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.
Highlights
Health systems in many different countries have increasingly been reorienting the delivery of dementia care to home and community care settings
The qualitative data examined in this paper provides both micro- and meso-level exploration of resource allocation decision-making among health and social care professionals (HSCPs) for people with dementia living at home in Ireland
Freedom from a budget constraint allowed HSCPs to consider a broader range of services and to take a more expansive view of need, with a particular emphasis on proactive, preventative responses
Summary
Health systems in many different countries have increasingly been reorienting the delivery of dementia care to home and community care settings. While recognising the limit on word count – the paper could benefit from greater explanation of how resource allocation when viewed through this pragmatic lens may result in an over-reliance on residential care – when relative costs are considered over and above person-centred outcomes. This provides a significant context for the innovative approach adopted for this study which examines ‘micro’ decisionmaking on resource allocation across a continuum of dementia (varying stages of disease progression) and with a particular focus on community or home care which includes consideration of ‘informal’ family care
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