Developing a core outcome set for people living with dementia at home in their neighbourhoods and communities: study protocol for use in the evaluation of non-pharmacological community-based health and social care interventions.

BACKGROUND: The key aim of the study is to establish an agreed standardised core outcome set (COS) for use when evaluating non-pharmacological health and social care interventions for people living at home with dementia. METHODS/DESIGN: Drawing on the guidance and approaches of the Core Outcome Measures in Effectiveness Trials (COMET), this study uses a four-phase mixed-methods design: 1 Focus groups and interviews with key stakeholder groups (people living with dementia, care partners, relevant health and social care professionals, researchers and policymakers) and a review of the literature will be undertaken to build a long list of outcomes. 2 Two rounds of Delphi surveys will be used with key stakeholder groups. Statements for the Delphi surveys and participation processes will be developed and informed through substantial member involvement with people living with dementia and care partners. A consensus meeting will be convened with key participant groups to discuss the key findings and finalise the COS. 3 A systematic literature review will be undertaken to assess the properties of tools and instruments to assess components of the COS. Measurement properties, validity and reliability will be assessed using the Consensus-based Standards for the Selection of Health Measurement (COSMIN) and COMET guidance. 4 A stated preference survey will elicit the preferences of key stakeholders for the outcomes identified as important to measure in the COS. DISCUSSION: To the best of our knowledge, this study is the first to use a modified Delphi process to involve people living with dementia as a participant group. Though the study is confined to collecting data in the United Kingdom, use of the COS by researchers will enhance the comparability of studies evaluating non-pharmacological and community-based interventions. TRIAL REGISTRATION: The study is registered on the COMET initiative, registered in 2014 at comet-initiative.org .

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

OBJECTIVE: Integrated community mental health teams (CMHTs) are a key component of specialist old age psychiatry services internationally. However, in England, significant shifts in policy, including a focus on dementia and age inclusive services, have influenced provision. This study portrays teams in 2009 against which subsequent service provision may be compared. METHODS: A bespoke national postal survey of CMHT managers collected data on teams' structure, composition, organisation, working practices, case management, and liaison activities. RESULTS: A total of 376 CMHTs (88%) responded. Teams comprised a widespread of disciplines. However, just 28% contained the full complement of professionals recommended by government policy. Over 93% of teams had a single point of access, but some GPs bypassed this, and 40% of teams did not accept direct referrals from care homes. Initial assessments were undertaken by multiple disciplines, and 71% of teams used common assessment documentation. Nevertheless, many social workers maintained both NHS and local authority records. In 92% of teams, nominated care coordinators oversaw the support provided by other team members. However, inter-agency care coordination was less prevalent. Few teams offered the range of outreach/liaison activities anticipated in the national dementia strategy. CONCLUSIONS: Compared with previous studies, teams had grown and changed, with a clear increase in non-medical practitioners, particularly support workers. Measures to facilitate integrated care within CMHTs (eg, common access and documentation) were widespread, but integration across health and social care/primary and secondary services was less developed. Consideration of barriers to further integration, and the impact of current reforms is potentially fruitful.

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.

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.

Identifying alternatives to old age psychiatry inpatient admission: an application of the balance of care approach to health and social care planning.

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.

Membership and management: structures of inter-professional working in community mental health teams for older people in England.

BACKGROUND: Community mental health services are regarded as the preferred first tier of specialist psychogeriatric support, with integrated multidisciplinary teams believed to offer improved decision-making and greater continuity of care than separate single-profession services. In England over 400 community mental health teams (CMHTs) form the cornerstone of such support, yet research has neither assessed progress toward integrating key professional disciplines nor the nature of their membership and management arrangements. METHODS: A self-administered questionnaire was sent to all CMHTs for older people in England, seeking a combination of objective and subjective information on team structure and management. RESULTS: Responses from 376 (88%) teams highlighted broader multidisciplinary membership than found in a 2004 survey, with particular growth in the number of support workers and other unqualified practitioners. Only modest progress was found in the integration of psychologists and social workers within CMHTs. The data also revealed a trend toward "core" team membership, and away from "sessional" membership in which staff may have divided loyalties between services. Multidisciplinary working was reported as beneficial by many respondents, but examples of "silo working" were also found, which may have hampered service delivery in a minority of teams. CONCLUSIONS: The reported growth in the number of practitioners without professional registration raises issues about the appropriate skill mix and substitution within CMHTs, while local agencies should review barriers to the integration of psychologists and social workers. Further research is required to explore the quality of multidisciplinary team working.

