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Carter L, O'Neill S, Austin PC, Keogh F, Pierce M, O'Shea E. Admission to long-stay residential care and mortality among people with and without dementia living at home but on the boundary of residential care: a competing risks survival analysis. Aging Ment Health 2021; 25:1869-1876. [PMID: 33317328 DOI: 10.1080/13607863.2020.1857698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Health policy in many countries is underpinned by a commitment to support dependent older people to remain in their own home for as long as possible and practicable. This study explores factors affecting both admission to long-stay residential care (LSRC) and mortality among people with and without dementia who are currently living at home with intensive formal care support. METHODS This is a cross-sectional study based on administrative data collected on 429 dependent older people in Ireland, 269 of whom were people with dementia. A cause-specific hazard model was used to investigate the hazard of admission to LSRC, while accounting for mortality as a competing risk and vice versa. RESULTS Admission to LSRC was higher for people with dementia relative to people without and for those receiving lower amounts of informal care. The hazard of mortality was significantly higher for older people aged 85+, whereas it was lower for individuals with a medium level of dependency relative to those with high levels of dependency. The hazard of mortality was also influenced by the amount of informal care provision. CONCLUSION People with dementia are more likely to be admitted to LSRC than people without. Care for people with dementia needs to be more specialised and personal, and intensity of provision should not be equated to the number of care hours on offer. Informal care provision may help to prevent admission to LSRC. Advanced age, physical dependency and informal care provision affect mortality, raising interesting issues in relation to resource allocation.
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Affiliation(s)
- L Carter
- Centre for Economic and Social Research on Dementia, Institute for Lifecourse and Society, National University of Ireland, Galway, Ireland
| | - S O'Neill
- J.E. Cairnes School of Business and Economics, Upper Newcastle, National University of Ireland, Galway, Ireland
| | - Peter C Austin
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada. Institute of Health Management, Policy and Evaluation, University of Toronto, Toronto, Canada
| | - F Keogh
- Centre for Economic and Social Research on Dementia, Institute for Lifecourse and Society, National University of Ireland, Galway, Ireland
| | - M Pierce
- Faculty of Science and Health, Dublin City University, Dublin, Ireland
| | - E O'Shea
- Centre for Economic and Social Research on Dementia, Institute for Lifecourse and Society, National University of Ireland, Galway, Ireland
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2
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Keogh F, Pierse T, Challis D, O'Shea E. Resource allocation across the dementia continuum: a mixed methods study examining decision making on optimal dementia care among health and social care professionals. BMC Health Serv Res 2021; 21:243. [PMID: 33736620 PMCID: PMC7977590 DOI: 10.1186/s12913-021-06230-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 03/01/2021] [Indexed: 11/10/2022] Open
Abstract
Background The understanding of appropriate or optimal care is particularly important for dementia, characterised by multiple, long-term, changing needs and the increasing expectations of people using services. However, the response of health and social care services is limited by resource constraints in most countries. This study sought to determine the optimal level, mix and cost of services for different dementia case types across the dementia continuum, and to better understand the resource allocation decision making process among health and social care professionals (HSCPs). Methods A balance of care framework was applied to the study questions and developed in three ways; firstly by considering optimality across the course of dementia and not just at the margin with residential care; secondly, through the introduction of a fixed budget to reveal constrained optimisation strategies; and thirdly through the use of a mixed methods design whereby qualitative data was collected at workshops using nominal group technique and analysed to obtain a more detailed understanding of the decision-making process. Twenty four HSCPs from a variety of disciplines participated in the resource allocation decision-making exercise. Results HSCPs differentiated between case type severity; providing 2.6 times more resources to case types with higher level needs than those with lower level needs. When a resource constraint was introduced there was no evidence of any disproportionate rationing of services on the basis of need, i.e. more severe case types were not favoured over less severe case types. However, the fiscal constraint led to a much greater focus on meeting physical and clinical dependency needs through conventional social care provision. There was less emphasis on day care and psychosocial provision when resources were scarcer following the introduction of a fixed budget constraint. Conclusions HSCPs completed complex resource allocation exercises for people with dementia, including expected differentiation across case type severity. When rationing was introduced, HSCPs did not discriminate in favour of case types with high levels of need. They did, however, support conventional home care provision over psychosocial care, although participants were still keen to provide some residual cover for the latter, especially for case types that might benefit. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06230-9.
