Can extra care housing support the changing needs of older people living with dementia?

With over two-thirds of people with dementia living in the community and one-third of those living alone, it is important to consider the future housing needs of this population, particularly as symptoms of cognitive impairment increase. Policy in England has focused on enabling people living with dementia to remain in their own homes for as long as possible, often with the support of a family carer. However, many people struggle to maintain an acceptable quality of life in their own homes as their dementia advances, often due to the design limitations of mainstream housing and the challenge of finding specialist domiciliary care that is affordable and of sufficient quality. Extra care housing offers a model that aims to support older people living in their own apartments, whilst also offering specialist person-centred care as and when it is needed. This paper reports on a longitudinal project that explored how extra care housing can respond to the changing social care needs of residents, including those living with dementia. Participants included residents and staff from four extra care housing schemes, one of which was a specialist dementia scheme, in two regions of England. Interviews were carried with 51 residents across 4 rounds at 5 month intervals between October 2015 and June 2017. Interviews were also carried out with 7 managers, 20 care staff and 2 local authority commissioners of housing for older people. Key factors included person-centred care and support, flexible commissioning and staffing, appropriate design of the environment and suitable location of the scheme within the wider community. The challenge of delivering services that addresses these issues during a period of reduced public spending is acknowledged. Further research is suggested to compare different approaches to supporting people with dementia, including integrated and separated accommodation, and different stages of dementia.

'You have got to stick to your times': Care workers and managers' experiences of working in extra care housing.

Extra care housing (ECH) has been lauded as an innovative model of housing with care for older people that promotes and supports independent living. The study used a qualitative design to explore how care is delivered in four extra care settings in England over 20 months during 2016-2017. This paper reports findings from semi-structured interviews with 20 care workers and seven managers. The article argues that, despite being heralded as a new model, care workers in ECH face similar organisational pressures as those working in more conventional settings and, in turn, the care which they are able to provide to residents mimics traditional forms of care.

Using longitudinal qualitative research to explore extra care housing.

PURPOSE: The process of individual ageing in the context of a care environment is marked by continuity and change. It is shaped by individual, health-related factors as well as by diverse social and environmental factors, including characteristics of the places where older people live. The aim of this paper was to explore how longitudinal qualitative research, as a research method, could be used to explore older people's changing care needs. METHODS: The study used a longitudinal design to examine how the care and support needs of residents and their expectations of services developed over time and how these were influenced by changes in the organisation of their housing as well as in the make-up of the resident population. Residents were interviewed on four occasions over 20 months. RESULTS: The study highlighted the complex ways in which some participants proactively managed the care and support they received, which we argue would have been difficult to discern through other methods. CONCLUSION: The study adds to the growing evidence base that supports the use of qualitative longitudinal research; the approach enables the researcher to capture the diverse and mutable nature of older people's experiences at a time of profound change in their lives.

The relationship between building design and residents' quality of life in extra care housing schemes.

Well-designed housing is recognised as being an important factor in promoting a good quality of life. Specialised housing models incorporating care services, such as extra care housing (ECH) schemes are seen as enabling older people to maintain a good quality of life despite increasing health problems that can accompany ageing. Despite the variation in ECH building design little is known about the impact of ECH building design on the quality of life of building users. The evaluation of older people's living environments (EVOLVE) study collected cross-sectional data on building design and quality of life in 23 ECH schemes in England, UK. Residents' quality of life was assessed using the schedule for the evaluation of individual quality of life-direct weighting (SEIQoL-DW) and on the four domains of control, autonomy, self-realisation and pleasure on the CASP-19. Building design was measured on 12 user-related domains by means of a new tool; the EVOLVE tool. Using multilevel linear regression, significant associations were found between several aspects of building design and quality of life. Furthermore, there was evidence that the relationship between building design and quality of life was partly mediated by the dependency of participants and scheme size (number of living units). Our findings suggest that good quality building design in ECH can support the quality of life of residents, but that designing features that support the needs of both relatively independent and frail users is problematic, with the needs of highly dependent users not currently supported as well as could be hoped by ECH schemes.

The characteristics of residents in extra care housing and care homes in England.