Promoting personalization in social care services for older people.

This article presents findings on 4 themes associated with the personalization of social care for older people: integration of health and social care services; initiatives that prevent the need for more costly interventions; services to maintain people at home; and systems that promote choice, control, and flexibility. The quantitative study utilized data from a national postal survey conducted in England. Findings suggest variable progress regarding the range and style of support available to older people. These are discussed in the context of service integration, community-based services, and consumer-directed care. Implications for service development and future research are highlighted.

Towards integrated community mental health teams for older people in England: progress and new insights.

OBJECTIVE: To investigate progress in joint working within community mental health teams for older people (CMHTsOP) against a range of national standards, and to consider team characteristics that may hinder or facilitate integrated practice. METHODS: A postal questionnaire was sent to the managers of all CMHTsOP in England. A total of 376 teams responded representing a response rate of 87.7%. Hypothesis testing and regression analysis, using a composite score based on nine indicators of integration, were conducted to address the study's aims. RESULTS: Whilst the study suggests that progress was being made against a number of key standards of joint working, the study finds that most teams could not access local authority service user records, nor were health staff within most teams able to commission social care services. After controlling for other characteristics, teams with the lowest levels of integration tended to work across multiple local authorities; were managed by a nurse; had high referral rates and were located in formally integrated Care Trusts. CONCLUSIONS: Improved integration could develop by NHS Trusts and local authorities encouraging more information sharing, and further delegating powers to arrange social care services to CMHTOP members. The paper highlights team and locality features that appear to cause obstacles to joint working, but there is a clear gap in the evidence relating team structures and characteristics to the quality of patient care.

Emergent approaches to care coordination in England: exploring the evidence from two national organizations.

For many years, there has been an international concern about the fragmented nature of health and social care services for vulnerable older people and younger adults. This article examines the implementation of two major policies in England designed to ensure frail adults and older people receive services appropriate to their needs. First, care management, which was introduced in 1993 and provided by local government, and second case management, which was introduced in 2005 and provided by primary care through the National Health Service. An analysis of the implementation of the two policies is presented, and data from two national surveys are used to describe similarities and differences between the two approaches in terms of goals, arrangements, service characteristics, and indicators of integration and differentiation within care coordination arrangements. Both were designed to promote the provision of care at home as an alternative to more costly alternatives. Discretion within the policy implementation process has militated against the development of a more differentiated approach to care management in local authorities as compared with case management in primary care trusts and more generally, integration between the two. Future developments within both service settings will be influenced by the introduction of personal budgets.

Changing patterns of care coordination within old-age services in England.

There has been a focus internationally in recent years on policies and strategies to divert the long-term care of frail older people away from residential and nursing home care and enhance provision of community-based care by improving care coordination through increased differentiation within care management arrangements and service integration between health and social care. The aim of this article is to explore variations over time in care coordination arrangements within old-age services using data from national postal surveys of English local authorities. Indicators of differentiation and integration developed from earlier research were used to compare changes over time. There appeared to be some evidence of change relating to integration at both organizational and practice levels, but little change was detected in respect of differentiation within care management arrangements. The impact of the findings in the context of four enduring themes related to international case/care management literature--eligibility, integrated health and social care, shared information, and targeting--are discussed and the relevance of these in relation to possible future trends is explored.

Developing multidisciplinary assessment--exploring the evidence from a social care perspective.

BACKGROUND: This paper provides an initial evaluation of the impact of the Single Assessment Process (SAP) in England upon practice regarding multidisciplinary assessment. OBJECTIVES: To investigate changes in recorded health needs of older people and in the number of multidisciplinary assessments undertaken using social care agencies' case files. To examine differences in approaches to the use of multidisciplinary assessment for older people with different health needs. METHODS: An audit of case files of older people living in the community in receipt of social care in three areas carried out at two time periods before and after implementation of the SAP in 2004. Information extracted from files covered a number of domains including evidence of multidisciplinary assessments, and presence of mental and physical health problems. RESULTS: Data from 144 files at Time 1 were compared with 145 files from Time 2. Little evidence emerged that older people at Time 2 were more dependent. However, significantly more multidisciplinary assessments were undertaken following the introduction of the SAP, in particular by occupational therapists and secondary health care teams. Cognitive impairment was a significant predictor of multidisciplinary assessment at both time periods. CONCLUSIONS: The impact of the introduction of the SAP has been mediated by the influence of other policies in England: intermediate care and integrated health and social care provision. Nevertheless, the data suggest that consideration be given to more effective targeting of multidisciplinary assessments on the grounds of both cost and more accurate identification of those who will benefit from the process.