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Affiliation(s)
- Fiona Keogh
- Centre for Economic and Social Research on Dementia, National University of Ireland Galway, Newcastle Road, Galway, H91 TK33, Ireland.
| | - Tom Pierse
- Centre for Economic and Social Research on Dementia, National University of Ireland Galway, Newcastle Road, Galway, H91 TK33, Ireland
| | - David Challis
- Institute of Mental Health, University of Nottingham, Nottingham, NG7 2RD, UK
| | - Eamon O'Shea
- Centre for Economic and Social Research on Dementia, National University of Ireland Galway, Newcastle Road, Galway, H91 TK33, Ireland
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3
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Poss J, Mitchell L, Mah J, Keefe J. Disparities in Utilization of Psychiatry Services Among Home Care Clients: The Tale of Two Canadian Jurisdictions. Front Psychiatry 2021; 12:712112. [PMID: 34603103 PMCID: PMC8484907 DOI: 10.3389/fpsyt.2021.712112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/09/2021] [Indexed: 11/28/2022] Open
Abstract
Publicly funded home care in Canada supports older adults in the community to delay institutional care, which results in complex care populations with multimorbidity that includes mental health problems. The purpose of this study is to examine prevalence of psychiatric diagnoses and other mental health symptoms among older clients in two publicly funded Home Care (HC) Programs and their psychiatry service utilization (psychiatrist visits) after being admitted to home care. This retrospective cohort study examines clients age 60 years and older in the two Canadian provinces of Manitoba (MB), specifically the Winnipeg Regional Health Authority (WRHA) (n = 5,278), and Nova Scotia (NS) (n = 5,323). Clients were admitted between 2011 and 2013 and followed up to 4 years. Linked data sources include the InterRAI Resident Assessment Instrument for Home Care (RAI-HC), physician visit/billing data and hospital admission data. Both regions had similar proportions (53%) of home care clients with one or more psychiatric diagnoses. However, we observed over 10 times the volume of psychiatry visits in the WRHA cohort (8,246 visits vs. 792 visits in NS); this translated into a 4-fold increased likelihood of receiving psychiatry visits (17.2% of WRHA clients vs. 4.2% of NS clients) and 2.5 times more visits on average per client (9.1 avg. visits in MB vs. 3.6 avg. visits in NS). The location of psychiatry services varied, with a greater number of psychiatry visits occurring while in hospital for WRHA HC clients compared to more visits in the community for NS HC clients. Younger age, psychotropic medication use, depressive symptoms, dementia, and having an unstable health condition were significantly associated with receipt of psychiatry visits in both cohorts. Access to psychiatric care differed between the cohorts despite little to no difference in need. We conclude that many home care clients who could have benefitted from psychiatrist visits did not receive them. This is particularly true for rural areas of NS. By linking the RAI-HC with other health data, our study raises important questions about differential access to psychiatry services by site of care (hospital vs. community), by geographical location (MB vs. NS and urban vs. rural) and by age. This has implications for staff training and mental health resources in home care to properly support the mental health needs of clients in care. Study results suggest the need for a mental health strategy within public home care services.
