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.

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.

Reliability of needs assessments in the community care of older people: impact of the single assessment process in England.

BACKGROUND: The single assessment process (SAP) for older people, introduced in England across health and social care agencies from April 2004, aimed at improving assessment processes. We examined the impact of this policy in terms of the reliability of needs identification within statutory social services assessments. METHODS: An observational study compared the accuracy of needs identification in samples of older people before and after SAP introduction. Participants, at risk of entering care homes, were interviewed using standardized measures. Needs elicited from interviews were compared with those from statutory social services assessments to ascertain the reliability of needs identification at both times. Inter-rater reliabilities were calculated using the kappa (k) statistic. A Chi-squared statistic tested the equality of kappa values pre- and post-SAP. RESULTS: Most needs were identified more reliably after SAP introduction (range adjusted k = 0.05-0.58) than before (range adjusted k = -0.09 to 0.28), this being statistically significant for 9 out of 15 needs. Depression, and associated apathy, was an exception. CONCLUSION: Statutory social services assessments better captured need following the introduction of the SAP. However, the extent to which these findings can be attributed to SAP introduction is limited by the introduction of multiple policy initiatives throughout the study period.

Identifying need in care homes for people with dementia: the relationship between two standard assessment tools.

Considerable effort has been invested in improving assessment processes for older people, some of the most vulnerable of whom live in care homes. The paper compares two well-known assessment tools used in care homes, the CANE and the Minimum Data Set/Resident Assessment Instrument. There was poor agreement between the tools in terms of domains of need covered. Nineteen pairs of items could be compared, with agreement greater than 60% found on 11 items. Of the 15 items where kappa could be computed, seven significant values were found. High levels of agreement existed in relation to behaviour, psychological wellbeing, mood state, psychotic symptoms, incontinence, mobility and inadvertent self-harm (risk). The study suggests that tools commonly used for assessment are not interchangeable and that the selection of assessment tool should be determined by the setting in which it is used, the needs of the population being assessed, the skills and knowledge of those undertaking the assessment and the purpose of the assessment itself.

The balance of care: reconfiguring services for older people with mental health problems.

The belief that most older people, including those with complex needs, can, and would prefer to be, cared for in their own homes underpins community care policy in many developed nations. There is thus a common desire to avoid the unnecessary or inappropriate placement of older people in care homes or in hospital by shifting the balance of provision. This paper demonstrates the utility of a 'balance of care' approach to address these issues in the context of commissioners' intention to reconfigure services for older people with mental health problems in a defined geographical area of the North West of England. The findings suggest that, if enhanced community services were available, a number of people currently admitted to residential or hospital beds could be more appropriately supported in their own homes at a cost that is no greater than local agencies currently incur.

The assessment of older people's needs in care homes.

In many countries there is a concern to improve assessment procedures for older people to avoid misplacement in nursing homes and ensure that rehabilitation takes place where possible. The study examined assessment documentation in 126 care homes in North West England. On a set of core domains for assessing need, the level of coverage varied considerably. The use of standardised scales was infrequent apart from those that measured risk of developing pressure sores. Some important key domains were infrequently mentioned on the assessment forms including mental health, pain, oral health and foot care. The most frequently covered items were the activities of daily living. There were clear differences in the assessment approaches employed in different types of home. The lack of inclusion of certain key health areas on some assessment forms suggests that the well-being and quality of life of some residents may be poorly addressed, and that further work is required for the standard of assessment in care homes to match that in community-based care.

The use of assessment scales in Old Age Psychiatry Services in England and Northern Ireland.

Implementation of the Single Assessment Process in the UK is designed to ensure that more standardized assessment procedures are in place across all areas and agencies, that practice improves and older people's needs are comprehensively assessed. This study provides a unique picture of the range and prevalence of standardized scales used within Old Age Psychiatry Services in England and Northern Ireland, reported by 73% of old age psychiatrists. Most services (64%) used three or more standardized assessment scales (range 1-12). Sixty-two separate instruments were identified. The six most used measures were the Mini Mental State Examination (95%), the Geriatric Depression Scale (52%) and the Clock Drawing (50%), the Clifton Assessment Procedures for the elderly (26%), the Barthel Index (18%) and the Health of the Nation Outcome Scales (HoNOS) 65 + (18%). A number of factors were associated with greater use of certain standardized assessment scales. Shared documentation, along with other indicators of integration between health and social care were associated with greater use of standardized scales. The provision of a memory clinic was associated with greater use of neuropsychiatric scales and lower levels of use of cognitive scales. These results provide key material for shaping the provision of psychiatric services for older people

Care management and the care programme approach: towards integration in old age mental health services.

