The changing face of community and institutional care for the elderly

The NHS and Community Care Act 1990

Aims and Method

The Community Care Act came into effect in April 1993. In order to see what impact this would have on the discharge profile of dementia inpatients, prospective studies of inpatient discharges from a dementia assessment ward before the Act, and five and 41 months after the Act were conducted.

Results

The proportion of patients discharged to their own homes and to residential/nursing homecare remained unaffected by the Act. Duration of hospital stay increased after the Act in 1993 and 1996 (P=O.02) largely due to delays in placement into care homes. Placement delay was increased both in 1993 and 1996, but by 1996 the difference was no longer statistically significant. Duration of hospital stay was unaffected by the Act for those patients discharged to their own homes.

Clinical Implications

The new care management process by social services was found to be associated with delayed discharges for people with dementia requiring residential/nursing home placements, thus causing pressures on beds and hig her in-patient costs.

The use of community-based social services by elderly people at risk of institutionalization: an evaluation

OBJECTIVE

To examine the use of community-based social services by elderly people at risk of institutionalization, who prefer to remain at home.

METHODS

A study with a longitudinal design (measurements at two points in time) was conducted.

RESULTS

One hundred and thirty-four elderly people (mean age=82 years) were interviewed twice. At baseline, 81 respondents indicated that they made use of at least one social service (60.4%). After 1 year the use of these services did not increase significantly (64.2%, p=0.53). Only two services (socio-cultural activities and restaurant facility) out of five services were used frequently. The respondents reported more autonomy and fewer feelings of loneliness after 1 year. These positive changes cannot be related to an increased use of services.

DISCUSSION

Overall, the use of social services remained moderate. This raises questions about the need for these services, the possible barriers and the ability of these social services to contribute to de-institutionalization.

Coordination and integration of disability services for the elderly: a viewpoint

The provision of disability services for the elderly in Australia is fragmented with areas of duplication arising chiefly from disorganized planning with the States and Territories providing certain services independent of Commonwealth contribution. It is suggested that the Commonwealth should be responsible for the complete provision of disability services for the elderly comprising community services and residential care. Private providers competing with each other for efficient provision of such services should be sought with financial incentives in funding arrangements encouraging healthy ageing thereby reducing expenditure in health care in the next decades.

Ageing in Portugal: regional iniquities in health and health care

The health of the Portuguese has improved considerably in the last twenty years. Economic and social transformations that have contributed to the progressive amelioration of problems of feeding, sanitation, hygiene, housing and social conditions in general, as well as health services, have had decisive effect on this phenomenon. The spectacular regression of the indicators related to transmitted diseases, infant, perinatal (more than 50% between 1985 and 1994) and maternal mortality, and the mortality of children 1 to 4 yr old, also reflects this impact. The positive changes that took place in health indicators were reflected in the growth of life expectancy at birth (2.2 yr more for male and 2.3 more for women between 1985 and 1994) in spite of the fact that the difference in life expectancy in relation to EU countries has grown. Improvement in life expectancy, especially in the older age groups, is not normally associated with significant reductions in morbidity. In fact, increased longevity has become more generally associated with chronic illness or other disabilities requiring more medical services and other forms of personal care. This paper reviews some of the evidence for regional differences in the health status of elderly people in Portugal and considers how health services have reacted to these differences. A preliminary study of health status and patterns of utilisation of elderly people was undertaken. After 30 yr of a National Health Service (NHS) in Portugal we may ask why do inequities in health and access to health care of the elderly population persist? Proactive policies to prevent illness and promote health are still relatively underdeveloped in the Portuguese NHS, and the factors that influence health, such as housing, diet and occupational health hazards, remain largely absent from health and welfare policies. Poor accessibility to health services is the most serious barrier consumers have to face in order to get a medical appointment, and this is more relevant to the oldest part of the population. Geographical location of health care facilities unequally affects the ease of access of different groups of consumers and influences utilisation patterns. Examining the distribution of health services resources is an important way to understand the inequities of access to health and to health care.

Socioeconomic and demographic predictors of mortality and institutional residence among middle aged and older people: results from the Longitudinal Study

STUDY OBJECTIVES

To identify socioeconomic and demographic predictors of long term mortality and institutional residence in old age, taking into account changes in socioeconomic and demographic circumstances between the 1971 and 1981 censuses.

DESIGN

Multivariate logistic regression modelling of outcomes for 10 year age cohorts of each gender. The outcomes were death by 31 December 1992; being in an institution in 1991.

SETTING

Members of the Longitudinal Study (a 1% sample of the British Census): 43,092 men and 50,839 women aged 55-74 in 1971.