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Affiliation(s)
- Jeffrey Poss
- School of Public Health and Health Systems, Faculty of Applied Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Lori Mitchell
- Winnipeg Regional Health Authority, Winnipeg, MB, Canada
| | - Jasmine Mah
- Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Janice Keefe
- Department of Family Studies and Gerontology, Mount Saint Vincent University, Halifax, NS, Canada.,Nova Scotia Centre on Aging, Mount Saint Vincent University, Halifax, NS, Canada
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Keogh F, Pierse T, O'Shea E, Fitzgerald C, Challis D. Resource allocation decision-making in dementia care with and without budget constraints: a qualitative analysis. HRB Open Res 2020; 3:69. [PMID: 33506175 PMCID: PMC7808053 DOI: 10.12688/hrbopenres.13147.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2020] [Indexed: 12/11/2022] Open
Abstract
Introduction: Health systems in many different countries have increasingly been reorienting the delivery of dementia care to home and community care settings. This paper provides information on how health and social care professionals (HSCPs) in Ireland make decisions on resource allocation for people with dementia living at home and how resource constraints affect their decisions and choices. Methods: A balance of care approach was used to assess resource allocation across six dementia case types, from low to high needs. Workshops were held with 24 HSCPs from multiple disciplines. Participants allocated services in two scenarios: allocation with and without a budget constraint. Nominal group technique was used to structure discussions around resource allocation in both scenarios. Thematic analysis was applied to analyse the qualitative data using a general inductive approach. Results: The following themes influenced allocative deliberations: whose needs are being met; what needs are identified; decision making context; decision making process; and allocation outcomes. Participants were proficient in making decisions, using 'decision rules' or heuristics to help them make decisions under fixed budget rules and sticking to conventional provision when constraints were in place. Conclusions: Freedom from a budget constraint allowed HSCPs to consider a broader range of services and to take a more expansive view on what needs should be considered, with a particular emphasis on adopting a proactive, preventative approach to the allocation of resources. The effect of the budget constraint overall was to narrow all considerations, using heuristics to limit the type of needs addressed and the range of services and supports provided. The consequences were a largely reactive, less personalised system of care. The findings emphasise the need for an integrated and comprehensive assessment process that is more concerned with individualised responses rather than relying on existing models of care alone.
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Affiliation(s)
- Fiona Keogh
- Centre for Economic and Social Research on Dementia, National University of Ireland, Galway, Galway, Ireland
| | - Tom Pierse
- Centre for Economic and Social Research on Dementia, National University of Ireland, Galway, Galway, Ireland
| | - Eamon O'Shea
- Centre for Economic and Social Research on Dementia, National University of Ireland, Galway, Galway, Ireland
| | - Christine Fitzgerald
- Centre for Economic and Social Research on Dementia, National University of Ireland, Galway, Galway, Ireland
| | - David Challis
- Institute of Mental Health, University of Nottingham, Nottingham, UK
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5
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Keogh F, Pierse T, O'Shea E, Fitzgerald C, Challis D. Resource allocation decision-making in dementia care with and without budget constraints: a qualitative analysis. HRB Open Res 2020; 3:69. [PMID: 33506175 PMCID: PMC7808053 DOI: 10.12688/hrbopenres.13147.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2020] [Indexed: 11/20/2022] Open
Abstract
Introduction: Health systems in many different countries have increasingly been reorienting the delivery of dementia care to home and community care settings. This paper provides information on how health and social care professionals (HSCPs) in Ireland make decisions on resource allocation for people with dementia living at home and how resource constraints affect their decisions and choices. Methods: The study employed a balance of care approach to assess resource allocation across six dementia case types, ranging from low to high needs. Decision-making workshops were held with 24 HSCPs from a range of backgrounds. Participants were asked to allocate services and supports across dementia case types in two scenarios: allocation with and without a budget constraint. Nominal group technique was used to structure discussions around resource allocation in both scenarios. Thematic analysis was applied to analyse the qualitative data using a general inductive approach. Results: The following themes influenced allocative deliberations: whose needs are being met; what needs are identified; decision making context; decision making process; and allocation outcomes. Participants used 'decision rules' or heuristics to help them make decisions under fixed budget rules. Conclusions: Freedom from a budget constraint allowed HSCPs to consider a broader range of services and to take a more expansive view on what needs should be considered, with a particular emphasis on adopting a proactive, preventative approach to the allocation of resources. The effect of the budget constraint overall was to narrow all considerations, using heuristics to limit the type of needs addressed and the range of services and supports provided. The consequences were a largely reactive, less personalised system of care. The findings emphasise the need for an integrated and comprehensive assessment process that is more concerned with individualised responses rather than relying on existing models of care alone.
