Hydration Innovation – exploring a digital solution to improve hydration in care home residents

Dehydration in care homes for the elderly is a nationally recognised concern:

• “Good hydration is a core element of care and plays a role in the prevention of avoidable harm associated with other known patient safety issues.”  – Caroline Lecko, NHS England Patient Safety Lead, July 2013
• Hydration is a benchmark on the Enhanced Health in Care Homes framework (Sub-element 1:3) and Regulation 14 of CQC’s regulations for service providers and managers
• 2015 study: older people admitted to hospital from care homes are 5 times more likely to be dehydrated than those admitted from home
• 2016 study: 20% of elderly care home residents were dehydrated and further 28% had impending dehydration
• BNSSG 2018 data: 46.2% of emergency admissions from care homes were with primary diagnoses that were reduced in targeted hydration pilots elsewhere (UTIs, falls etc)
• People admitted to hospital dehydrated appear to experience significantly greater risks of in-hospital mortality – particularly Stroke patients

Dehydration is defined by NHS England as ‘A state in which a relative deficiency of fluid causes adverse effects on function and clinical outcome.’ These outcomes include:

• UTIs
• Falls
• Pressure sores
• Constipation
• Acute Kidney Injury (AKI)
• Confusion

Some of these avoidable issues require treatment with antibiotics, increasing the risk of antimicrobial resistance, and puts strain on health services. Fluid loss can be exacerbated by certain medication taken to treat conditions like heart failure, high blood pressure and inflammation, as well as common medication like some types of antihistamines, antacids and laxatives. Older people living in care homes, particularly nursing homes, are more likely to be receiving multiple medications, which may include those which exacerbate fluid loss.

An assumption, based on nudge theory, had prompted the Project Team to hypothesise and develop prototypes based on altering the environment within the care home with the aim of testing whether environmental factors prompted residents to drink. In collaboration with residents and Activities Coordinators, a CD was created which included songs previously identified by residents and associated with drinks or drinking. However, when the CD was played for an afternoon, no impact on behaviour was observed. The same outcome was observed in response to another prototyping exercise where large wall collages depicting visual representations of a variety of drinks were placed around the kitchen area of one lounge. It was concluded that for these residents, environmental factors had no impact on their desire to drink. This may not be the case for residents who have diagnoses other than dementia.

During alpha phase, new and existing care home residents would be assessed upon admission using the Hydration application prototype. Functional ability, personal preferences, previous medical history and the level of reliance on carers to achieve adequate hydration will be stored within the individual’s profile on the application. Carers will have full access to an individual’s hydration story which will support them in their caring role. This application differs from others because it is aimed at proactively supporting an individual’s hydration needs ensuring that dehydration is avoided, rather than focusing on identifying and treating existing dehydration. Future iterations of the app would aim to include hydration monitoring which would could involve the development of a cup with the capability of measuring the amount of liquid consumed and conveying this data via Bluetooth to the application.

Diagram 2: Customer journey – see PDF

Unlike poor nutrition the cost of poor hydration hasn’t been established, this is surprising as inadequate hydration is widely acknowledged to be associated with risk of harm and increased morbidity as described above (National Institute for Health and Care Excellence, Campbell, N.). Hydration monitoring is fraught with difficulties because many factors impact on a carers ability to accurately measure the volume of liquid consumed by a resident. There are many reasons for this including the demands on carers time; ability to measure and record accurately; keeping track of mobile residents; monitoring spillages, standard mugs do not have measuring devices within them. However, there is a growing body of evidence which relates to the costs of the outcomes associated with dehydration:

• Reducing admissions associated with UTI’s is important because every avoided uncomplicated admission has a potential minimum saving of £1331.00 per day in the NHS (Lean et Al, BMJ Quality Improvement Report, 2018)
• If nothing changes in current admission rates, admissions for people aged 75+ could cost an additional £30m by 2027 according to the Healthier Together BNSSG study on frailty.
• A pilot of the ROC to drink hydration assessment tool in Kent, Surrey and Sussex estimated a £202,531 reduction in admission costs which represents a year-on-year reduction of 18.3%.
• 6% of hospital admissions from care homes in BNSSG have a primary diagnosis of UTI, fall or neck of femur fracture, although not all of these are directly attributable to dehydration, the aim would be to reflect a similar reduction in costs as the Kent, Surrey and Sussex pilot.
• The average cost of an ambulance journey (2017/18) is approximately £210.00, see below:
  1. Hear & Treat Only £50
  2. See & Treat (patient left at home after an ambulance attendance) £180
  3. See & Treat & Convey (patient conveyed to a treatment location after attendance) £265