MAIN RESULTS

Being in rented accommodation and in a household without access to a car carried 35-45% higher mortality rate over 21 years and similar excess risk of being in an institution in 1991. Marital status and living arrangements were weaker predictors of death but being single was a major predictor of moving to an institution for men. Losing household access to a car was a strong factor for mortality for men and for institutionalisation for men aged 55-64 in 1971. The effects were weaker for women. Moving into rented accommodation was a predictor of both outcomes for women and of death for the younger cohort of men. People who started to live alone in the inter-census period were at reduced risk of dying.

CONCLUSIONS

These results demonstrate persistence of inequalities in health related outcomes throughout old age, both in those with unfavourable circumstances in mid-life and in those who, in later life, have lost earlier advantages.

Socioeconomic differences in general practice consultation rates in patients aged 65 and over: prospective cohort study

OBJECTIVE

To examine socioeconomic differences in general practice consultation rates among patients aged 65 years and over.

DESIGN

Secondary analysis of data from the fourth national survey of morbidity in general practice.

SETTING

60 general practices in England and Wales.

SUBJECTS

71 984 people aged 65 years and over.

MAIN OUTCOME MEASURES

Annual contact rates and home visiting rates with general practitioners and practice nurses.

RESULTS

Social class differences in tact rates were greatest in 65-74 year olds, with rates 23% higher in patients from social class V than in class I (4.82 v 3.93 per person). In 75-84 year olds there was no clear association between social class and contact rates, and in people aged >/=85 years contact rates were highest in patients from class I. Home visiting rates were twice as high in patients from class V as in patients from class I (1.38 v 0.66 per person). Contact rates were 17% higher in people living in communal establishments and 8% higher in those living alone than in those living with others but not in a communal establishment. 66% of contacts with patients in communal establishments and 26% of those with patients living alone were in patients' homes compared with 18% with those living in standard accommodation. These differences persisted after adjustment in a generalised linear model.

CONCLUSIONS

Elderly people show socioeconomic differences in consultation rates. The extra workload generated by elderly people living alone and in communal establishments suggests additional payments to general practitioners are needed.

Profile of disability in elderly people: estimates from a longitudinal population study

OBJECTIVES

To provide estimates of the numbers of cognitively impaired and physically disabled elderly people in England and Wales, subdivided by a range of sociodemographic, dependency, care receipt, and survival variables, to support debates on the form and funding of health and welfare programmes.

DESIGN

Interviews at baseline and 2 year follow up plus data on resource use extracted from records for those with disability.

SUBJECTS

10 377 people aged 65 years and over in Cambridgeshire, Newcastle, Nottingham, and Oxford. All estimates weighted to population of England and Wales in 1996.

RESULTS

11% of men and 19% of women aged 65 and over were disabled, totalling 1.3 million people; 38% of these were aged 85 or over and a similar percentage were cognitively impaired. Overall, more than 80% of elderly disabled people needed help on at least a daily basis. Over a third of people with limitations to daily activity living in private households were wholly or partly dependent on formal services for help. 63% of disabled elderly people used acute hospitals during the 2 year follow up, 43% as inpatients. 53% of those with cognitive impairment and limitations to daily activity were living in institutions.

CONCLUSIONS

Very elderly people and those with cognitive impairment make up a large proportion of those in need of long term care. A large proportion of even the most disabled elderly people currently live outside institutions and depend on formal services as well as informal care givers. Disabled elderly people use acute hospitals extensively, underlining the interrelations between acute and long term care.

Factors associated with use of community support services in an older Australian population

OBJECTIVE

To assess prevalence and risk factors associated with use of community support services in a representative older Australian population.

METHODS

The Blue Mountains Eye Study surveyed 3,654 people aged > or = 49 years, 82.4% of eligible residents from an area west of Sydney during 1992-94. Questions about use of community support services were asked during face-to-face interview. Information on marital and living status, socio-economic status measures, past medical history and self-ranked health status were also collected.

RESULTS

186 (5.4%) persons including 124 women (6.3%) and 62 men (4.2%) reported regular use of community support services, including Meals-on-Wheels (n = 52), Home Care (n = 147) or visits from a community nurse (n = 63). All three services were used by 17 persons and two services by 42 persons. There was a marked age-related increase in use of services from 1.8% in persons aged < 60 years to 25.3% in persons aged 80+ years. Factors significantly associated with use of community services in a multivariate model were: age (OR 1.7 per age decade), living alone (OR 2.5), walking disability (OR 4.1), visual impairment (OR 3.0), stroke history (OR 2.2), arthritis history (OR 1.8), low perceived health status (OR 1.7), cancer history (OR 1.7) and a history of any falls in the past 12 months (OR 1.6).

CONCLUSIONS

Our study has found a wide range of health-related factors that impact on the use of community support services, particularly conditions causing difficulty in walking.

IMPLICATIONS

These data may assist health planners in identifying target populations for the provision of community support services.