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Affiliation(s)
- Fiona Keogh
- Centre for Economic and Social Research on Dementia, National University of Ireland, Galway, Galway, Ireland
| | - Tom Pierse
- Centre for Economic and Social Research on Dementia, National University of Ireland, Galway, Galway, Ireland
| | - Eamon O'Shea
- Centre for Economic and Social Research on Dementia, National University of Ireland, Galway, Galway, Ireland
| | - Christine Fitzgerald
- Centre for Economic and Social Research on Dementia, National University of Ireland, Galway, Galway, Ireland
| | - David Challis
- Institute of Mental Health, University of Nottingham, Nottingham, UK
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6
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Carter L, O'Neill S, Keogh F, Pierce M, O'Shea E. Intensive home care supports, informal care and private provision for people with dementia in Ireland. DEMENTIA 2019; 20:47-65. [PMID: 31349753 DOI: 10.1177/1471301219863580] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND This study analysed the cost of intensive home care packages for people with dementia living on the boundary of home care and residential care facilities in Ireland. The cost of community-based services and supports, including informal care and private out-of-pocket expenditure, was compared to the cost of public and private residential care. METHODS The study recruited 42 people with dementia and/or their caregivers, who were living on the boundary of home care and residential care, to an in-depth study on the cost of care. The Resource Utilization in Dementia scale was used to collect data on the utilization of standard formal care and informal care by people with dementia in receipt of an intensive home care package. Information on private out-of-pocket expenditure on care was also collected. Unit costs were assigned and community-based care was compared with public and private residential care alternatives. RESULTS The average weekly cost of home care, including the intensive home care package, standard formal community care provision, medications, consumption and housing, was estimated at €1127. This is lower than the average weekly cost of public long-stay care facilities (€1526) and around the same as for private nursing home fees in the Dublin region (€1149). When the opportunity cost valuation of informal care is included, the cost of home care is higher than all types of residential care. Adding private care expenditure further inflates the cost of home care. CONCLUSION Keeping highly dependent people with dementia living at home is not cheap and raises questions about optimal resource allocation on the boundary of home care and residential care. Even with significant public spending on intensive home care packages, family care costs remain high. So too does private out-of-pocket expenditure on care for some people with dementia.
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Affiliation(s)
- Laura Carter
- Centre for Economic and Social Research on Dementia, Institute for Lifecourse and Society, National University of Ireland, Galway, Ireland
| | - Stephen O'Neill
- School of Business and Economics, National University of Ireland, Galway, Ireland
| | - Fiona Keogh
- Centre for Economic and Social Research on Dementia, Institute for Lifecourse and Society, National University of Ireland, Galway, Ireland
| | - Maria Pierce
- Faculty of Science and Health, Dublin City University, Dublin, Ireland
| | - Eamon O'Shea
- Centre for Economic and Social Research on Dementia, Institute for Lifecourse and Society, National University of Ireland, Galway, Ireland
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7
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Tucker S, Hughes J, Jolley D, Buck D, Hargreaves C, Challis D. Reconfiguring in-patient services for adults with mental health problems: changing the balance of care. BJPsych Open 2018; 4:420-426. [PMID: 30450220 PMCID: PMC6235991 DOI: 10.1192/bjo.2018.60] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 07/18/2018] [Accepted: 09/20/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Research suggests that a significant minority of hospital in-patients could be more appropriately supported in the community if enhanced services were available. However, little is known about these individuals or the services they require. AIMS To identify which individuals require what services, at what cost. METHOD A 'balance of care' (BoC) study was undertaken in northern England. Drawing on routine electronic data about 315 admissions categorised into patient groups, frontline practitioners identified patients whose needs could be met in alternative settings and specified the services they required, using a modified nominal group approach. Costing employed a public-sector approach. RESULTS Community care was deemed appropriate for approximately a quarter of admissions including people with mild-moderate depression, an eating disorder or personality disorder, and some people with schizophrenia. Proposed community alternatives drew heavily on carer support services, community mental health teams and consultants, and there was widespread consensus on the need to increase out-of-hours community services. The costs of the proposed community care were relatively modest compared with hospital admission. On average social care costs increased by approximately £60 per week, but total costs fell by £1626 per week. CONCLUSIONS The findings raise strategic issues for both national policymakers and local service planners. Patients who could be managed at home can be characterised by diagnosis. Although potential financial savings were identified, the reported cost differences do not directly equate to cost savings. It is not clear whether in-patient beds could be reduced. However, existing beds could be more efficiently used. DECLARATION OF INTEREST None.