OBJECTIVE: To examine the relationship between care management arrangements and the Care Programme Approach (CPA) in the context of old age mental health services and, particularly, dementia services. METHOD: The information reported is from a national study of care management arrangements, funded by the Department of Health. A response rate of 77% was obtained from local authority social services departments. RESULTS: In old age mental health services over half of the respondents reported joint screening arrangements for health and social care, almost four-fifths reported both joint criteria for the allocation of key workers and a clear definition of monitoring responsibilities. Of the latter over two-fifths were reported as being the same in care management and the CPA. Forty-six per cent of respondents provided a specialist service for people with dementia. Three-fifths of respondents reported that they did not apply CPA to people with dementia who were in receipt of care management or did so in less than 20% of cases. Where the CPA was applied it was more likely that a priority would be accorded to care management. A quarter of respondents reported the shared use of assessment documentation for people with dementia. DISCUSSION: The findings are set in the context of service developments to date and the implementation of the two systems of community based coordinated care for older people with mental health problems. Inter-authority variations are noted and the potential for greater service integration within the current legislative framework assessed.

Dependency in older people recently admitted to care homes.

OBJECTIVE: to investigate dependency and general health status of a cohort of older people admitted to residential or nursing homes for long-term care. METHOD: we assessed 308 people aged over 65 years within 2 weeks of admission for long-term care to one of 30 nursing or residential homes in north-west England. Dependency was assessed using the Barthel activities of daily living index and the Crichton Royal Behaviour Rating Scale. We collected information from the homes' records on diagnosed conditions and current medication. RESULTS: 50% of the cohort were in a 'low dependency' band (Barthel score 13 - 20): 31% of those in nursing homes and 71% of those in residential homes. In nursing homes, low-dependency residents were more likely to be self-funding than those with higher dependency. Of a number of broad diagnostic groupings, only a diagnosis of dementia was associated with nursing- rather than residential-home admission. Of 47 residents who scored 9 or less on the Mini-Mental State Examination (indicating severe cognitive impairment), 85% had no diagnosis of dementia, neurological disorder or other psychiatric disorder. DISCUSSION: the high proportion of new admissions of subjects with low dependency needs raises questions about the effective targeting of resources and about management of the boundary between home-based and institutional care. The existence of an important group of self-funded, low-dependency new admissions to nursing homes suggests a need to provide better assessment and placement services for those who are financially independent of local authorities. Many new admissions had conditions which might benefit from rehabilitation but there were almost no therapy staff in the studied homes. In some cases where severe cognitive impairment was evident, there was no evidence that the result of any formal pre-admission psychiatric evaluation had been communicated to nursing or care staff.

Targeting and quality of nursing home care. A five-nation study.

The objective of this study was to demonstrate that appropriate targeting and quality monitoring of institutional care of the elderly is possible using person-based information on residents of nursing homes. This cross-sectional study used Minimum Data Set (MDS) assessments of nursing home residents in 6 US states, Copenhagen, Reykjavik, and selected locations in Italy and Japan. The outcome measures were life expectancy at age 65, population over 65, percentage over 65's in nursing homes, and clinical characteristics of nursing home residents from a multinational database of RAI/MDS assessments. We found that Japan has the highest life expectancy, and the second lowest expenditure on health care. The United States has the highest expenditure on health care and intermediate life expectancy. Italy has the highest proportion of population over 65 and the lowest proportion of over 65's in nursing homes. Iceland, a relatively young country, has the highest proportion of over 65's in nursing homes. Residents in Italy and the United States had the most severe physical, cognitive and clinical characteristics, those in Iceland the least. There was wide variation in markers of quality of care, with no country either uniformly good or bad across multiple measures. In conclusion, headline statistics comparing nations' percentage of Gross Domestic Product (GDP) spent on health care, age structure of the population, percentage of over 65's in nursing homes and clinical characteristics bear no consistent relationship. Local policy and practice also affect quality of care. Standardized assessment enables comparisons at local, national and international levels making possible further research on targeting and the appropriate use of institutional care, thus permitting a range of efficiency measures to be developed to inform policy.

