A Psychogeriatric Outreach Service to Nursing Homes in Sydney

Exploring the implementation of an outreach specialist program for nursing home residents in Macao: A multisite, qualitative study

Background

The "Specialist Medical Outreach Project (SMOP)" involving inter-disciplinary hospital-based healthcare professionals is a government initiative that aims to provide integrative specialist care to high-risk residents at the nursing homes. However, research exploring the implementation and impact of SMOP is lacking. This study aimed to evidence the impact of SMOP on the quality of care at the nursing home and the key contextual determinants influencing SMOP outcomes.

Method

Semi-structured key informant audio-recorded face-to-face interviews were conducted with eight managers, six doctors, 28 nursing staff, and seven pharmacy staff at the nursing homes participating in the SMOP to collect insights about how SMOP was operated and performed, and the impact of SMOP as observed and expected. Participants were recruited with purposive sampling. A thematic analysis approach was employed and key themes were identified using open coding, grouping, and categorizing.

Results

Forty-nine interviews were conducted. Thematic analysis identified three principal themes: the overall perception about SMOP, the benefits as observed; and the areas of improvement. Together with the 10 subthemes, the results highlighted the expectations for SMOP to address the unmet needs and promote patient-centered care, and the benefits of SMOP in supporting effective use of resources for the nursing home, reducing the risks of adverse events for the residents, promoting communication and capacity building for the healthcare providers and facilitating efficient use of healthcare resources for the health system. Requests for more frequent visits by a larger inter-disciplinary specialist team were raised. Careful staff and workflow planning, and mechanisms for data-sharing and communication across care settings were deemed the most important actions for improvement.

Conclusion

It is a general perception that the SMOP is beneficial in enhancing the quality of care for high-risk residents in the nursing home in Macao. Cross-sector inter-disciplinary collaboration and efficient data-sharing and communication mechanism play a crucial role in ensuring the success of the program. A robust assessment framework to monitor and evaluate the cost-effectiveness of the program is yet to be developed.

Community mental health teams for older people in England: Variations in ways of working

OBJECTIVE

Integrated community mental health teams (CMHTs) are a key component of specialist old age psychiatry services internationally. However, in England, significant shifts in policy, including a focus on dementia and age inclusive services, have influenced provision. This study portrays teams in 2009 against which subsequent service provision may be compared.

METHODS

A bespoke national postal survey of CMHT managers collected data on teams' structure, composition, organisation, working practices, case management, and liaison activities.

RESULTS

A total of 376 CMHTs (88%) responded. Teams comprised a widespread of disciplines. However, just 28% contained the full complement of professionals recommended by government policy. Over 93% of teams had a single point of access, but some GPs bypassed this, and 40% of teams did not accept direct referrals from care homes. Initial assessments were undertaken by multiple disciplines, and 71% of teams used common assessment documentation. Nevertheless, many social workers maintained both NHS and local authority records. In 92% of teams, nominated care coordinators oversaw the support provided by other team members. However, inter-agency care coordination was less prevalent. Few teams offered the range of outreach/liaison activities anticipated in the national dementia strategy.

CONCLUSIONS

Compared with previous studies, teams had grown and changed, with a clear increase in non-medical practitioners, particularly support workers. Measures to facilitate integrated care within CMHTs (eg, common access and documentation) were widespread, but integration across health and social care/primary and secondary services was less developed. Consideration of barriers to further integration, and the impact of current reforms is potentially fruitful.

Evaluating the Utility of a Structured Clinical Protocol for Reducing the Impact of Behavioural and Psychological Symptoms of Dementia in Progressive Neurological Diseases: A Pilot Study

Objectives

Behavioural and psychological symptoms of dementia (BPSD) cause significant distress to both aged care residents and staff. Despite the high prevalence of BPSD in progressive neurological diseases (PNDs) such as multiple sclerosis, Huntington's disease, and Parkinson's disease, the utility of a structured clinical protocol for reducing BPSD has not been systematically evaluated in PND populations.

Method

Staff (n = 51) and individuals with a diagnosis of PND (n = 13) were recruited into the study, which aimed to evaluate the efficacy of a PND-specific structured clinical protocol for reducing the impact of BPSD in residential aged care (RAC) and specialist disability accommodation (SDA) facilities. Staff were trained in the clinical protocol through face-to-face workshops, which were followed by 9 weeks of intensive clinical supervision to a subset of staff (“behaviour champions”). Staff and resident outcome measures were administered preintervention and immediately following the intervention. The primary outcome was frequency and severity of BPSD, measured using the Neuropsychiatric Inventory-Nursing Home Version (NPI-NH). The secondary outcome was staff coping assessed using the Strain in Dementia Care Scale (SDCS).