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Affiliation(s)
- Sue Tucker
- Research Fellow, Personal Social Services Research Unit, University of Manchester, UK
| | - Jane Hughes
- Senior Research Fellow, Personal Social Services Research Unit, University of Manchester, UK
| | - David Jolley
- Honorary Reader, Personal Social Services Research Unit, University of Manchester, UK
| | - Deborah Buck
- Research Associate, Personal Social Services Research Unit, University of Manchester, UK
| | - Claire Hargreaves
- Research Associate, Personal Social Services Research Unit, University of Manchester, UK
| | - David Challis
- Professor of Community Care Research and Director, Personal Social Services Research Unit, University of Manchester, UK
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Verbeek H, Worden A, Wilberforce M, Brand C, Tucker S, Abendstern M, Challis D. Community mental health teams for older people in England: Variations in ways of working. Int J Geriatr Psychiatry 2018; 33:475-481. [PMID: 28833581 DOI: 10.1002/gps.4775] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 07/14/2017] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Hilde Verbeek
- Personal Social Services Research Unit, University of Manchester, UK.,CAPHRI School for Public Health and Primary Care, Department of Health Services Research, Maastricht University, The Netherlands
| | - Angela Worden
- Personal Social Services Research Unit, University of Manchester, UK
| | - Mark Wilberforce
- Personal Social Services Research Unit, University of Manchester, UK
| | - Christian Brand
- Personal Social Services Research Unit, University of Manchester, UK.,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Sue Tucker
- Personal Social Services Research Unit, University of Manchester, UK
| | | | - David Challis
- Personal Social Services Research Unit, University of Manchester, UK
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Stewart K, Hargreaves C, Jasper R, Challis D, Tucker S, Wilberforce M. Provision and perceived quality of mental health services for older care home residents in England: a national survey. Int J Geriatr Psychiatry 2018. [PMID: 28639286 DOI: 10.1002/gps.4753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE This study examined the nature, extent and perceived quality of the support provided by community mental health teams for older people (CMHTsOP) to care home residents. METHODS A postal survey was sent to all CMHTsOP in England. Information was collected about teams' staffing and their involvement in case finding, assessment, medication reviews, care planning and training as well as team managers' rating of the perceived quality of the service they provided for care home residents. Data were analysed using chi-squared tests of association and ordinal regression. RESULTS Responses were received from 225 (54%) CMHTsOP. Only 18 per cent of these teams contained staff with allocated time for care home work. Services for care home residents varied considerably between teams. Two-fifths of teams provided formal training to care home staff. Team managers were more likely to perceive the quality of their service to care homes as good if they had a systematic process in place for reviewing antipsychotic drugs or routine mental health reviews, including contact with a GP. CONCLUSION The findings suggested that more evidence is needed on the best approach for supporting care home residents with mental health needs. Areas to consider are the potential benefits of training to care home staff and regular mental health reviews, utilising links between GPs and CMHTsOP. Copyright © 2017 John Wiley & Sons, Ltd.