Assessment approaches for older people receiving social care: content and coverage.

BACKGROUND: Assessment was identified as one of the 'cornerstones' of community care. This study presents findings from the first nationally representative analysis of assessment documents used by social services agencies in the UK. METHOD: In this paper analysis is made of 50 assessment documents used for the 'comprehensive' assessment of older people. The documents were examined in the extent to which they covered 33 assessment domains, grouped into four areas: functional domains; cognitive, mood and psychosocial domains; social environment domains; and clinico-medical domains. The documents were analysed on three dimensions: whether the domains were covered at all; whether the domain was covered in sufficient detail; and whether it would elicit a structured response. RESULTS: Activities of daily living were covered to some extent on the majority of documents, as were the instrumental activities of daily living. Very few documents were designed to elicit information on the potential for rehabilitation. Whilst the majority of forms were designed to collect some information on cognitive patterns, mood state and social activity, very few were designed to collect this in any detail. Although functional activities of daily living were covered in greater detail than the other domains overall, there was enormous variability between the documents, thus hampering their ability to generate any standardized information.

Case management in social and health care. Lessons from a United Kingdom program.

In the United Kingdom, despite a stated commitment to community care, centralized planning and financing through the Social Security System, rather than the Social Services Department, resulted in a serious distortion in policy. Social Security funded care in residential and nursing homes, and not community care. As in the United States, central government expenditures for expensive institutional care rose dramatically in the 1980s as a result. By the end of the decade, changes were implemented to decentralize the provision and funding of social care. Several projects were undertaken to demonstrate effective means of applying the new policies. In each instance, case managers worked with relatively small caseloads of the frail elderly and were responsible for allocating funds to purchase the services needed within a fixed budget. In all settings, there was a reduction in the use of institutional care facilities; the quality of life of both the clients and their caregivers improved significantly; and these gains were achieved at no greater cost than for individuals receiving the traditional services without case management. Despite the fact that issues such as what happens to costs when the system is expanded to other target clienteles remain to be resolved, the success of the projects highlights the significant gains to be achieved with case managers who have control of both service selection and budgets.

An evaluation of an alternative to long-stay hospital care for frail elderly patients: II. Costs and effectiveness.

This paper provides the main findings of an evaluation of a service to provide alternative care at home for patients receiving long-stay hospital care. Elderly people receiving the service were compared with a group of similar patients in an adjacent health district. The paper presents data on length of time at home and in hospital, changes in quality of life and care of elderly people, and effects upon informal carers for the two groups. Elderly people receiving community-based care had a higher quality of life, and there was no evidence of greater stress upon their carers. The community-based service, although it involved extra costs to the social services department, had lower costs for the health service and society as a whole than long-stay hospital provision. It is concluded that the model of care can effectively integrate the new approach of case management into an existing geriatric multidisciplinary team.

Case finding in elderly people: validation of a postal questionnaire.

A continuing concern of primary care is to produce economical methods of case finding among elderly patients to reduce unmet need in practice populations. This paper reports the use of a postal questionnaire to identify high dependency groups and the use of statistical methods to produce a formula which weights the relative importance of different items in identifying patients with a high level of dependency. It appears possible to identify such high dependency cases reliably at the cost of assessing between one half and two thirds of the population aged 75 years and over.

Home care of the frail elderly in the United Kingdom: matching resources to needs.

The paper reports the essential features and evaluation of a scheme to improve the effectiveness of home care for the frail elderly. Decisions about resource allocation were devolved to front line social work staff giving them greater autonomy within clear expenditure parameters. More imaginative responses were noted in the management of a number of difficult problems and the results of the evaluation were generally positive. It appeared that the scheme was most cost-effective for the extremely mentally and physically frail living with others and also for the less frail, socially isolated, depressed elderly person.

Hypertension due to renal tuberculosis: assessment by renal vein renin sampling.

A 36-year-old man with asymptomatic hypertension was shown to have destruction of the right kidney due to renal tuberculosis. The peripheral renin level was normal, but renal vein renin sampling showed predominant renin secretion from the right kidney both in basal samples and after acute stimulation of renin release with intravenous diazoxide. Nephrectomy has resulted in marked reduction of blood pressure without treatment one year after operation. The findings support the predictive value of renal vein renin sampling when hypertension is associated with renal parenchymal disease, even when peripheral renin is normal.