Integrating mental health services for older people in England - from rhetoric to reality

Older Adults' Demand for Community-Based Adult Services (CBAS) Integrated with Medical Care and Its Influencing Factors: A Pilot Qualitative Study in China

INTRODUCTION

The number of older people in China who require formal care is increasing. In response, China is creating a service delivery mode of health and social care combination for older people-community-based adult services (CBAS) integrated with medical care-in some provincial capital cities, such as Changsha. However, the needs of most older people for this service delivery mode are not well understood.

AIM

To assess older people's awareness of and demand for CBAS integrated with medical care and to determine influencing factors.

METHODS

Semi-structured guideline interviews were conducted with 20 older people (aged 65+ years) from two communities at different economic development levels and from a nursing home in Changsha, China. Interviews were analyzed using qualitative content analysis.

RESULTS

The specific needs that older adults expect from CBAS integrated with medical care involve daily care, primary care, self-management guidance, rehabilitation therapy services, and mental health services. Contrary to expectations, most interviewees showed low awareness of and demand for CBAS integrated with medical care. Individual, family, and community factors influence older people's demand, as do exogenous variables such as gender and number of children.

DISCUSSION

The influencing mechanism of older people's demand for CBAS integrated with medical care is complex and multifaceted. To implement and promote CBAS integrated with medical care, attention should be given to older people's individual needs, family backgrounds and community environment improvement. Furthermore, improving awareness of integrated care and increasing ageing-in-place opportunities for more older adults is essential and urgent.

Better care through an optimized mental health services continuum (Eastern Townships, Québec, Canada): A systematic and multisource literature review

INTRODUCTION

In 2014, the health authorities of the Eastern Townships (Québec, Canada) commissioned an evaluation of the mental health admission system for adults (GASMA) to identify the best GASMA organizational or structural elements and optimize the mental health services continuum.

METHODS

To develop better services, seven indicators (ie, accessibility to services, integration of levels of services, user satisfaction, guidance and management time, evaluation tools, professional composition, and interprofessional collaboration) were examined through four evaluation questions. A three-step systematic and multisource evaluation was realized. A systematic review of the scientific and gray literature was performed. This evaluation also included key informant opinions to contextualize results from this review.

RESULTS

Results from 91 scientific articles, 40 gray literature documents, and 10 interviews highlighted determinants and barriers associated with the examined indicators. From these results, 24 preliminary recommendations were formulated and discussed in a steering committee. These recommendations were then weighted and validated. This served to formulate three final recommendations.

CONCLUSION

To optimize the regional mental health services continuum, stakeholders should (1) implement a single-window access for adults with mental health needs, (2) develop alternative services based on users' needs, and (3) test the effectiveness of new methods, initiatives, and tools.

Understanding new models of integrated care in developed countries: a systematic review

Background

The NHS has been challenged to adopt new integrated models of service delivery that are tailored to local populations. Evidence from the international literature is needed to support the development and implementation of these new models of care.

Objectives

The study aimed to carry out a systematic review of international evidence to enhance understanding of the mechanisms whereby new models of service delivery have an impact on health-care outcomes.

Design

The study combined rigorous and systematic methods for identification of literature, together with innovative methods for synthesis and presentation of findings.

Setting

Any setting.

Participants

Patients receiving a health-care service and/or staff delivering services.

Interventions

Changes to service delivery that increase integration and co-ordination of health and health-related services.

Main outcome measures

Outcomes related to the delivery of services, including the views and perceptions of patients/service users and staff.

Study design

Empirical work of a quantitative or qualitative design.

Data sources

We searched electronic databases (between October 2016 and March 2017) for research published from 2006 onwards in databases including MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Science Citation Index, Social Science Citation Index and The Cochrane Library. We also searched relevant websites, screened reference lists and citation searched on a previous review.

Review methods

The identified evidence was synthesised in three ways. First, data from included studies were used to develop an evidence-based logic model, and a narrative summary reports the elements of the pathway. Second, we examined the strength of evidence underpinning reported outcomes and impacts using a comparative four-item rating system. Third, we developed an applicability framework to further scrutinise and characterise the evidence.

Results

We included 267 studies in the review. The findings detail the complex pathway from new models to impacts, with evidence regarding elements of new models of integrated care, targets for change, process change, influencing factors, service-level outcomes and system-wide impacts. A number of positive outcomes were reported in the literature, with stronger evidence of perceived increased patient satisfaction and improved quality of care and access to care. There was stronger UK-only evidence of reduced outpatient appointments and waiting times. Evidence was inconsistent regarding other outcomes and system-wide impacts such as levels of activity and costs. There was an indication that new models have particular potential with patients who have complex needs.