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Affiliation(s)
- Karen Stewart
- Personal Social Services Research Unit, University of Manchester, Manchester, UK
| | - Claire Hargreaves
- Personal Social Services Research Unit, University of Manchester, Manchester, UK
| | - Rowan Jasper
- Personal Social Services Research Unit, University of Manchester, Manchester, UK
| | - David Challis
- Personal Social Services Research Unit, University of Manchester, Manchester, UK
| | - Sue Tucker
- Personal Social Services Research Unit, University of Manchester, Manchester, UK
| | - Mark Wilberforce
- Personal Social Services Research Unit, University of Manchester, Manchester, UK
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10
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Tucker S, Hargreaves C, Wilberforce M, Brand C, Challis D. What becomes of people admitted to acute old age psychiatry wards? An exploration of factors affecting length of stay, delayed discharge and discharge destination. Int J Geriatr Psychiatry 2017; 32:1027-1036. [PMID: 27515770 DOI: 10.1002/gps.4563] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 07/07/2016] [Accepted: 07/13/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVES The study sought to identify the variables associated with increased length of stay on old age psychiatry inpatient wards. It also explored the factors related to delayed discharge and the likelihood of patients admitted from home returning there. METHODS Data were collected on the sociodemographic, clinical and service receipt characteristics of a 6-month series of admissions to seven wards in England in 2010/2011. The cohort was followed for a 9- to 11-month period. The relationship between patients' status on admission and the specified outcome variables was explored. RESULTS Information was collected on 216 admissions, of whom 165 were discharged in the study period. Mean length of stay was 64 days. Female gender, higher dependency, greater challenging behaviour and locality predicted extended stay. Forty per cent of cases experienced delayed discharge. Better physical health, more cognitive impairment, receipt of social care and locality were associated with delayed discharge. The vast majority of patients admitted from home returned there. Younger patients and patients with less dependency, cognitive impairment and challenging behaviour had a higher likelihood of returning home. Patients receiving social care or admitted because of carer stress, a risk of self-neglect, accidental self-harm or abuse/exploitation were less likely to return home. CONCLUSIONS The study provides a useful starting point for identifying cases on which future efforts to improve inpatient outcomes might centre and suggests local rather than national responses may be needed. It also highlights an urgent need for a national focus on the scope, purpose and effectiveness of acute inpatient care. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Sue Tucker
- Personal Social Services Research Unit, University of Manchester, Manchester, UK
| | - Claire Hargreaves
- Personal Social Services Research Unit, University of Manchester, Manchester, UK
| | - Mark Wilberforce
- Personal Social Services Research Unit, University of Manchester, Manchester, UK
| | - Christian Brand
- Personal Social Services Research Unit, University of Manchester, Manchester, UK.,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - David Challis
- Personal Social Services Research Unit, University of Manchester, Manchester, UK
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11
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Tucker S, Sutcliffe C, Bowns I, Challis D, Saks K, Verbeek H, Cabrera E, Karlsson S, Leino-Kilpi H, Meyer G, Soto ME. Improving the mix of institutional and community care for older people with dementia: an application of the balance of care approach in eight European countries. Aging Ment Health 2016; 20:1327-1338. [PMID: 26327584 DOI: 10.1080/13607863.2015.1078285] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To examine whether the mix of community and institutional long-term care (ILTC) for people with dementia (PwD) in Europe could be improved; assess the economic consequences of providing alternative services for particular groups of ILTC entrants and explore the transnational application of the 'Balance of Care' (BoC) approach. METHOD A BoC study was undertaken in Estonia, Finland, France, Germany, the Netherlands, Spain, Sweden, and the UK as part of the RightTimePlaceCare project. Drawing on information about 2014 PwD on the margins of ILTC admission, this strategic planning framework identified people whose needs could be met in more than one setting, and compared the relative costs of the possible alternatives. RESULTS The findings suggest a noteworthy minority of ILTC entrants could be more appropriately supported in the community if enhanced services were available. This would not necessarily require innovative services, but more standard care (including personal and day care), assuming quality was ensured. Potential cost savings were identified in all countries, but community care was not always cheaper than ILTC and the ability to release resources varied between nations. CONCLUSIONS This is believed to be the first transnational application of the BoC approach, and demonstrates its potential to provide a consistent approach to planning across different health and social care systems. Better comparative information is needed on the number of ILTC entrants with dementia, unit costs and outcomes. Nevertheless, the findings offer important evidence on the appropriateness of current provision, and the opportunity to learn from different countries' experience.