Care management in mental health services in England and Northern Ireland: do integrated organizations promote integrated practice?

OBJECTIVE: To explore whether integrated structures are associated with more integrated and differentiated forms of care management in mental health services. METHOD: Cross-sectional postal survey of care management arrangements in local authority social services departments in England (n=101) and health and social services Trusts in Northern Ireland (NI) (n=11). RESULTS: Some, but not all, indicators showed more evidence of integrated practice in NI mental health and social services. This included: greater involvement of health care staff in care management; greater multidisciplinary working and a more integrated approach to assessment and care planning processes; a more differentiated approach to care management, including greater targeting of care management resources; a closer link between care management and specialist provision; and overall more integrated practice. CONCLUSIONS: This study concurs with previous research showing that structurally integrated health and social services in NI are more conducive towards, although insufficient to secure, integrated working. As the nature, type of services and ways of working appear to be broadly similar in England and NI, this may imply that greater structural integration per se may not lead to better service outcomes.

Care managers' time use: differences between community mental health and older people's services in the United Kingdom.

Since the community care reforms of the early 1990s, care management in the United Kingdom has become the usual means of arranging services for even the most straightforward of social care needs. This paper presents data from a diary study of care managers' time use, from a sample of social services commissioning organizations representing the most common forms of care management practiced in England at the end of the 20th century. It compares the working practices of care managers in community mental health service settings to the practices of those situated in older people's services. Evidence is provided to suggest that while the former follow a more clinical model of care management, those working with older people take an almost exclusively administrative approach to their work. In addition, the multidisciplinary nature of mental health service teams appears to facilitate a more integrated health and social care approach to care management compared to the approach to older people's services. Further enquiry is needed as to the comparative effectiveness of these different modes of working in each service setting.

Levels of integration and specialisation within professional community teams for people with dementia.

BACKGROUND: Delivering integrated and specialist mental health services for the growing population of older people with dementia in Britain is a key concern of the present government. AIMS: To consider the nature of current practice among multi-disciplinary and single discipline health and social care teams providing a service to people with dementia and compare the quality of service offered. METHODS: A postal survey of professional community teams in North West England, providing services to people with dementia. Responses were analysed according to a number of standards measuring service quality, developed from research and policy documents. A response rate of 59% yielded a final sample of 52 teams. RESULTS: Multi-disciplinary teams scored more highly than single discipline teams on many of the measures used. Single discipline teams achieved a higher score on just one measure, culturally sensitive services. Generally teams were found to provide a more integrated, targeted and person-centred service, as measured in this study, compared with earlier findings. Teams performed less well on measures of flexibility and culturally sensitive provision. CONCLUSIONS: These findings indicate some potential gains from integration, and highlight the level of work still needed to achieve it. Further research is needed to build on the structural and process measures used in this research in order that the costs and outcomes consequent upon these practices can be measured.

Frail old people at the margins of care: some recent research findings.

BACKGROUND: Community-based care at the margin is a substitute for institutional care. Three factors are considered critical: definitions of eligibility, assessment procedures and balance of care. AIMS: To examine determinants of the margin between institutional and home-based care, review current practice, identify the implications and contribute to planning of integrated long-term care services. METHOD: A selective review was made of findings from research conducted after the community care reforms. RESULTS: Marked variability and inconsistency in eligibility and assessment processes may contribute to misplacement of frail older people. There remains capacity to shift the balance of care from institutional to home-based care within reasonable cost parameters, particularly with more integrated services. CONCLUSIONS: Greater standardisation of approaches to the determination of eligibility for social care and to assessment of need is required. Providing care at home for some of those currently entering care homes is feasible, but will require different service structures and staff roles, including specialist clinicians.