 140 CGA, averaging 14 CGA per month. Only 10 months of data was collated due to the onset of the COVID-19 pandemic which drastically shifted the focus of the role. This resulted in a wide range of interventions which included but were not restricted to 123 medications rationalised, 110 outpatient appointments rationalised, 79 new ACPs agreed and 136 resuscitation discussions (table 1).
Common interventions performed by the Extensivist and frailty severity of residents
Frailty severity assessment
The Extensivist identified that the Electronic Frailty Index on GP systems often did not correlate with their view of frailty severity, therefore, the Rockwood Clinical Frailty Score (CFS) was embedded into CGA assessments and MDMs to enable a common language across the MDT around frailty. Residents seen by the Extensivist were mostly CFS 7–8 (table 1).
MDT and acute care need identification
During the data collection period, 75 referrals to community services were identified as required by the Extensivist including referrals for earlier proactive intervention with AHPs, earlier acute support with the Hospital@Home service and earlier escalation for palliative care. Table 1 summarises common AHP inputs.
Qualitative data
Case studies
Box 1 illustrates that the Extensivist was invaluable for identifying and supporting acute illnesses, ACPs, supporting end-of-life care and preferred place of care, supporting families, identifying rehabilitation potential and supporting de-escalation from care homes back to the community.
Case examples of the impact of the Extensivist
Case study 1—supporting families during end-of-life care: Younger resident with advanced early-onset dementia and a category 3 sacral pressure ulcer. Clinical frailty score: 8. Poor oral intake and at-risk feeding. Family struggling to come to terms with end-of-life scenario. Supported family with understanding dementia, frailty and the connections with eating/drinking and swallowing. Supported advance care planning and palliative care with ongoing practical support for the family and staff at the home.
Case study 2—supporting preferred place of care and death: ‘Fast track’ resident with metastatic lung cancer who was not deteriorating as rapidly as expected. Expressed wish to return to Jamaica to be with his family for EOL care. Extensivist facilitated mental capacity assessment and risk/benefit discussions with resident and his family. Coordinated discharge with the multidisciplinary team, palliative care team and the Home Office to enable the resident to reach his preferred place of death safely.
Case study 3—stroke rehabilitation to move home: Resident moved to nursing home from hospital following a stroke who had later been on COVID-19 ward. Comprehensive Geriatric Assessment by the extensivist resulted in identifying that the COVID-19 ward had forgotten to refer for community neurorehabilitation. Identified clear rehabilitation potential and transferred to inpatient intermediate care neuro rehab. Enabled discharge back to his own home rather than remaining in nursing home placement.
Case study 4—mental capacity and rehabilitation to move home: Moved to the nursing home following hospital admission with recurrent falls and pneumonia. Poor functional improvement during hospital stay. Extensivist assessed resident and felt had mental capacity and expressed a wish not to be in a care home. Identified decision for placement had been made when the resident had delirium in the hospital (no known prior cognitive impairment). Identified polypharmacy and postural hypotension limiting his rehabilitation abilities, made medication adjustments which improved symptoms. Referred for community rehabilitation in the home and worked with them and the care home to get to bed-based intermediate care rehabilitation. Following bed-based rehab, he was able to return home with better mobility and function as per his wishes.
Feedback from care homes and professionals
Feedback was obtained via electronic survey from care home managers and other professionals including GPs supporting the care homes. A total of 13 responses were received including 3 GPs, 1 geriatrician, 2 palliative care nurses, 1 consultant frailty practitioner, 4 care home managers, 2 care home directors and 1 care home administrator. 92% (12) of respondents found the Extensivist extremely helpful to their role, 100% (13) stated the role was extremely helpful to the care home and healthcare team and 92% (12) thought the role was extremely helpful to the residents or families. Themes identified from the free-text comments identified that the Extensivist positively impacted clinical care, were support for care homes, residents, families and wider MDT, supported education and training for care home workers and held a number of valued interpersonal skills (table 2).
