Improving health and care for physically unwell care home residents

Care home residents are among the most vulnerable people in the health system, with complex needs and high dependency on joined-up health and social care. When residents become physically unwell, the default response is often hospital admission – yet hospitalisation carries serious risks for frail older adults, including deconditioning, hospital-acquired infection, cognitive decline, and significant distress for those living with dementia.

Hospital at Home – where hospital-level treatment is delivered in the place a person lives – offers an alternative. But how well does it work in care homes? And how well are care homes and the NHS actually working together when residents deteriorate?

Our approach and partners

The team used a mixed-methods approach to understand frontline realities. An online survey of 50 care home staff and in-depth interviews with 20 staff from the Buckinghamshire, Oxfordshire and Berkshire West (BOB) and Frimley integrated care systems explored how staff manage physical deterioration and access health services, including Hospital at Home.

Earlier work with the Oxford and Thames Valley Health Innovation Network examined the implementation of RESTORE2 – a structured tool for recognising and escalating physical deterioration in care homes. That research revealed wider challenges in how care homes navigate NHS services, prompting the deeper investigation into Hospital at Home and acute care pathways that followed. Throughout, the research was shaped by engagement with care home providers, NIHR ENRICH (Enriching Research in Care Homes), Immedicare (a telemedicine service), care associations, and health and social care stakeholders across the region.

What we found – and why it matters

The research exposed a clear gap between policy ambition and day-to-day practice. Key findings:

1. Hospital admission remains the dominant pathway. 68% of staff reported hospital admission happening "always" or "often" when residents deteriorated, compared with 39% for admission-avoidance Hospital at Home and 42% for early-discharge Hospital at Home.Hospitalisation causes measurable harm. Staff described deconditioning, infection, cognitive decline, and distress – compounded by communication failures at discharge, including missing summaries, medication discrepancies, and unplanned readmissions.
2. Hospital at Home works when relationships are strong. Where care homes had established links with GPs and Hospital at Home teams, staff valued the rapid response, shared decision-making, and continuity of care in familiar surroundings. These examples show what effective integration looks like in practice.
3. Care between care homes and the NHS is not yet integrated as well as it should be. The disconnect between what policy promises and what staff experience on the ground is substantial.

What this means

Better-integrated community services could reduce avoidable hospital admissions, preserve residents' independence, and improve quality of life for some of the most vulnerable older adults in England. By documenting the practical barriers care homes face – and the conditions under which Hospital at Home succeeds – this research gives commissioners and service designers the evidence they need to act.

What needs to happen next

Realising the potential of Hospital at Home for care home residents requires action on several fronts: sustained investment in workforce capacity; equitable availability of Hospital at Home across areas, not just where relationships happen to be strong; and community health pathways designed specifically for acutely unwell care home residents. Hospital services themselves need to be better tailored to the needs of frail older people, including rehabilitation support after acute illness.

Improved communication and digital infrastructure are essential – enabling timely access to medical records, advance care planning, and shared decision-making during crises. And care home staff expertise needs greater recognition, alongside targeted training to support engagement with Hospital at Home models.

The team's follow-on research is already building on this work by incorporating residents' and families' perspectives – voices that must be central to any service redesign.