Individualized funding interventions to improve health and social care outcomes for people with a disability: A mixed-methods systematic review

Developing an Operationalized Framework for Comparing Consumer-Directed Care for Older Adults: Evidence from Expert Survey and Cross-National Comparison

Consumer-directed care (CDC) programs for older people aim to optimize health outcomes by offering clients control and flexibility regarding service arrangements. However, policy design features may differ due to heterogenous sociostructural systems. By operationalizing a framework with three dimensions of CDC, i.e. control and direct services, variety of service options, and information and support, we analyzed how countries vary in their policy designs to achieve consumer direction. Using an expert survey (n = 20) and cross-national document analysis, we analyzed 12 CDC programs from seven selected countries: the United States, the United Kingdom, Germany, the Netherlands, China, Australia, and Spain. Among the three dimensions, CDC programs placed more emphasis on and displayed more homogenous performance of policy designs that achieve consumer direction in the dimension of control and direct services, while less emphasis was placed on and more heterogenous performance displayed in the dimensions of variety of service options and information and support. We offer a systematically operationalized framework to investigate CDC policy designs. Findings advance our understanding of CDC policy features from a cross-national perspective. Policymakers could incorporate these findings to empower older people in their respective societies.

'You're out on a limb, on your own': Social care personal assistants' (PAs') reflections on working in the Covid-19 pandemic - implications for wider health and care services

CONTEXT

In England, Personal Assistants (PAs) are part of an international trend towards state funded but client-hired or directly employed care workers. The Covid-19 pandemic highlighted and exacerbated pre-existing risks and advantages of this arrangement for both PAs and people with care and support needs.

OBJECTIVES

We aim to report PAs' reflections on their experiences of working since the pandemic started in 2020 and highlight the longer-term implications for health and care services.

METHODS

We undertook a large-scale, qualitative study in 2016-17 involving interviews with 104 PAs about their working lives. We re-interviewed PAs from this group twice to ask how the pandemic had affected them, once at the start of the pandemic in Spring 2020 and again in December 2021 -April 2022. This article reports findings from the last set of interviews undertaken with 38 PAs. Thematic analysis was conducted of interviews in which PAs discussed changes in tasks and responsibilities, pay and conditions, training, relationships and plans.

FINDINGS

This article focuses on the following themes: PAs' perceptions of their outsider status; support and training needs; job security; and whether PAs have an appetite for regulation to provide greater professional standing and connections.

LIMITATIONS

Interviews in this study were carried out during the Covid-19 pandemic over the telephone or virtually rather than in person so may have missed certain body language or informal relationship building. The sample may be under-representative of non-British PAs. We were unable to triangulate participants' accounts with others'.

IMPLICATIONS

This study highlights the importance of national and local government including the PA workforce in planning for national emergencies. Consideration should be given by policy makers and local health and care systems to how PAs can be better supported than currently.

"God is my only health insurance": a mixed-methods study on the experiences of persons with disability in accessing sexual and reproductive health services in Ghana

Background

Access to sexual and reproductive health (SRH) services is a fundamental human right, but people with disabilities (PwDs) in low-and middle-income countries often face multiple barriers to utilisation. This study aimed to assess the level of SRH services utilisation and the enabling and inhibiting factors among PwDs in Ghana's Ashanti region.

Methods

A sequential explanatory mixed-methods study design was employed, involving quantitative (n = 402) and qualitative (n = 37) data collection from PwDs. Quantitative data were analysed using descriptive and inferential statistics, while qualitative data were analysed using inductive thematic analysis.

Results

The study found that only 33.8% of the PwDs had ever used SRH services. Utilisation was associated with sex, marital status and travel duration to health facility. The qualitative data revealed that factors at the individual, family/community and health facility levels influenced utilisation of SRH services, acting as both enablers and barriers.

Conclusion

PwDs had relatively low utilisation of SRH services in Ghana's Ashanti region. To increase utilisation, it is recommended to address the stigma and discrimination towards PwDs, provide more training for healthcare providers, improve the accessibility of healthcare facilities, and strengthen the national health insurance scheme. Further research could explore PwDs' SRH outcomes and strategies to improve these outcomes in Ghana.