Results

In SDA, significant reductions in staff ratings of job-related stress were observed alongside a statistically significant decrease in BPSD from T1 to T2. In RAC, there was no significant time effect for BPSD or staff coping; however, a medium effect size was observed for staff job stress.

Conclusions

Staff training and clinical support in the use of a structured clinical protocol for managing BPSD were linked to reductions in staff job stress, which may in turn increase staff capacity to identify indicators of resident distress and respond accordingly. Site variation in outcomes may relate to organisational and workforce-level barriers that may be unique to the RAC context and should be systematically addressed in future RCT studies of larger PND samples.

Provision of specialist continuing care services for older adults across the UK

BACKGROUND

Older people with mental health problems who meet needs based criteria for National Health Service (NHS) continuing care funding may be cared for in a variety of settings. These services have evolved due to socio-economic and political pressure, with the extent of movement of care from traditional NHS run long stay units into the private sector being unclear. Little attention has been paid to the best model of service provision for this group in terms of quality of care, patient outcomes, and cost effectiveness.

METHODS

A literature review was conducted in order to explore what is known about service models for long-term psychiatric care for older people and their cost effectiveness. Following this review, an online survey was conducted in order to establish current specialist continuing care service provision by provider organizations, as well as any planned developments in services.

RESULTS

The way specialist mental health continuing care services are provided in the United Kingdom (UK) varies, with just 45% (33) of NHS providers still operating their own services. Specialist mental health continuing care is an area of current service review for a number of organizations.

CONCLUSIONS

Specialist care services for older adults with mental health problems in the UK are changing, but there is a lack of research on models of service delivery for this group of vulnerable individuals with complex needs. In the context of financial pressures within the NHS, and an increasing awareness of the need to develop and improve quality of services both for those with dementia and other mental illnesses, an urgent need for further research in this area is identified.

An RCT to evaluate the utility of a clinical protocol for staff in the management of behavioral and psychological symptoms of dementia in residential aged-care settings

OBJECTIVES

Behavioral and psychological symptoms of dementia (BPSD) cause significant stress and distress to both aged-care residents and staff. This study evaluated a training program to assist staff to manage BPSD in residential care.

METHOD

A randomised controlled trial (RCT) was employed. The study was included in the Australian and New Zealand Clinical Trial Register residential care facilities. Staff (n = 204) and residents (n = 187) were from 16 residential care facilities. Facilities were recruited and randomly assigned to four staff training conditions: (1) training in the use of a BPSD-structured clinical protocol, plus external clinical support, (2) a workshop on BPSD, plus external clinical support, (3) training in the use of the structured clinical protocol alone, and (4) care as usual. Staff and resident outcome measures were obtained pre-intervention, three months and six months post-intervention. The primary outcome was changes in BPSD, measured using the Cohen-Mansfield Agitation Inventory (CMAI) as well as frequency and duration of challenging behaviors. Secondary outcomes were changes in staff adjustment.

RESULTS

There were improvements in challenging behaviors for both intervention conditions that included training in the BPSD instrument, but these were not maintained in the condition without clinical support. The training/support condition resulted in sustained improvements in both staff and resident variables, whereas the other conditions only led to improvement in some of the measured variables.

CONCLUSION

These results demonstrate the effectiveness of the BPSD protocol in reducing BPSD and improving staff self-efficacy and stress.

Efficacy of integrated interventions combining psychiatric care and nursing home care for nursing home residents: a review of the literature

BACKGROUND

Nursing home residents needing both psychiatric care and nursing home care for either somatic illness or dementia combined with psychiatric disorders or severe behavioural problems are referred to as Double Care Demanding patients, or DCD patients. Integrated models of care seem to be necessary in order to improve the well-being of these residents.

OBJECTIVES

Two research questions were addressed. First, which integrated interventions combining both psychiatric care and nursing home care in DCD nursing home residents are described in the research literature? And second, which outcomes of integrated interventions combining both psychiatric care and nursing home care in DCD nursing home residents are reported in the literature?

METHOD

A critical review of studies was done that involved integrated interventions combining both psychiatric care and nursing home care on psychiatric disorders and severe behavioural problems in nursing home patients. A systematic literature search was performed in a number of international databases.

