Improving hydration for care home residents

Preventing dehydration in care homes for older people is a pressing concern for the social care sector, as it can lead to unnecessary hospital admissions and functional decline for residents.


Hydration app - screen shot
Hydration app - screen shot

In North Somerset, there are currently 77 care homes for older people with 2,641 beds. Given the county’s ageing population, the number of people living in care homes is set to increase by 88 per cent by 2030. Dehydration can increase the risk of care home residents developing other problems, such as urinary tract infections (UTIs), pressure sores and confusion. To ensure safe care for residents, the council has been exploring options around hydration monitoring technology.

Dehydration is five times more common amongst older people admitted to hospitals from care homes compared to those admitted from their own home.

North Somerset Council are seeking a way to ensure care home residents drink enough – focusing on preventing dehydration, rather than treating the effects of dehydration.

To prevent this issue, the council are developing a hydration app to be used in care homes, to improve hydration for care home residents. The hydration app will be developed by Nomensa and will provide care home staff with a tool to record the hydration preferences of residents and identify elevated risk of dehydration (via the GULP assessment).

Key aims and achievements

  • Happier healthier residents because of increased hydration level.
  • More sustainable health and care system due to decreased service dependency.
  • Forecast cash savings of £3,285,348 over 10 years based on a reduction of urinary tract infections within care home residents.
  • Forecast non-cash savings of £912,600 over 10 years (eg use of GP / ambulance time etc).

Implementation

The first three months of 2020 were focused on procuring an app developer. The project team worked in collaboration with the procurement team at North Somerset Council to draft an invitation to tender and specification for this procurement. Nomensa were awarded the contract to develop the hydration app in March 2020. In mid-May the first project meeting was held with Nomensa, a timeline was developed and an action plan for the development of the hydration app was agreed. The hydration app was prototyped for user testing in October 2020.

At the beginning of the implementation phase, it was agreed that a standardised assessment and prevention tool would be used within the hydration app, which was supplied by a third party. In December 2020, due to issues around copyrighting the tool, North Somerset Council were required to identify a new assessment tool which could be used within their app.

They identified the GULP assessment, developed by Cambridge University Hospitals NHS Trust, and have added further questions to aid decision making, based on user engagement from the discovery phase. A revised project plan was agreed with Nomensa to develop and test the app.

During this phase, the project team had the opportunity to write an article which was published in OTNews and they were also invited to speak at the Royal College of Occupational Therapists about the app and how their work aligns with the government’s digital strategy.

User research and prototyping

  • Nomensa developed a prototype of the hydration app which has been through one remote testing round with a care home in October 2020. 
  • This testing session used 10 tablets and the virtual session was recorded. This session enabled the team to get feedback from service users and carers (positive features and areas for improvement), and the tablets were able to track the eye movements of those using the hydration app to understand how they were using it (eg were they following the expected user process).
  • The project team has also been engaging with care homes (with two currently on board) to organise further remote user testing of the next iteration of the hydration app prototype (in March 2021).

Simple, clear and straightforward. The sooner it is implemented, the better.

Comments from staff involved in testing

Financial and social benefits

Throughout the implementation phase, project teams were asked to produce reports forecasting the cash, non-cash, societal and quality benefits. The following benefits have been forecast (over the next 10 years).

Forecast benefits
Benefit Description
Cash £3,285,348 which is based on a reduction of UTIs within care home residents (eg reduction in hospital stays or length of stay).
Non-cash £912,600 (eg use of GP / ambulance time etc).
Quality £912,600 (eg use of GP / ambulance time etc).

 

Please note that due to delays in this project, quantitative benefits are likely to be realised in 2021/22 onwards (once the app is being used in care homes).

Measuring success

During the discovery phase, the council developed a logic model to guide the implementation phase and to help quantify the inputs, activities, outputs, outcomes and impacts which are likely to result from the delivery of this project.

Key outcomes and impact measures:

  • Reduction in the number of falls, UTIs, antibiotic prescriptions and behaviour change linked to dehydration (measured as a part of benefits reporting)
  • Fewer 999 call outs to care homes (measured as a part of benefits reporting)
  • Increased staff satisfaction, leading to a more sustainable workforce
  • Happier, healthier residents due to increased hydration levels
  • More sustainable health and care system due to reduced service dependence – if nothing changes in current admission rates, admissions for people aged 75 and over could cost an additional £30m by 2027.

Project benefits

  • The hydration project has increased staff awareness of the importance of hydration and staff feel empowered to deliver a better standard of care (based on feedback from staff during testing).
  • Both the project team and care home have shown resilience in transferring to digital working as evidenced through remote user testing. 
  • Willingness of both staff and service users to get involved.
  • The ability of staff to be flexible and respond to external changes whilst remaining focused on the final outcome.
  • In terms of commissioning services, there is greater awareness and capability across the Council in relation to developing and procuring digital projects.

Challenges and lessons learned

  • The copyright issue led to a wider restructure of the hydration app towards the end of the project. Whilst this was an unusual circumstance, the team highlighted lessons around communication and written documentation over ownership and legal matters.
  • Significant changes to the personnel within the project team and the main contact at the care home. There is a need for agility and resilience in project delivery.
  • The care home being used for user testing experienced an outbreak of Covid-19, reducing engagement during the first wave. Widen the number of care homes engaged with throughout the project.
  • The project team were unable to enter the care home for user testing due to the Covid-19 outbreak. This was overcome by remote user testing which was a success and enabled the team to gather feedback for the next iteration of the prototype.
  • Covid-19 has delayed the project timeline.

Impact of Covid-19

  • The care home used for testing during the implementation phase was significantly impacted by Covid-19 throughout 2020. This meant that engagement was more difficult (including user testing) than anticipated. Sometimes engagement was postponed and then undertaken remotely.
  • The focus of the project team at North Somerset had to be re-prioritised due to the Covid-19 first wave (April-May 2020), which reduced the staffing resource available to focus on the hydration project during this time.
  • User testing of the prototype through remote sessions with care homes using tablet devices was completed.

Future potential

The intention is that this project will be scaled up, in the first instance to all care homes associated with the organisation that is responsible for the initial pilot care home and then to all care and nursing homes in the Bristol, North Somerset and South Gloucestershire (BNSSG) CCG area. The feasibility of using the hydration app within the domiciliary care sector is also being explored.

There is hope that once the hydration app has been rolled out within BNSSG, that replication will be possible in other council areas. For this to be successful, the following criteria would be required:

  • An exploration period to understand the local context, such as:      
    • private / local authority care providers
    • digital maturity of local care homes
    • electronic care record systems used
    • if previous hydration work has been completed        
  • Resources would be required for provider engagement and launching the product into care providers and to respond to local feedback.

In addition, the North Somerset project team are hoping to formally tender for ongoing support for technical / digital innovation in the area, whilst also securing external funding for the continuation of this project and working with the team on the hydration app.

Find out more

Fiona Shergold: fiona.shergold@n-somerset.gov.uk

Nicky Birkby: nicky.birkby@n-somerset.gov.uk

John Vowles: john.vowles@n-somerset.gov.uk

Related links

Bedfordshire Community Health Services: GULP Dehydration Risk Screening Tool (PDF)

Discovery Phase review report: (PDF)