My assistive technology outcomes framework: rights-based outcome tools for consumers to 'measure what matters'

AT outcomes research is the systematic investigation of changes produced by AT in the lives of AT users and their environments. In contrast to focal outcome measures, My Assistive Technology Outcomes Framework (MyATOF) envisions an alternative starting point, co-designing a holistic and evidence-based set of outcome dimensions enabling AT users to quantify their own outcomes. International classification systems, research evidence, regulatory and service delivery frameworks underpin six optional tools: supports, outcomes, costs, rights, service delivery pathway and customer experience. Designed to empower the consumer-as-researcher and self-advocate, MyATOF has the potential to fill an identified gap in policy-relevant, consumer-focussed and consumer-directed outcome measurement in Australia and internationally. This paper presents the need for consumer-focussed measurement and articulates the conceptual foundations of MyATOF. The iterative development and results of MyATOF use-cases collected to date are presented. The paper concludes with next steps in using the Framework internationally, as well as its future development.

The Effects and Costs of Personalized Budgets for People with Disabilities: A Systematic Review

This article reviews the peer-reviewed and grey literature published from January 1985 to November 2022 that has quantitatively evaluated the effects of personalized budgets for people with disabilities (PwDs), in terms of a range of benefit and cost outcomes. Benefit metrics of interest comprised measures of well-being, service satisfaction and use, quality of life, health, and unmet needs. A search was conducted using the PsycINFO, MEDLINE, CINAHL, ASSIA, and Social Care Online databases. Based on inclusion criteria and a quality assessment using the Downs and Black Checklist, a final count of 23 studies were identified for in-depth review. Given the heterogeneous nature of the studies, a narrative synthesis, rather than a formal meta-analysis, was undertaken. Taking the relatively scarce and often methodologically limited evidence base at face value, the findings suggest that-overall-personalized budget users tend to benefit in terms of well-being and service satisfaction outcomes, with the exception of mixed effects for people with mental health conditions. Only a minority of studies have investigated the cost-effectiveness or costs-only of personalized budgets, finding mixed results. Two out of the three cost-effectiveness studies find personal budgets to be more cost-effective than alternative options, meaning that the possibly higher costs of personalized budgets may be more than outweighed by additional benefits. Some evidence looking at service use and/or costs only also points to significant reductions in certain service use areas, which at least hints at the potential that personalized budgeting may-in some cases-entail reduced costs. Further research is needed to explore the generalizability of these conclusions and to better capture and understand the factors driving the observed heterogeneity in some of the results.

Adaptation among aged care and disability service providers in response to the COVID-19 pandemic: Lessons for the future

Aged care and disability service organizations are critical infrastructure. However, in 2020, restrictions were introduced to reduce the infection risk of the coronavirus disease 2019 (COVID-19), and these organizations needed to quickly devise COVID-safe ways of working to continue to meet the needs of their clients. To investigate how these organizations adapted their service delivery and which innovations they felt were worthwhile for sustaining beyond the COVID-19 pandemic, interviews were undertaken with representatives from 26 aged care and disability service organizations across three states in Australia (Western Australia, New South Wales, and Victoria). Findings revealed that organizations adapted their practices across three key innovation areas: (1) developing new approaches or expanding existing services, particularly around food provision, social connection, information dissemination, and technology support; (2) modifying the mode of service delivery, through safe in-person contact or offering alternative online services; and (3) reducing bureaucracy and introducing remote working. A common theme across all service innovations was the strong focus on providing clients and staff with choice and control. Moving forward, many organizations wanted to integrate and maintain these innovations, as they were associated with additional benefits such as increased client health and safety, service flexibility, and sufficient human resources to serve clients. However, continued maintenance of some initiatives require additional resourcing. The continuation of COVID-19 pandemic adaptations and, indeed, ongoing innovation, would therefore be facilitated by greater flexibility of funding to allow organizations and their clients to determine the service types and modes that best meet their needs. Further, these innovations have implications for sector-wide best practice.

