A before and after study of the impact of Specialist Workers for Older People

A realist review of the home care literature and its blind spots

RATIONALE, AIMS AND OBJECTIVES

There is a large body of literature from all over the world that describes, analyzes, or evaluates home care models and interventions. The present article aims to identify the practical lessons that can be gained from a systematic examination of that literature.

METHOD

We conducted a three-step sequential search process from which 113 documents were selected. That corpus was then narratively analysed according to a realist review approach.

RESULTS

A first level of observation is that there are multiple blind spots in the existing literature on home care. The definition and delimitation of what constitutes home care services is generally under-discussed. In the same way, the composition of the basket of care provided and its fit with the need of recipients is under-addressed. Finally, the literature relies heavily on RCTs whose practical contribution to decisions or policy is disputable. At a second level, our analysis suggests that three mechanisms (system integration, case management and relational continuity) are core characteristics of home care models' effectiveness.

CONCLUSION

We conclude by providing advice for supporting the design and implementation of stronger home care delivery systems. Our analysis suggests that doing so implies a series of sequential steps: identify what system-level goals the model should achieve and which populations it should serve; identify what type of services are likely to achieve those goals in order to establish a basket of services; and finally, identify the best ways and specific means to effectively and efficiently provide those services. Those same steps can also support ex-post evaluations of existing home care systems.

Community-based case management does not reduce hospital admissions for older people: a systematic review and meta-analysis

Objective The aim of this study was to investigate the effectiveness of community-based case management in reducing hospital admissions for older people. Methods Five databases were searched from inception to March 2018. Trials were included if: (1) participants were community-dwelling adults aged ≥65 years; (2) intervention was community-based case management for ≥3 months; (3) outcomes related to hospital admissions; and (4) the design included a control group. The quality of evidence was independently assessed by two reviewers using the Physiotherapy Evidence Database (PEDro) scale and the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach. Data were analysed descriptively and using meta-analyses where possible. Results Nine trials (n=5468 participants) were included in the analysis. Meta-analysis found community-based case management did not reduce hospital admissions (standard mean difference -0.09; 95% confidence interval (CI) -0.27, 0.10), but did reduce emergency department (ED) presentations (mean difference -0.26; 95% CI -0.51, -0.01). Conclusion Community-based case management intervention may be effective in reducing ED presentations for older people. What is known about the topic? Although community-based case management is common in Australia, little is known about its effectiveness in reducing healthcare utilisation for community-dwelling older people. What does this paper add? The results indicate that community-based case management may decrease the number of ED presentations among older people. What are the implications for practitioners? Patients with high ED presentation rates may benefit from community-based case management to reduce the number of unnecessary ED presentations.

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.

Navigation roles support chronically ill older adults through healthcare transitions: a systematic review of the literature

Transitions between various healthcare services are potential points for fragmented care and can be confusing and complicated for patients, formal and informal caregivers. These challenges are compounded for older adults with chronic disease, as they receive care from many providers in multiple care settings. System navigation has been suggested as an innovative strategy to address these challenges. While a number of navigation models have been developed, there is a lack of consensus on the desired characteristics and effectiveness of this role. We conducted a systematic literature review to describe existing navigator models relevant to chronic disease management for older adults and to investigate the potential impact of each model. Relevant literature was identified using five electronic databases - Medline, CINAHL, the Cochrane database, Embase and PsycINFO between January 1999 and April 2011. Following a recommended process for health services research literature reviews, exclusion and inclusion criteria were applied to retrieved articles; 15 articles documenting nine discrete studies were selected. This review suggests that the role of a navigator for the chronically ill older person is a relatively new one. It provides some evidence that integrated and coordinated care guided by a navigator, using a variety of interventions such as care plans and treatment goals, is beneficial for chronically ill older adults transitioning across care settings. There is a need to further clarify and standardise the definition of navigation, as well as a need for additional research to assess the effectiveness and cost of different approaches to the health system.

Role of disability-case manager for chronic diseases: using the ICF as a practical background

PURPOSE

To report on the case manager's activity in a hospital setting as a supporting professional for families that need to deal with different services and professionals to get answers on their health and psychosocial needs.

METHOD

A qualitative analysis and interpretation based on the case manager observations and ICF checklist evaluation with medical and rehabilitation professionals were employed.

RESULTS

The case study presented aimed to show one of the most typical interventions of the case manager: the creation of a network around a person with complex and multifaceted needs, where this network does not exist. Case manager bridged the gap between health and social services, specifically organising home-based rehabilitation and helping to find appropriate assistive devices.

CONCLUSIONS

This case study showed that the case manager's role is fundamental to support patients and their families in relating to the different services and professionals they need, and illustrated one of the most typical interventions of the case manager: the creation of a network around a person with complex and multifaceted needs, where this network does not exist.