Extra care housing aims to meet the housing, care and support needs of older people, while helping them to maintain their independence in their own private accommodation. It has been viewed as a possible alternative, or even a replacement for residential care. In 2003, the Department of Health announced capital funding to support the development of extra care housing and made the receipt of funding conditional on participating in an evaluative study. This paper presents findings on the characteristics of the residents at the time of moving in, drawing on information collected from the 19 schemes in the evaluation, and a recent comparable study of residents who moved into care homes providing personal care. Overall, the people who moved into extra care were younger and much less physically and cognitively impaired than those who moved into care homes. However, the prevalence of the medical conditions examined was more similar for the two groups, and several of the schemes had a significant minority of residents with high levels of dependence on the Barthel Index of Activities of Daily Living. In contrast, levels of severe cognitive impairment were much lower in all schemes than the overall figure for residents of care homes, even among schemes designed specifically to provide for residents with dementia. The results suggest that, although extra care housing may be operating as an alternative to care homes for some individuals, it is providing for a wider population, who may be making a planned move rather than reacting to a crisis. While extra care supports residents with problems of cognitive functioning, most schemes appear to prefer residents to move in when they can become familiar with their new accommodation before the development of more severe cognitive impairment.

What types of home are closing? The characteristics of homes which closed between 1996 and 2001.

Closures of care homes have received considerable public attention. Fee levels and the cost of upgrading homes to meet the national minimum standards have been identified as the main factors influencing closures. The present paper compares private residential homes, dual-registered homes and nursing homes for older people which have closed between 1996 and 2001 with homes which have remained open. Homes which closed tended to be: smaller; to have had lower occupancy levels in 1996; to be the only home run by the organisation; to occupy converted buildings; to occupy multi-storey buildings, and if so, to have no lift; to have more shared bedrooms; and to have en suite facilities in none or only some of the bedrooms. These factors were interrelated and the effect of these variables in combination was examined using multivariate (logistic regression) analysis. Among the homes which remained open, only 34% provided at least 80% of places in single rooms, which was to have become the national minimum standard for existing homes until the standards were amended in March 2003. A separate analysis of data on social climate found that the homes with a more positive social environment were those most likely to have closed. The findings support the view that there is likely to be an increase in the importance of homes run by corporate providers relative to homes run as single, owner-managed homes, with a consequent reduction in choice for potential residents. At the same time, projections of future demand in a range of countries indicate that a considerable increase in provision will be required to meet the expected growth in the population of dependent older people, while developments in alternative forms of accommodation are unlikely to meet the growth in demand in the foreseeable future.

Nursing home closures: effects on capacity and reasons for closure.

OBJECTIVES: to identify the rate of closure of nursing homes for older people, the types of homes closing and the reasons for closure. DESIGN: mixed method study including a census and telephone survey of registration and inspection units and interviews with independent providers. PARTICIPANTS: 81 of 96 health authority and joint registration and inspection unit managers in England completed the census and 39 managers participated in a further telephone survey. Twenty-five independent providers were interviewed. RESULTS: closures resulted in a net loss of 6% of nursing homes and 4.9% of nursing places during 2000-2001. Smaller homes were more likely to close and were increasingly seen as unviable. The majority of closed homes were reported to have provided good quality care. Shortages of nursing staff were of widespread concern. The dominant combination of factors identified by providers was low fees and concerns about the cost implications of the new care standards. Changes in demand were reflected in the placement of high dependency residents in residential rather than nursing homes. CONCLUSIONS: in the absence of policy interventions capacity will continue to reduce, with smaller homes most likely to disappear. There is an urgent need to address the supply and efficient use of nursing staff skills in care homes. While fee levels are the primary concern the effect of the proposed care standards was clearly having an effect. Even with subsequent amendment to these standards, unless authorities use capacity funding to raise fees and improve expectations, providers are likely to continue to exit the market.

The cost implications of the changing population and characteristics of care homes.

BACKGROUND: Recent increases in care home closures suggest that homes may not be able to balance pressures to reduce costs against pressures to increase standards. Commissioning requires an understanding of the factors affecting costs and how they change over time. METHODS: A survey of care homes for older people was conducted in 21 local authorities in England in 1996. A complete response was obtained for 618 homes (75%) and 11,900 residents. Findings were compared with surveys conducted in 1986 and 1988. RESULTS: Dependency was significantly related to prices, primarily due to the differential payments to nursing and residential homes. Home characteristics were also related to price, the proportion of single rooms having the largest impact. However, prices were most sensitive to local wage rates, particularly in residential homes. Compared with previous surveys levels of dependency had increased, particularly in voluntary residential homes and nursing homes. Independent homes were more likely to be purpose built, and a higher proportion of beds were in single rooms, although only 30% of private residential, dual registered and nursing homes achieved the proposed level of 80% of beds in single rooms. Staffing ratios appeared to have increased, but price rises were modest, particularly for nursing homes. CONCLUSIONS: Standards of provision have improved over time, although prices appear to have been kept below those expected from increases in costs. Continuing pressures on costs and prices are likely to lead to further closures and a restriction of choice for older people.