Lessons learned from the impact of Covid-19 on the work of disability support organisations that support employers of social care personal assistants in England

Social care Personal Assistants (PAs) are directly employed by individuals to assist with activities of daily living such as help or support with personal care, shopping, household tasks and community participation. This option is encouraged by UK public funding. In England, disabled people's support organisations initially offered assistance with such arrangements, although numbers doing this have declined. The Covid-19 pandemic provided the opportunity to ask those remaining organisations providing support for PA employers about their activities during this time and the questions being posed to them by PA employers. This paper reports data from 15 interviews undertaken March-July 2021 with disability support organisation representatives. We identified one overarching theme 'Working to prevent and challenge marginalisation of PA employers', with three related subthemes: (1) Advocating for the voice of a forgotten group; (2) Needing to be proactive and (3) Adapting to new tasks and ways of working. Participant accounts focused on representing the needs of disabled people to the authorities and providing concise, timely and accurate information to PA employers, particularly around the use of public funds during Covid-19. Remote working amplified the digital-divide, resulting in these organisations working hard to ensure PA employers received important information about their support options. Befriending services and Covid-hubs were established by some organisations to reduce isolation and risks of poor mental health amongst PA employers. Many of the challenges facing PA employers existed pre-pandemic but were perceived to have been heightened during it, reflecting the value of and need for the work of these local support organisations. Our findings suggest areas where effective contingency planning drawn from closer collaboration between disability support organisations and central and local government might usefully be focussed. The potential for specific services or organisations to be commissioned to provide such support is discussed.

Intermediary Services to Assist People With Disabilities to Implement Individualized Funding Plans: A Rapid Systematic Review

A systematic review was conducted to describe, and evaluate the effectiveness and cost-effectiveness of, intermediary services to support people with a disability to implement individualized funding plans. We included six records, including one subanalysis of randomized trial data, three qualitative studies, and two systematic reviews (reporting on 73 and 18 studies, respectively). No studies directly compared “consumer-directed plan plus intermediary services” to “consumer-directed plan with no/alternative intermediary,” so effectiveness of these interventions is uncertain. There is qualitative evidence from the perspective of disability planners and workers that intermediary interventions are important enablers of successful plan implementation. There is also qualitative evidence from consumer and family perspectives that external support is required to successfully navigate self-directed systems and that strong, trusting, and collaborative relationships with both paid and unpaid individuals in the person’s support network were facilitators of successful plan implementation. There was evidence of disabling practices and attitudes among some support agencies, resulting in coordinators being very risk averse in order to safeguard their clients. Suggestions for future research include carefully planned and ethically robust comparative trial designs, clear description and consistent delivery of interventions, and long-term evaluation of impact. The protocol was published on PROSPERO (CRD42020177607).

Interventions for social and community participation for adults with intellectual disability, psychosocial disability or on the autism spectrum: An umbrella systematic review

Objective

This umbrella systematic review examined the effectiveness, facilitators, and barriers of interventions for social, community and civic participation for adults on the autism spectrum, or with intellectual or psychosocial disability.

Data Sources

Eight databases were searched to identify eligible reviews defined by the: Sample (≥50% adults on the autism spectrum or with intellectual or psychosocial disability), Phenomena of Interest (interventions in community settings that aimed to improve social, community or civic participation, or capacity to participate), Design (any), Evaluation (any method that evaluated impacts on participation or capacity to participate), and Research type (reviews as journal articles, dissertations or in grey literature, in English, published 2010-2020).

Review Methods

Rapid review methods were used. One researcher screened 27,890 records and 788 potentially eligible full texts. A second reviewer independently screened 20% of records, and ambiguous full text publications. Study quality was extracted, and review quality was assessed with the Assessing Methodological Quality of Systematic Reviews (AMSTAR) checklist. Data from 522 studies in 57 eligible systematic reviews were extracted for narrative synthesis. The Corrected Covered Area (CCA) was calculated to indicate overlap between reviews.