Limitations

Defining new models of integrated care is challenging, and there is the potential that our study excluded potentially relevant literature. The review was extensive, with diverse study populations and interventions that precluded the statistical summary of effectiveness.

Conclusions

There is stronger evidence that new models of integrated care may enhance patient satisfaction and perceived quality and increase access; however, the evidence regarding other outcomes is unclear. The study recommends factors to be considered during the implementation of new models.

Future work

Links between elements of new models and outcomes require further study, together with research in a wider variety of populations.

Study registration

This study is registered as PROSPERO CRD37725.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The effects of integrated care: a systematic review of UK and international evidence

BACKGROUND

Healthcare systems around the world have been responding to the demand for better integrated models of service delivery. However, there is a need for further clarity regarding the effects of these new models of integration, and exploration regarding whether models introduced in other care systems may achieve similar outcomes in a UK national health service context.

METHODS

The study aimed to carry out a systematic review of the effects of integration or co-ordination between healthcare services, or between health and social care on service delivery outcomes including effectiveness, efficiency and quality of care. Electronic databases including MEDLINE; Embase; PsycINFO; CINAHL; Science and Social Science Citation Indices; and the Cochrane Library were searched for relevant literature published between 2006 to March 2017. Online sources were searched for UK grey literature, and citation searching, and manual reference list screening were also carried out. Quantitative primary studies and systematic reviews, reporting actual or perceived effects on service delivery following the introduction of models of integration or co-ordination, in healthcare or health and social care settings in developed countries were eligible for inclusion. Strength of evidence for each outcome reported was analysed and synthesised using a four point comparative rating system of stronger, weaker, inconsistent or limited evidence.

RESULTS

One hundred sixty seven studies were eligible for inclusion. Analysis indicated evidence of perceived improved quality of care, evidence of increased patient satisfaction, and evidence of improved access to care. Evidence was rated as either inconsistent or limited regarding all other outcomes reported, including system-wide impacts on primary care, secondary care, and health care costs. There were limited differences between outcomes reported by UK and international studies, and overall the literature had a limited consideration of effects on service users.

CONCLUSIONS

Models of integrated care may enhance patient satisfaction, increase perceived quality of care, and enable access to services, although the evidence for other outcomes including service costs remains unclear. Indications of improved access may have important implications for services struggling to cope with increasing demand.

TRIAL REGISTRATION

Prospero registration number: 42016037725 .

Is integrated care associated with service costs and admission rates to institutional settings? An observational study of community mental health teams for older people in England

OBJECTIVES

To evaluate the association between the degree of integration in community mental health teams (CMHTs) and: (i) the costs of service provision; (ii) rates of mental health inpatient and care home admission.

METHODS

An observational study of service use and admissions to institutional care was undertaken for a prospectively-sampled cohort of patients from eight CMHTs in England. Teams were chosen to represent 'high' or 'low' levels of integrated working practice and patients were followed-up for seven months. General linear models were used to estimate service costs and the likelihood of institutional admission.

RESULTS

Patients supported by high integration teams received services costing an estimated 44% more than comparable patients in low integration teams. However, after controlling for case mix, no significant differences were found in the likelihood of admission to mental health inpatient wards or care homes between team types.

CONCLUSIONS

Integrated mental health and social care teams appeared to facilitate greater access to community care services, but no consequent association was found with community tenure. Further research is required to identify the necessary and sufficient components of integrated community mental health care, and its effect on a wider range of outcomes using patient-reported measures. © 2016 The Authors. International Journal of Geriatric Psychiatry published by John Wiley & Sons, Ltd.

The Impact of a Participatory Care Model on Work Satisfaction of Care Workers and the Functionality, Connectedness, and Mental Health of Community-Dwelling Older People

This study describes and evaluates an innovative program designed to reduce functional decline among seniors, using a participatory care approach and integrated health teams. The evaluation provides older people and community support workers (CSWs) with the opportunity to share their experiences of being involved with an innovative program to reduce functional decline (mobility, skin integrity, nutrition, mental health, continence) of older, community dwelling adults implemented by a Nursing Service in a major capital city in Australia. As part of the program, CSWs were trained to provide care that aimed to reduce functional decline, and improve the quality of life for the care recipients. Data were collected through in-depth interviews with older people receiving care and a focus group (FG) was conducted with CSWs. Seven themes emerged during data analysis: 1) functionality/independence; 2) prevention; 3) confidence; 4) connection; 5) the approach; 6) care plans; and 7) the role of the CSWs. The relationship built between care giver and receiver and the mutual respect facilitated through adopting a participatory care approach was crucial. This relationship-focused care contributed to improved functionality and consequently quality of life for the older person, and for the CSW professional it contributed to their development, improved satisfaction with their role, and increased pride in the difference they make in the lives of their clients. Opportunities for improvement of the program included ensuring that participants understood the rationale for all aspects of the program, including regular reminders, as well as the use of regular reviews of individual outcomes.

