Improving community support for older people's needs through commissioning third sector services: a qualitative study

AIM

This exploratory study of commissioning third sector services for older people aimed to explore whether service data was fed back to commissioners and whether this could improve intelligence about the population and hence inform future commissioning decisions.

BACKGROUND

Third sector services are provided through charities and non-profit community organizations, and over recent years services have developed that assess and advise people for self-management or provide wellbeing support in the community. Third sector services have an opportunity to reach vulnerable populations and to provide intelligence about them. Some third sector services are state funded (commissioned) in the United Kingdom. While evidence is available about the commissioning of statutory health and social care, as well as private providers, there is limited evidence about how third sector health services are funded.

METHODS

Participants were recruited from commissioner organizations and third sector organizations, both with an interest in supporting the independence, self-management and wellbeing of older people. Organizations were recruited from five purposively selected sites within one region of England (East Midlands). Semi-structured interviews explored the relationships between commissioners and providers and the nature of funding arrangements, including co-production. Interviews also explored collection of data within the service and how data were fed back to commissioners. Focus groups were held with older people with the potential to benefit from wellbeing services.

RESULTS

Commissioning arrangements were varied, sometimes complex, and often involved co-production with the third sector. Commissioners valued third sector organizations for their engagement with the local community, value for money, outreach services and ability to provide information about the community. Assessing the needs and outcomes of individuals was integral to delivery of support and advice to older people. Diverse approaches were used to assess an individual's needs and outcomes, although there were concerns that some assessment questionnaires may be too complex for this vulnerable group. Assessment and outcomes data were also used to monitor the service contract and there was potential for the data to be summarized to inform commissioning strategies, but commissioners did not report using assessment data in this way, in practice. While the policy context encouraged partnerships with third sector organizations and their involvement in decision making, the relationship with third sector organizations was not valued within contract arrangements, and may have been made more difficult by the tendering process and the lack of analysis of service data.

CONCLUSION

This exploratory study has demonstrated a diversity of commissioning arrangements for third sector services across one region of England. Most commissioners invited co-production; that is, the commissioners sought input from the third sector while specifying details of the service. Service data, including assessments of needs and outcomes, were reported to commissioners, however commissioners did not appear to use this to full advantage to inform future commissioning decisions. This may indicate a need to improve measurement of needs and outcomes in order to improve the credibility of the commissioning process.

The effectiveness of the Older prisoner Health and Social Care Assessment and Plan (OHSCAP): a randomised controlled trial

Background

Older people are the fastest-growing group in prisons in England and Wales and have complex health and social care needs that often remain unmet.

Objectives

(1) Evaluate the efficacy of the Older prisoner Health and Social Care Assessment and Plan (OHSCAP) in improving (i) the ability to meet older male prisoners’ health and social care needs, (ii) health-related quality of life (HRQoL), (iii) depressive symptoms and (iv) functional health and well-being and activities of daily living; (2) assess the quality of care plans produced; (3) explore the experiences of older prisoners receiving, and staff conducting, the OHSCAP; and (4) evaluate the cost-effectiveness of the OHSCAP compared with treatment as usual (TAU).

Design

Multicentre, parallel-group randomised controlled trial (RCT) with follow-up at 3 months, with a nested qualitative study and quality audit of care plans (n = 150, 68%).

Setting

Ten English prisons.

Participants

Four hundred and ninety-seven newly arrived male prisoners aged ≥ 50 years with a discharge date at least 3 months from recruitment. A total of 14 prisoners and 11 staff participated in qualitative interviews.

Intervention

Randomisation to OHSCAP or TAU. The OHSCAP group had health and social needs assessed by a trained health-care worker or prison officer. Care plans were devised and subsequent actions included professional support and appropriate referrals.

Main outcome measures

Primary outcome measure – mean number of unmet health and social care needs as measured by the Camberwell Assessment of Need – Short Forensic Version. Secondary outcome measures – measures of functional health and well-being, depressive symptoms and HRQoL. A health economic evaluation was undertaken using service contact between baseline and follow-up and appropriate unit cost information.