Results

There was a pooled sample of 28,154 study participants, predominantly from studies in North America, the UK and Europe. There was very low overlap between reviews (CCA = 0.3%). Reviews were predominantly low quality: 77.2% of reviews met <50% of AMSTAR criteria. Most studies were low (45.4%) or moderate (38.3%) quality. Three broad intervention categories improved participation, inclusion and belonging outcomes: (1) interventions to help people identify and connect with participation opportunities (e.g., person centred planning); (2) participation opportunities or activities (e.g., joining a community group, sports or outdoor activities, or arts-based activities); and (3) supports to build skills and capacity to participate socially and in the community.

Conclusions

The evidence highlighted that improved social and community participation requires purposeful strategies that identify meaningful participation preferences (e.g., where, when, how, and with whom) and provide support to build capacity or enable ongoing participation. Community capacity building, peer support and advocacy may also be needed to make the community more accessible, and to enable people to exercise genuine choice.

NDIS Participants with Psychosocial Disabilities and Life-Limiting Diagnoses: A Scoping Review

This research aimed to map evidence about system supports and gaps for Australians with psychosocial disabilities and life-limiting diagnoses. A scoping review of available policy documents, academic, and grey literature was completed to discover key characteristics of this concept and provide context around the phenomenon. Our focus was on Australia's National Disability Insurance Scheme (NDIS), a key reform providing support to the disability population nationally. No peer-reviewed or grey literature was retrieved on the phenomena. Therefore, three lines of enquiry were developed: experiences of NDIS participants living with psychosocial disabilities; the death, dying, and palliative care supports and experiences of NDIS participants of any disability type; and the experiences for people living with severe and persistent mental illness (SPMI) and life-limiting diagnoses. Five themes were identified: (1) the person; (2) advocacy; (3) informal supports; (4) formal supports; and (5) existing research. NDIS participants living with SPMI and their informal and formal support systems are still struggling to navigate the NDIS. While there are no specific publications about their end-of-life experiences, people with SPMI often experience poor end-of-life outcomes. Rigorous research into their death, dying, and palliative care experiences is needed to inform improved support to them, including their end-of-life care.

How personalisation programs can exacerbate socio-economic inequities: findings from budget utilisation in the Australian National Disability Insurance Scheme

BACKGROUND

Researchers and policymakers are increasingly concerned that personalisation schemes in social and health care might be worsening social and health inequities. This has been found internationally, where better outcomes from such schemes have been found amongst those who have higher education and more household income.

METHOD

This study looks at one of the world's largest personalisation schemes, the Australian National Disability Insurance Scheme. Using publicly available data we examine the allocation and utilisation of NDIS funds according to social gradient.

RESULTS

We find that the rate at which people with disability 'spend' or effectively use their disability care funds follows a social gradient. That is, those in areas of higher socioeconomic disadvantage are not spending as much of their allocated budgets on care services across the year compared to people in areas of higher socioeconomic advantage. This represents a clear issue of equity in the use of public money to people with disability in Australia.

CONCLUSION

We argue that this points to the need to provide targeted supports for the use of disability care funds in areas of higher socioeconomic disadvantage. Without effective supports for fund use, the NDIS and other personalisation schemes may be positioned to worsen existing social inequalities.

Evidence and gap map of studies assessing the effectiveness of interventions for people with disabilities in low-and middle-income countries

Background

There are approximately 1 billion people in the world with some form of disability. This corresponds to approximately 15% of the world's population (World Report on Disability, 2011). The majority of people with disabilities (80%) live in low- and middle-income countries (LMICs), where disability has been shown to disproportionately affect the most disadvantaged sector of the population. Decision makers need to know what works, and what does not, to best invest limited resources aimed at improving the well-being of people with disabilities in LMICs. Systematic reviews and impact evaluations help answer this question. Improving the availability of existing evidence will help stakeholders to draw on current knowledge and to understand where new research investments can guide decision-making on appropriate use of resources. Evidence and gap maps (EGMs) contribute by showing what evidence there is, and supporting the prioritization of global evidence synthesis needs and primary data collection.

Objectives

The aim of this EGM is to identify, map and describe existing evidence of effectiveness studies and highlight gaps in evidence base for people with disabilities in LMICs. The map helps identify priority evidence gaps for systematic reviews and impact evaluations.