Equity of utilisation of cardiovascular care and mental health services in England: a cohort-based cross-sectional study using small-area estimation

Background

A strong policy emphasis on the need to reduce both health inequalities and unmet need in deprived areas has resulted in the substantial redistribution of English NHS funding towards deprived areas. This raises the question of whether or not socioeconomically disadvantaged people continue to be disadvantaged in their access to and utilisation of health care.

Objectives

To generate estimates of the prevalence of cardiovascular disease (CVD) and common mental health disorders (CMHDs) at a variety of scales, and to make these available for public use via Public Health England (PHE). To compare these estimates with utilisation of NHS services in England to establish whether inequalities of use relative to need at various stages on the health-care pathway are associated with particular sociodemographic or other factors.

Design

Cross-sectional analysis of practice-, primary care trust- and Clinical Commissioning Group-level variations in diagnosis, prescribing and specialist management of CVD and CMHDs relative to the estimated prevalence of those conditions (calculated using small-area estimation).

Results

The utilisation of CVD care appears more equitable than the utilisation of care for CMHDs. In contrast to the reviewed literature, we found little evidence of underutilisation of services by older populations. Indeed, younger populations appear to be less likely to access care for some CVD conditions. Nor did deprivation emerge as a consistent predictor of lower use relative to need for either CVD or CMHDs. Ethnicity is a consistent predictor of variations in use relative to need. Rates of primary management are lower than expected in areas with higher percentages of black populations for diabetes, stroke and CMHDs. Areas with higher Asian populations have higher-than-expected rates of diabetes presentation and prescribing and lower-than-expected rates of secondary care for diabetes. For both sets of conditions, there are pronounced geographical variations in use relative to need. For instance, the North East has relatively high levels of use of cardiac care services and rural (shire) areas have low levels of use relative to need. For CMHDs, there appears to be a pronounced ‘London effect’, with the number of people registered by general practitioners as having depression, or being prescribed antidepressants, being much lower in London than expected. A total of 24 CVD and 41 CMHD prevalence estimates have been provided to PHE and will be publicly available at a range of scales, from lower- and middle-layer super output areas through to Clinical Commissioning Groups and local authorities.

Conclusions

We found little evidence of socioeconomic inequality in use for CVD and CMHDs relative to underlying need, which suggests that the strong targeting of NHS resources to deprived areas may well have addressed longstanding concerns about unmet need. However, ethnicity has emerged as a significant predictor of inequality, and there are large and unexplained geographical variations in use relative to need for both conditions which undermine the principle of equal access to health care for equal needs. The persistence of ethnic variations and the role of systematic factors (such as rurality) in shaping patterns of utilisation deserve further investigation, as does the fact that the models were far better at explaining variation in use of CVD than mental health services.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

A retrospective study of medical comorbidities in psychogeriatric patients

BACKGROUND

This study contributes further research into the assessment and treatment of older psychiatric patients with medical comorbidities.

METHODS

A retrospective file audit was conducted at the acute inpatient psychogeriatric unit of St Vincent's Aged Mental Health Service, Melbourne, in order to determine the prevalence of certain medical comorbidities and the nature of medical interventions provided for psychogeriatric inpatients.

RESULTS

This study, investigating 165 admissions into an acute inpatient psychogeriatric unit, highlights that psychiatric and medical comorbidities are routine in this population: the vast majority (91.5%) of all inpatients had at least one medical comorbidity.

CONCLUSIONS

As the population ages, psychogeriatric wards are likely to see more of the oldest-olds, who are likely to have comorbid medical illnesses. Currently, appropriate detection, investigation, and management of these illnesses are often suboptimal and can affect quality of life, increase mortality, and complicate treatment. This paper adds to the literature about the need for integrating medical and psychiatric care to create a more comprehensive strategy for treating the older person with psychiatric illness.

National trends and local delivery in old age mental health services: towards an evidence base. A mixed-methodology study of the balance of care approach, community mental health teams and specialist mental health outreach to care homes

Background

The rising number of older people with mental health problems makes the effective use of mental health resources imperative. Little is known about the clinical effectiveness and/or cost-effectiveness of different service models.