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Affiliation(s)
- S Tucker
- a Personal Social Services Research Unit , University of Manchester , Manchester , UK
| | - C Sutcliffe
- a Personal Social Services Research Unit , University of Manchester , Manchester , UK
| | - I Bowns
- a Personal Social Services Research Unit , University of Manchester , Manchester , UK
| | - D Challis
- a Personal Social Services Research Unit , University of Manchester , Manchester , UK
| | - K Saks
- b Department of Internal Medicine , University of Tartu , Tartu , Estonia
| | - H Verbeek
- c Department of Health Services Research, CAPHRI School for Public Health and Primary Care , Maastricht University , Maastricht , The Netherlands
| | - E Cabrera
- d School of Health Sciences, Tecno Campus , University Pompeu Fabra , Barcelona , Spain
| | - S Karlsson
- e Department of Health Sciences , Lund University , Lund , Sweden
| | - H Leino-Kilpi
- f Department of Nursing Science , University of Turku and Turku University Hospital , Turku , Finland
| | - G Meyer
- g Faculty of Health, School of Nursing Science , University of Witten/Herdecke , Witten , Germany.,h Institute for Health and Nursing Science , Martin Luther University Halle-Wittenberg , Halle-Wittenberg , Germany
| | - M E Soto
- i Geriatrics Department, Gerontôpole , Toulouse University Hospital , Toulouse , France
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Wilberforce M, Tucker S, Brand C, Abendstern M, Jasper R, Challis D. 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. Int J Geriatr Psychiatry 2016; 31:1208-1216. [PMID: 26833970 PMCID: PMC5108488 DOI: 10.1002/gps.4424] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 12/09/2015] [Accepted: 12/09/2015] [Indexed: 11/12/2022]
Abstract
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.
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Affiliation(s)
- Mark Wilberforce
- Personal Social Services Research Unit, University of Manchester, UK.
| | - Sue Tucker
- Personal Social Services Research Unit, University of Manchester, UK
| | - Christian Brand
- Personal Social Services Research Unit, University of Manchester, UK
| | | | - Rowan Jasper
- Personal Social Services Research Unit, University of Manchester, UK
| | - David Challis
- Personal Social Services Research Unit, University of Manchester, UK
- Manchester Mental Health and Social Care Trust, Manchester, UK
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Abendstern M, Tucker S, Wilberforce M, Jasper R, Challis D. Occupational therapists in community mental health teams for older people in England: Findings from a five-year research programme. Br J Occup Ther 2016. [DOI: 10.1177/0308022616657840] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Michele Abendstern
- Research Associate, Personal Social Services Research Unit (PSSRU), University of Manchester, UK
| | - Sue Tucker
- Research Fellow, PSSRU, University of Manchester, UK
| | | | - Rowan Jasper
- Research Assistant, PSSRU, University of Manchester, UK
| | - David Challis
- Professor of Community Care Research; Director, PSSRU, University of Manchester; Associate Director, NIHR School for Social Care Research, Manchester, UK
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Multi-agency working and implications for care managers. JOURNAL OF INTEGRATED CARE 2016. [DOI: 10.1108/jica-11-2015-0044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
To examine the association between multi-agency working and psychosocial characteristics of work, practitioner time-use and job satisfaction.