RESULTS

Eight intervention trials, including four RCTs (2b level of evidence), were identified as relevant studies for the purpose of this review. Seven studies, three of which were RCTs, showed beneficial effects of a comprehensive, integrated multidisciplinary approach combining medical, psychiatric and nursing interventions on severe behavioural problems in DCD nursing home patients.

CONCLUSIONS

Important elements of a successful treatment strategy for DCD nursing home patients include a thorough assessment of psychiatric, medical and environmental causes as well as programmes for teaching behavioural management skills to nurses. DCD nursing home patients were found to benefit from short-term mental hospital admission.This review underlines the need for more rigorously designed studies to assess the effects of a comprehensive, integrated multidisciplinary approach towards DCD nursing home residents.

An evaluation of the effectiveness of a case-specific approach to challenging behaviour associated with dementia

OBJECTIVES

Treatment of challenging behaviour in dementia using standardized psychopharmacological or psychosocial approaches remains problematical. A case-specific approach was trialled in this study, based on extensive evidence that each case is different in aetiology, the effects of the behaviour on others and what interventions are possible given the available resources.

METHOD

Forty-four consecutive referrals for challenging behaviour (two-thirds in residential care) were assessed across multiple causal domains. Both assessment and development of interventions were undertaken in collaboration with family carers and care staff. Measures of behaviour and associated carer distress, as well as medication and service use, were taken pre-intervention and at 2- and 5-month follow-ups.

RESULTS

Psychotropic medication was used with a minority of participants but, overall, antipsychotic use was reduced. Psychosocial methods predominated, with 77% of cases judged as mainly or entirely psychosocial by an expert panel. There were significant mean improvements in behaviour and carer distress. Using conservative criteria there was a 65.9% clinical success rate.

CONCLUSION

Results confirm those of other studies which have used multifaceted interventions tailored to the unique needs of each case. They compare favourably with results from trials of standardized psycho-pharmacological or psychosocial approaches. More trials are needed, necessarily involving further development of robust methodologies which reflect the case-specific nature of challenging behaviour associated with dementia.

Consultation-liaison psychiatry services to nursing homes

OBJECTIVE

The aim of the present paper is to review current opinion relating to the provision of mental health consultation to nursing homes, and to provide recommendations for future research.

METHOD

The current literature pertaining to consultation-liaison psychiatry within nursing homes was reviewed.

RESULTS

There is a paucity of well-designed empirical studies of mental health service provision to Australian nursing homes. This is of particular concern given the ageing Australian population and the prevalence of psychiatric symptoms in nursing home residents. Psychiatric consultation and liaison to nursing homes may result in reduced need for crisis intervention, improved use of behavioural management strategies for the symptoms associated with dementia, and reduced nursing home staff stress and burnout.

CONCLUSIONS

Further research is required to evaluate the costs and benefits of providing regular mental health services to nursing homes in Australia, particularly in rural areas. Future service development should be complemented by methodologically sound evaluation.

The effectiveness of old age psychiatry services

The objective of this study was to review outcomes of acute service delivery in old age psychiatry. Sources of data included Medline, PsycINFO and Cochrane Collaboration databases of English language papers to 1998 on service delivery evaluation in 'old age psychiatry', 'psychogeriatrics' and 'geriatric psychiatry', supplemented by a manual search of references from relevant literature. All controlled trials, audits, and surveys of the outcomes of service delivery in old age psychiatry located in acute hospitals and community settings were included. Service delivery by medical, adult psychiatry and consultation/liaison services were included. With the exception of outreach services to nursing homes, long term institutional care was excluded. All data were extracted by the author. Data quality was assessed by applying an evidence hierarchy. Evaluation strategies were qualitatively reviewed. Controlled trials, audits and surveys were each found to provide important data in the evaluation of service delivery. There is better quality evidence to support the effectiveness of components of old age psychiatry services than other service types. The majority of studies indicate that old age psychiatry services have positive acute treatment outcomes, particularly with depression. There is insufficient evidence to determine which processes of care are associated with better outcomes. Pluralistic evaluations indicate that carers often have unmet needs and are not as positive about outcomes. There have been no controlled comparisons of service delivery provided by other services. In conclusion, controlled trials and audits indicate that old age psychiatry services are effective. Further pluralistic evaluations and comparisons with other services are required.