Results

A total of 497 prisoners were recruited (248 to OHSCAP and 249 to TAU). The 404 completed follow-ups were split evenly between the trial arms. No significant differences were observed between the intervention and TAU groups in relation to the primary outcome measure. The OHSCAP did not demonstrate convincing benefits in HRQoL over TAU, and there were no significant differences in relation to costs. Audit and qualitative data suggest that the intervention was not implemented as planned.

Limitations

As a result of the limited follow-up period, potential long-term gains of the intervention were not measured. Some of the standardised tools had limited applicability in prison settings. Cost-effectiveness data were limited by unavailability of relevant unit cost data.

Conclusions

The OHSCAP failed in its primary objective but, fundamentally, was not implemented as planned. This appears to have been attributable, in some part, to wider difficulties currently affecting the prison landscape, including reduced levels of staffing, the loss of specialist support roles for such initiatives and increased prevalence of regime disruption.

Future work

Partnership working and information sharing across disciplines within prison settings require improvement. Research should explore the potential involvement of other prisoners and third-sector organisations in identifying and addressing older prisoners’ health and social care needs to better match community provision. Further examination should be undertaken of how the prison regime and system affects the well-being of older prisoners. Future prison-based RCTs should carefully balance the fidelity of initiatives being evaluated and testing in a ‘real-life’ setting.

Trial registration

Current Controlled Trials ISRCTN11841493.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 5, No. 31. See the NIHR Journals Library website for further project information.

An electronic referral system supporting integrated hospital discharge

Purpose

The purpose of this paper is to evaluate the implementation and potential value of an electronic referral system to improve integrated discharge planning for hospitalised older adults with complex care needs. This new technology formed part of the “Common Assessment Framework for Adults” policy in England.

Design/methodology/approach

Mixed methods were undertaken as part of a case study approach within an acute hospital in the North West of England. First, qualitative interviews were undertaken with practitioners to explore early experiences using the new technology. Second, routinely collected administrative data were analysed, comparing referrals made using the new technology and those made through the usual paper-based process.

Findings

Qualitative interviews found that an electronic discharge system has, in principle, the potential to improve the efficiency and suitability of integrated care planning. However, the implementation proved fragile to decisions taken elsewhere in the local care system, meaning its scope was severely curtailed in practice. Several “socio-technical” issues were identified, including the loss of valuable face-to-face communication by replacing manual with electronic referrals.

Research limitations/implications

The small number of patients referred during the implementation phase meant that patient outcomes could not be definitively judged. Research into the longer-term implications and value of electronic referral systems is needed.

Originality/value

There is concern that attempts to integrate health and social care are stymied by incompatible systems for recording service user information. This research explores a novel attempt to share assessment information and improve support planning across health and social care boundaries.

Validity of the EASYCare Standard 2010 assessment instrument for self-assessment of health, independence, and well-being of older people living at home in Poland

EASYCare Standard 2010 is a brief instrument identifying concerns in health, functional independence, and well-being, from older persons’ perspective. It has not previously been validated for self-assessment. Our aim was to determine whether self-assessment (EC1) can give comparable results to an evaluation performed by professionals (EC2), for older people living at home. The study included community-dwelling individuals (aged at least 60 years, n = 100; 67 females) without dementia (abbreviated mental test score [AMTS] above 6). It comprised two assessments (self and professional), including summarising indexes: Independence score [IS], Risk of breakdown in care [RBC], Risk of falls [RF], performed within a period between 1 and 2 weeks. Additionally, during EC1, reference tests of physical and mental function (Barthel Index: 96.3 ± 6.5, Lawton scale: 6.7 ± 2.0, geriatric depression scale: 3.0 ± 2.7, AMTS: 10.2 ± 1.0) were applied to test for concurrent validity. Cohen’s kappa values (self-assessment vs. professional assessment) across all EASYCare domains were high (0.89–0.95). Results of all summarising indexes derived from self-assessment correlated strongly with reference tests. No differences were found in IS and RBC between EC1 and EC2 (8.6 ± 12.0 vs. 9.0 ± 12.7 and 1.0 ± 1.1 vs. 1.2 ± 1.4). Results of RF were higher in EC2 (1.0 ± 1.1 vs. 1.1 ± 1.4; p = 0.005), due to a different response to the item “Do you feel safe outside your home?” We conclude that self-assessment with EASYCare Standard in older people without severe functional impairment living at home can deliver valid results, similar to those obtained through professional assessment, thus providing an efficient system for assessment of relatively independent individuals.