Aims

The programme aimed to (1) refine and apply an existing planning tool [‘balance of care’ (BoC)] to this client group; (2) identify whether, how and at what cost the mix of institutional and community services could be improved; (3) enable decision-makers to apply the BoC framework independently; (4) identify variation in the structure, organisation and processes of community mental health teams for older people (CMHTsOP); (5) examine whether or not different community mental health teams (CMHTs) models are associated with different costs/outcomes; (6) identify variation in mental health outreach services for older care home residents; (7) scope the evidence on the association between different outreach models and resident outcomes; and (8) disseminate the research findings to multiple stakeholder groups.

Methods

The programme employed a mixed-methods approach including three systematic literature reviews; a BoC study, which used a systematic framework for choosing between alternative patterns of support by identifying people whose needs could be met in more than one setting and comparing their costs/outcomes; a national survey of CMHTs’ organisation, structure and processes; a multiple case study of CMHTs exhibiting different levels of integration encompassing staff interviews, an observational study of user outcomes and a staff survey; national surveys of CMHTs’ outreach activities and care homes. A planned randomised trial of depression management in care homes was removed at the review stage by the National Institute for Health Research (NIHR) prior to funding award.

Results

BoC: Past studies exhibited several methodological limitations, and just two related to older people with mental health problems. The current study suggested that if enhanced community services were available, a substantial proportion of care home and inpatient admissions could be diverted, although only the latter would release significant monies. CMHTsOP: 60% of teams were considered multidisciplinary. Most were colocated, had a single point of access (SPA) and standardised assessment documentation. Evidence of the impact of particular CMHT features was limited. Although staff spoke positively about integration, no evidence was found that more integrated teams produced better user outcomes. Working in high-integration teams was associated with poor job outcomes, but other factors negated the statistical significance of this. Care home outreach: Typical services in the literature undertook some combination of screening (less common), assessment, medication review, behaviour management and training, and evidence suggested intervention can benefit depressed residents. Care home staff were perceived to lack necessary skills, but relatively few CMHTs provided formal training.

Limitations

Limitations include a necessary reliance on observational rather than experimental methods, which were not feasible given the nature of the services explored.

Conclusions

BoC: Shifting care towards the community would require the growth of support services; clarification of extra care housing’s (ECH) role; timely responses to people at risk of psychiatric admission; and improved hospital discharge planning. However, the promotion of care at home will not necessarily reduce public expenditure. CMHTsOP: Although practitioners favoured integration, its goals need clarification. Occupational therapists (OTs) and social workers faced difficulties identifying optimal roles, and support workers’ career structures needed delineating. Care home outreach: Further CMHT input to build care home staff skills and screen for depression may be beneficial. Priority areas for further study include the costs and benefits for older people of age inclusive mental health services and the relative cost-effectiveness of different models of mental health outreach for older care home residents.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Inter-professional perspectives of dementia services and care in England: Outcomes of a focus group study

Many people living with dementia are supported at home using a variety of health and social care services. This paper reports the findings from a focus group study undertaken with staff in community mental health teams to explore areas for improvement in relation to national policies and recommendations for dementia care. Two focus groups were held with staff (n = 23) in 2011 to discuss topics including service delivery, information and communication, and provision of health and community care for people with dementia. Respondents identified problems with information sharing and incompatible electronic systems; inflexibility in home care services; and poor recognition of dementia in hospital settings. General practitioners had developed a greater awareness of the disease and some community services worked well. They felt that budgetary constraints and a focus on quality indicators impeded good dementia care. Key areas suggested by staff for improvements in dementia care included the implementation of more flexible services, dementia training for health and social care staff, and better quality care in acute hospital settings.

Older persons with dementia at risk for institutionalization in eight European countries: a cross-sectional study on the perceptions of informal caregivers and healthcare professionals

AIMS

To explore the perceptions of informal caregivers and healthcare professionals regarding potential reasons for the institutionalization of older persons with dementia in eight European countries.

BACKGROUND

Healthcare professionals may have an important role in facilitating informal caregivers' decision-making regarding institutionalization. Little is known about the perceptions of informal caregivers and healthcare professionals prior to institutionalization.

DESIGN

Cross-sectional survey in eight European countries (November 2010-January 2012).