Design/methodology/approach
A comparison of practitioners working in multi-agency (health and social care) and single-agency (social care only) teams, using data from the 2008 evaluation of Individual Budgets pilots in England. Participants worked in care manager roles supporting adult social care service users, and comprised social workers and a smaller number of health professionals. Data was collected using a self-completed questionnaire.
Findings
Data were returned from 249 respondents (a 29 per cent response rate), with two-thirds working in single-agency teams. No significant differences were found between team type and job satisfaction. Respondents in multi-agency teams reported greater decision autonomy but poorer supervisory support than those in single-agency teams. The latter finding was robust to further exploration using regression to control for confounding factors.
Research limitations/implications
These data were not specifically collected for the study and response rates were relatively low due to organisational upheaval at the time of data collection, which may affect interpretation.
Practical implications
Government policy is dedicated to extending integrated forms of working, including multi-agency teamwork. This research suggests that such structures need careful planning for them to work effectively, with particular attention to supervision arrangements.
Originality/value
This research gives a systematic and objective exploration of the relationship between job characteristics, time-use and satisfaction of practitioners in single as compared to multi-agency teams.
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Tucker S, Brand C, Wilberforce M, Abendstern M, Challis D. Identifying alternatives to old age psychiatry inpatient admission: an application of the balance of care approach to health and social care planning. BMC Health Serv Res 2015; 15:267. [PMID: 26183821 PMCID: PMC4504087 DOI: 10.1186/s12913-015-0913-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 06/08/2015] [Indexed: 11/10/2022] Open
Abstract
Background Mental health problems in older people are common and costly, posing multiple challenges for commissioners. Against this backdrop, a series of initiatives have sought to shift resources from institutional to community care in the belief that this will save money and concurs with user preferences. However, most of this work has focused on the use of care home beds and general hospital admissions, and relatively little attention has been given to reducing the use of mental health inpatient beds, despite their very high cost. Methods The study employed a ‘Balance of Care approach’ in three areas of North-West England. This long-standing strategic planning framework identifies people whose needs can be met in more than one setting, and compares the costs and consequences of the possible alternatives in a simulation modelling exercise. Information was collected about a six-month cohort of admissions in 2010/11 (n = 216). The sample was divided into groups of people with similar needs for care, and vignettes were formulated to represent the most prevalent groups. A range of key staff judged the appropriateness of these admissions and suggested alternative care for those considered least appropriate for hospital. A public sector costing approach was used to compare the estimated costs of the recommended care with that people currently receive. Results The findings suggest that more than a sixth of old age psychiatry inpatient admissions could be more appropriately supported in other settings if enhanced community services were available. Such restructuring could involve the provision of intensive support from Care Home Outreach and Community Mental Health Teams, rather than the development of crisis intervention and home treatment teams as currently advocated. Estimated savings were considerable, suggesting local agencies might release up to £1,300,000 per annum. No obvious trade-off between health and social care costs was predicted. Conclusions There is considerable potential to change the mix of institutional and community services provided for older people with mental health problems. The conclusions would be strengthened by further studies and the incorporation of evidence about relative outcomes. However, the utility of the approach in challenging established patterns of resource allocation and building local ownership for change is apparent. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-0913-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sue Tucker
- Personal Social Services Research Unit, University of Manchester, Crawford House, Booth Street East, Manchester, M13 9QS, UK.
| | - Christian Brand
- Personal Social Services Research Unit, University of Manchester, Crawford House, Booth Street East, Manchester, M13 9QS, UK.
| | - Mark Wilberforce
- Personal Social Services Research Unit, University of Manchester, Crawford House, Booth Street East, Manchester, M13 9QS, UK.
| | - Michele Abendstern
- Personal Social Services Research Unit, University of Manchester, Crawford House, Booth Street East, Manchester, M13 9QS, UK.
| | - David Challis
- Personal Social Services Research Unit, University of Manchester, Crawford House, Booth Street East, Manchester, M13 9QS, UK.
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