Free-text feedback on the Extensivist from other professional
Discussion
Since the EHCH framework’s initial release, it is well recognised that ICSs are on an improvement journey. Different systems have made different progress in developing their integrated offer with care homes. NHS England recognised that the EHCH framework also needed to do more to reach other audiences in the system outside healthcare. This has resulted in a revised framework released in 2023 following consultation across the system. The Extensivist was part of this progress to delivering EHCH in Southwark. The Extensivist enabled improved service delivery of personalised care planning based on the outcome of CGA, improved systematic review of care domains such as falls, nutrition, better coordination between different care providers, reduction in polypharmacy and improved end-of-life care.
This pilot demonstrated that the Extensivist role was feasible to embed within the care home single provider primary care service. The role was valued by others working in the system and despite the COVID-19 pandemic, the role has now transitioned into a contracted role, formally funded by the Alternative Provider Medical Services, within QHS Primary Care Home GP service. The Extensivist continues to provide care for all older people’s care homes within the borough of Southwark in London.
Previous Extensivist models are mainly GP or physician based. In Dorset, the Extensivist was a 1-year GP fellowship giving newly qualified GPs additional skills.13 In South Somerset, the Symphony Complex Care (funded by Vanguard programme) evaluated a hub at Yeovil Hospital providing additional medical capacity for complex care.14 The Fylde Coast Extensivist model, also funded by the Vanguard programme, operated a Complex Care Hub targeting the highest users of primary care and those at the highest risk of hospitalisation.14 The team consists of senior medics (physician or GP) working as Extensivists. They were supported by ANP, pharmacists, clinical care coordinators, pharmacy technicians, well-being support workers, primary care assistants, administrative staff and managers.
The Extensivist did not target their activity to the most frail by CFS. They targeted those returning from hospital admissions, new residents as well as those highlighted by the MDT/care home. By nature of this case prioritisation method, it is likely the more frail were seen ahead of those who were less frail given the number of interventions needing palliative care, speech and language therapy input and the Hospital@Home team. While not the purpose of this evaluation, it was noted through clinical practice that the electronic frailty index often did not correlate with the clinical impression or CFS impression of frailty severity. Further evaluation to understand the most reliable predictor of outcomes in care home populations is warranted.
This evaluation is the first to use an ANP to deliver the Extensivist role whereas the previous evaluations focused on doctors. There is only one full-time geriatrician per 8031 over-65s in the general population.15 This can only worsen in the context of the NHS workforce crisis alongside an ageing population. GPs in the UK are facing unprecedented pressures. The Royal College of GPs recommends better investment in expanding MDTs in general practice and support supervision of new roles.16 However, others have experienced challenges in recruiting frailty nurses in the delivery of EHCH.17 The evaluation has sought to demonstrate the key tasks and personal attributes associated with the role. Other systems may find other ways to deliver the content of the Extensivist work, which may be via a wider group if better suited to the local context than an individual. Local systems should review the key tasks and attributes that were identified as impactful and implement Extensivist models that work for the local context and resources. Southwark older people’s homes are mostly medium-large homes (48–128 beds), therefore, the clinical delivery may be easier than in areas where there are many more homes and are much smaller. The Extensivist role in this pilot is to work alongside and complement the work of GPs and geriatricians. Evaluating virtual Extensivist support models may be useful although with careful consideration to the need for relationship building. In the evaluation period, 140 residents were seen from a total population size of 467 beds. This highlights the capacity limitations for face-to-face CGA delivery for very frail care home residents, particularly where this requires follow-up interventions and complex conversations. Further development could include identifying tasks that could be completed by others as well as identifying how tasks and capacity may differ when outside an acute pandemic which impacted at least some of the resource diverting to acute activities.
There was no formal ‘before and after’ evaluation due to the number of transformation changes that had occurred in the 3 years prior to the pilot. The iterative development of partnership working to deliver EHCH, or other integrated care working approaches can make robust evaluation of impact challenging. However, such limited evaluations can still add value in providing ideas and lessons learnt for others who are earlier in their developmental journey.
This evaluation is the first to test the Extensivist role specifically for delivering care in care homes. All Extensivist models target the frailest and most clinically complex. This pilot demonstrated that targeting care home residents for this model of care was appropriate with most residents being CFS ≥7 and many requiring MDT interventions.