METHODS

Healthcare professionals reported why they clinically judged persons with dementia at risk for institutionalization. Informal caregivers reported potential reasons from their perspectives. Answers were openly coded and categorized. Variation between informal caregivers and healthcare professionals was investigated (agreement on at least one potential reason per case/proportion of maximum attainable kappa).

RESULTS

Judgements of healthcare professionals and informal caregivers on 1160 persons with dementia were included. A total of 22 categories emerged. Approximately 90% of informal caregivers reported potential reasons. In 41% of the cases, informal caregivers and healthcare professionals agreed on at least one reason. Discrepancy was high for potential reasons related to caregiver burden. For the most frequent categories (caregiver burden, caregiver unable to provide care, neuropsychiatric symptoms, overall deterioration, care dependency), 24-41% of the attainable kappa was achieved. Differences between countries emerged indicating more favourable agreement in Finland, Sweden and Estonia and lowest agreement in England and Spain.

CONCLUSION

Agreement between healthcare professionals and informal caregivers on potential reasons for institutionalization was low-to-moderate. Healthcare professionals are challenged to develop a detailed understanding of the perspectives and perceived burden of informal caregivers.

Variations in structures, processes and outcomes of community mental health teams for older people: a systematic review of the literature

OBJECTIVES

In the UK and elsewhere, specialist community mental health teams (CMHTs) are central to the provision of comprehensive services for older people with mental ill health. Recent guidance documents suggest a core set of attributes that such teams should encompass. This article reports on a systematic literature review undertaken to collate existing evidence regarding the structures and processes of CMHTs for older people and to evaluate evidence linking approaches to effectiveness.

METHOD

Relevant publications were identified via systematic searches, both electronic and manual. Searches were limited to the UK for descriptions of organisation and practice but included international literature where comparisons between different CMHT arrangements were evaluated. Empirical, peer-reviewed studies from 1989 onward were included, extended to non peer-reviewed nationally or regionally representative reports, published after 1998, for the descriptive element.

RESULTS

Forty-five studies met inclusion criteria of which seven provided comparative outcome data. All but one were UK based. The most robust evidence related to research conducted in exemplar teams. Limited evidence was found regarding the effectiveness of many of the core attributes recommended in policy directives although their presence was reported in much of the literature.

CONCLUSIONS

The contrast between presentation and evaluation of attributes is stark. Whilst some gaps can be filled from related fields, further research is required that moves beyond description to evaluation of the impact of team design on service user outcomes in order to inform future policy directives and practice guidance. A framework for an evidence-based model of CMHTs for older people is provided.

Frailty scales--their potential in interprofessional working with older people: a discussion paper

New models of interprofessional working are continuously being proposed to address the burgeoning health and social care needs of older people with complex and long-term health conditions. Evaluations of the effectiveness of these models tend to focus on process measures rather than outcomes for the older person. This discussion paper argues that the concept of frailty, and measures based on it, may provide a more user-centred tool for the evaluation of interprofessional services - a tool that cuts across unidisciplinary preoccupations and definitions of effectiveness. Numerous frailty scales have been developed for case identification and stratification of risk of adverse outcomes. We suggest that they may also be particularly suitable for evaluating the effectiveness of interprofessional working with community-dwelling older people. Several exemplars of frailty scales that might serve this purpose are identified, and their potential contributions and limitations are discussed. Further work is required to establish which is the most suitable scales for this application. The development of an appropriate frailty scale could provide an opportunity for interprofessional debate about the forms of care and treatment that should be prioritised to improve the health and well-being of this population.

Towards integrated community mental health teams for older people in England: progress and new insights

OBJECTIVE

To investigate progress in joint working within community mental health teams for older people (CMHTsOP) against a range of national standards, and to consider team characteristics that may hinder or facilitate integrated practice.

METHODS

A postal questionnaire was sent to the managers of all CMHTsOP in England. A total of 376 teams responded representing a response rate of 87.7%. Hypothesis testing and regression analysis, using a composite score based on nine indicators of integration, were conducted to address the study's aims.

RESULTS

Whilst the study suggests that progress was being made against a number of key standards of joint working, the study finds that most teams could not access local authority service user records, nor were health staff within most teams able to commission social care services. After controlling for other characteristics, teams with the lowest levels of integration tended to work across multiple local authorities; were managed by a nurse; had high referral rates and were located in formally integrated Care Trusts.

CONCLUSIONS

Improved integration could develop by NHS Trusts and local authorities encouraging more information sharing, and further delegating powers to arrange social care services to CMHTOP members. The paper highlights team and locality features that appear to cause obstacles to joint working, but there is a clear gap in the evidence relating team structures and characteristics to the quality of patient care.