Health and social care services for older male adults in prison: the identification of current service provision and piloting of an assessment and care planning model

Background

Older prisoners are the fastest growing subgroup in the English and Welsh prison estate. Existing research highlights that older prisoners have high health and social care needs and that, currently, these needs routinely remain unmet.

Objectives

(1) To explore the needs of men entering and leaving prison; (2) to describe current provision of services, including integration between health and social care services; and (3) to develop and pilot an intervention for identifying health and social care needs on reception into prison, ensuring that these are systematically addressed during custody.

Methods

The research programme was a mixed-methods study comprising four parts: (1) a study of all prisons in England and Wales housing older adult men, establishing current availability and degree of integration between health and social care services through a national survey and qualitative interviews; (2) establishing the health and social care needs of older men entering prison, including experiences of reception into custody, through structured (n = 100) and semistructured (n = 27) interviews; (3) the development and implementation of an intervention to identify and manage the health, social care and custodial needs of older men entering prison; and (4) exploration of the health and social care needs of older men released from prison into the community through qualitative interviews with older prisoners prior to and following discharge from prison. Descriptive statistics were produced for all quantitative data, and qualitative data were analysed using the constant comparison method.

Results

The number of older prisoner leads has increased in recent years but they do not all appear always to be active in their roles, nor in receipt of specialist training. Nearly half (44%) of establishments do not have an older prisoner policy. There is a lack of integration between health and social care services because of ambiguity regarding responsibility for older prisoners' social care. The responsible social service may be located a considerable distance from where the prisoner is held; in such instances, local social services do not co-ordinate their care. The most frequent unmet need on prison entry was the provision of information about care and treatment. Release planning for older prisoners was frequently non-existent.

Limitations

The study used a cut-off age of 60 years as the lower limit for the definition of an older prisoner; evidence has emerged that supports a redefinition of that cut-off to 50 years. Our study examined the care provided for men and this should be considered if contemplating using the Older prisoner Health and Social Care Assessment and Plan (OHSCAP) with older women in prison.

Conclusion

The OHSCAP, developed as part of this study, provided a feasible and acceptable means of identifying and systematically addressing older prisoners' health and social care needs. Future work will include the conduct of a randomised controlled trial to examine the impact of the OHSCAP in terms of improving a range of outcomes, including economic impact.

Funding

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

Development and evidence base of a new efficient assessment instrument for international use by nurses in community settings with older people

In a world where 12% of the population, and 22% of that of more developed regions, will be older than 65 years by 2030, new targeted programs and social protections will be needed for older people in many countries. As economic and human resources become more scarce, efficient instruments are needed to realize sustainable health care for these large populations of older subjects. To address this need a new assessment instrument was developed. The core of the instrument consists of focused geriatric assessment by a health or social care practitioner working in primary or community care, most often a nurse. The assessment data result in an efficiently targeted care and welfare action plan based on the patients' priorities. This instrument was initially developed, tested and spread within Europe, and then in validation studies across all WHO regions of the world. Because of the urgent societal questions on quality and sustainability of primary health care, especially for older people, we briefly review and summarize the development and evidence base of the instrument, which was called EASY-Care Standard. In a series of studies across many populations it proved to have high acceptability, reliability, validity and cost-effectiveness. Therefore, EASY-Care has great potential as a universal tool for global use in promoting independence in old age, and can make an important contribution to the quality and sustainability of health and social care in our aging societies.