Methods

The EGM included impact evaluation and systematic reviews assessing the effect of interventions for people with disabilities and their families/carers. These interventions were categorized across the five components of community-based rehabilitation matrix; health, education, livelihood, social and empowerment. Included studies looked at outcomes such as, health, education, livelihoods, social inclusion and empowerment, and were published for LMICs from 2000 onwards until January 2018. The searches were conducted between February and March 2018. The EGM is presented as a matrix in which the rows are intervention categories (e.g., health) and subcategories (e.g., rehabilitation) and the column outcome domains (e.g., health) and subdomains (e.g., immunization). Each cell lists the studies for that intervention for those outcomes, with links to the available studies. Included studies were therefore mapped according to intervention and outcomes assessed and additional filters as region, population and study design were also coded. Critical appraisal of included systematic review was done using A Measurement Tool to Assess Systematic Reviews' rating scale. We also quality-rated the impact evaluation using a quality assessment tool based on various approaches to risk of bias assessment.

Results

The map includes 166 studies, of which 59 are systematic reviews and 107 impact evaluation. The included impact evaluation are predominantly quasiexperimental studies (47%). The numbers of studies published each year have increased steadily from the year 2000, with the largest number published in 2017.The studies are unevenly distributed across intervention areas. Health is the most heavily populated area of the map. A total of 118 studies of the 166 studies concern health interventions. Education is next most heavily populated with 40 studies in the education intervention/outcome sector. There are relatively few studies for livelihoods and social, and virtually none for empowerment. The most frequent outcome measures are health-related, including mental health and cognitive development (n = 93), rehabilitation (n = 32), mortality and morbidity (n = 23) and health check-up (n = 15). Very few studies measured access to assistive devices, nutrition and immunization. Over half (n = 49) the impact evaluation come from upper-middle income countries. There are also geographic gaps, most notably for low income countries (n = 9) and lower-middle income countries (n = 34). There is a fair amount of evidence from South Asia (n = 73) and Sub-Saharan Africa (n = 51). There is a significant gap with respect to study quality, especially with respect to impact evaluation. There appears to be a gap between the framing of the research, which is mostly within the medical model and not using the social model of disability.

Conclusion

Investing in interventions to improve well-being of people with disabilities will be critical to achieving the 2030 agenda for sustainable development goals. The EGM summarized here provides a starting point for researchers, decision makers and programme managers to access the available research evidence on the effectiveness of interventions for people with disabilities in LMICs in order to guide policy and programme activity, and encourage a more strategic, policy-oriented approach to setting the future research agenda.

Personalisation schemes in social care and inequality: review of the evidence and early theorising

BACKGROUND

Personalisation is a growing international policy paradigm that aims to create both improved outcomes for individuals, and reduce fiscal pressures on government, by giving greater choice and control to citizens accessing social services. In personalisation schemes, individuals purchase services from a 'service market' using individual budgets or vouchers given to them by governments. Personalisation schemes have grown in areas such as disability and aged care across Europe, the UK and Australia. There is a wealth of evidence in public health and health care that demonstrates that practically all forms of social services, programs and interventions produce unequal benefit depending on socio-economic position. Research has found that skills required to successfully negotiate service systems leads to disproportionate benefit to the 'middle class. With an unprecedented emphasis on individual skills, personalisation has even greater potential to widen and entrench social inequalities. Despite the increase in numbers of people now accessing services through such schemes, there has been no examination of how different social groups benefit from these schemes, how this widens and entrenches social inequities, and - in turn - what can be done to mitigate this.

METHODS

This article presents a meta-review of the evidence on personalisation and inequality. A qualitative meta-analysis was undertaking of existing research into personalisation schemes in social services to identify whether and how such schemes are impacting different socio-economic groups.

RESULTS

No research was identified which seeks to understand the impact of personalisation schemes on inequality. However, a number of 'proxies' for social class were identified, such as education, income, and employment, which had a bearing on outcome. We provide a theoretical framework for understanding why this is occurring, using concepts drawn from Bourdieu.

CONCLUSION

Personalisation schemes are likely to be entrenching, and potentially expanding, social inequalities. More attention needs to be given to this aspect of personal budgets by policymakers and researchers.