Cost Estimation:

Expert judgement and analogous estimating will form the basis of cost estimation. Advice has been sought from design and development partners about product cost and learning from previous projects will be actioned.

Benefits Estimation:

A 3-stage plan would be implemented to evaluate the benefits of a potential beta phase. The plan would consider short, medium and long-term outcomes:

Short term plan:

Quantitative data from the care homes collected before and after implementation regarding:

• Number of falls
• diagnosed UTI’s
• hospital admissions,
• A&E attendances,
• ambulance call outs,
• antibiotic prescriptions
• GP visits

Qualitative data from ongoing staff engagement groups to gather feedback about ease of use, benefits for staff of using the application, benefits for the residents.

Medium term plan:

Qualitative data on impact on resident’s overall wellbeing using:

• Staff observation
• Validated wellbeing measures, chosen to reflect the resident’s level of cognitive ability

Long Term Plan:

Quantitative data from Local Authority and NHS statutory returns to measure factors listed in short term plan

Across the BNSSG we have a robust technology network under the banner of Healthier Together Sustainability and Transformation Partnership (STP). This well-established group will act as the project board for this group and meet bimonthly.  A Prince2 project management approach will underpin our work together, so all partners are aware of timescales, responsibilities and outcomes to report against. The project manager will sit within North Somerset Council, they will manage the budget as well as being a touchstone for the team and have overall responsibility for  project delivery.  During the set-up of the project team we will agree arrangements for remote working which will include, video conference, messaging facilities and cloud-based storage for shared documentation. All information shared will be done within GDPR.

We anticipate the whole team meeting for an initial project day at the beginning of alpha phase, the project team would discuss and agree roles and responsibilities and allocate tasks for the duration of the project. The team would review the tasks as the project progresses.

Project Governance would be applied:

• Appoint an individual to be responsible for the business case (sponsor)
• Create a project management plan
• Agree on clear and common reporting methods
• Stakeholder engagement
• Manage lessons learned to achieve a culture of continuous improvement
• Agree on clear roles and responsibilities (RACI)

Bi weekly project meetings would be held using Skype as the main method of communication because of the distance involved between project partners.

We will use the RACI model for identifying roles and responsibilities and avoiding confusion during a project.

• Responsible: The person who does the work to achieve the task. They have responsibility for getting the work done or decision made.
• Accountable: The person who is accountable for the correct and thorough completion of the task.
• Consulted: The people who provide information for the project and with whom there is two-way communication.
• Informed: The people kept informed of progress and with whom there is one-way communication.

Without clearly defined roles and responsibilities, it is easy for projects to run into trouble. When people know what management expect of them, it is easier for them to complete their work on time, within budget and to the right level of quality.

See RACI for project :

Diagram 3: RACI table – see PDF

Support and Guidance Needs:

Throughout the discovery phase of this project there has been ongoing project support from the LGA, Snook, NHS Digital and RMS Consulting. This support, which was tailored to the SCDIP funding has provided invaluable learning and project support to the project team and will underpin the work of the team going forward. Working collaboratively with the SCDIP team in this way has encouraged both the team and the individual members to grow and develop to meet the challenges of the project. Support of this type going forward would be welcomed and valued. A bonus of working in this way is that information is often shared regarding other parties with an interest in hydration which has led to additional opportunities for collaborative working and sharing of resources.

As the team and the size of the project grows formal project management training support and would be invaluable, investing in the correct skill set for the lead authority personnel should yield multiple benefits for future projects.

Support with developing an effective, tried and tested training programme and materials to ensure successful implementation of the application into the care home would be valued by the team. Ensuring that the staff training element of the project is as effective as possible would help build confidence in the process of rolling out the application to other care homes within the group.