The Extensivist demonstrated key relationship-enhancing skills including empathy and good communication. Working ‘with’ not ‘for’ care homes, was a key point of success. Previous studies have shown that investment in relational working is an enabler of continuity and shared learning between NHS and care home staff18 and that those working in homes need to invest in relationships with multiple parties (residents, families, care workers, MDT).19
Feedback included the advantages of a nurse in this role by the nurse-specific expertise and education including nursing leadership being valued. The British Geriatrics Society Ambitions for Change: Improving healthcare in care homes position statement 2021 includes a focus on older people-specific training with core competencies for all MDT members including those employed by care home providers.17 While individual providers do provide training, it is likely that NHS collaboration in supporting healthcare skills training within the care sector would be beneficial for the whole system.
The case studies highlight that some residents on Discharge to Assess (D2A) pathways may not yet have reached their potential. This demonstrates the need to have mechanisms in place to avoid missed opportunities for these older people accessing timely rehabilitation, moving back to the community or other goals important to them. There has been an increasing use of care homes as short-term discharge destinations to support patients on NHS D2A pathways. Not only for those with a clear need for permanent placement but also for those with ongoing rehabilitation needs or other barriers to direct discharge home. Whether by Extensivist models or by other models of care, systems need to ensure early hospital discharges have associated timely access to the MDT including rehabilitation and social workers in a climate where all services are stretched.
Limitations
First, due to the COVID-19 pandemic and other system changes during the course of the pilot, we were unable to evaluate the impact on hospital admissions and quantitative outcome had to be adjusted accordingly. The COVID-19 pandemic disproportionately affected frail older people in care homes and significantly altered hospital data during this period. However, other Extensivist evaluations (US based) have shown reduced 30-day readmissions, reduced costs and reduced length of hospital stay.20 A more robust evaluation in other areas outside COVID-19 pandemic is needed to further evaluate the role and its impact on outcomes.
We did not formally evaluate cost-effectiveness. The Extensivist was a Band 8A Agenda for Change pay scale. Frailty practitioners in other areas of the UK work as Band 7. Additional NHS costs were likely incurred by the proactive nature of the role, with greater referrals and involvement of MDT professionals. However, the pilot did identify potential for cost savings. Polypharmacy reduction, earlier escalation to Hospital@Home as well as ACPs has the potential to reduce hospital admissions where care could be better received at home. Hosptial@Home care has been shown to reduce costs of acute care for older people compared with inpatient stays.21 The Extensivist identified cases with potential for further rehabilitation with opportunity to move back to the community. Identifying such individuals with missed opportunity to improve function and independence can have significant impact on those individuals as well as on the system in terms of costs. Future studies with formal health economic evaluation are warranted.
The authors were all involved in the project including evaluation of outcomes. We used both quantitative and qualitative measures to mitigate bias as much as possible.
Through this pilot, we have gained valuable lessons not only in the importance of the Extensivist role in providing personalised care but also in terms of future service development in this area. We need to be mindful of the time it takes to deliver CGA, ACPs and the associated tasks that the initial assessment generates in order to optimise care. It is important to recognise that ACP is only the first step to delivering home-based care plans. In addition, given the variations of care homes and primary care links the role needs built-in flexibility to adapt in response to on-the-ground learning and allow this to guide the future direction of the role as it evolves.
Conclusion
The Extensivist is a valuable resource and a linchpin in the delivery of EHCH framework in care homes for older adults in Southwark. Further evaluations to assess reproducibility and different models of Extensivist care delivery are warranted.
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
Ethics statements
Patient consent for publication
Footnotes
Contributors All authors were either involved clinically, operationally or involved in the project design/evaluation (including the Extensivist, himself). NM reported the study. GS conducted and reported the study. DM planned, conducted and reported study. DA planned, conducted and reported study. NJ conducted the study. MK planned and conducted study. RD planned and conducted study. TK conducted, reported and is a contributor with responsibility for the overall content of study as guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests All authors were either involved clinically, operationally or involved in the project design/evaluation (including the Extensivist, himself). NM reported the study. GS conducted and reported the study. DM planned, conducted and reported study. DA planned, conducted and reported study. NJ conducted the study. MK planned and conducted study. RD planned and conducted study. TK conducted, reported and is contributor with responsibility for the overall content of study.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.