Services For Older People Research Articles

Age inclusive services or separate old age and working age services? A historical analysis from the formative years of old age psychiatry c.1940-1989.

The Equality Act 2010 made it unlawful to discriminate in the provision of services on the grounds of age. This legislation is open to interpretation, but it is affecting the way older people’s services are defined and provided. Historical evidence indicates that, since the 1940s, apart from psychiatrists working in dedicated old age services, most were unenthusiastic about working with mentally unwell older people and unsupportive of those who chose to do so. A historical analysis might shed light on current dilemmas about ‘all age’ or ‘old age’ services and inform decision-making on future mental health services.

Exploring patterns of care coordination within services for older people

Introduction Supporting frail older people at home is an international policy objective. This article explored variations in care coordination arrangements and their relationship with service level outcomes using England as a case study. Method Survey data and routinely generated data collected in 2006 from 119 local authorities responsible for social care were combined. Using cluster analysis, distinct groups were identified with regard to forms of care coordination. Results Considerable variation was evident both within and between different types of care coordination, reflecting implementation guidance. Links with service level outcomes were weak, the most notable being the provision of intensive home care, a component of intensive care management. Discussion Thus this study, using agency level data, confirmed the variability in care coordination arrangements and the relative absence of intensive care management, central to shifting the balance of care from residential and nursing provision to care at home.

Guest editorial: Integrated services for older people – the key to unlock our health and care services and improve the quality of care?

Across the United Kingdom, there is growing interest from politicians, national and local service leaders and clinicians in integration, care co-ordination and partnership working (Curry and Ham, 2010; Goodwin et al., 2013b; Ham et al., 2011, 2013; NHS Confederation and Royal College of General Practitioners, 2013). Some specific policy levers and targeted funds and financial instruments have aimed to facilitate integration and make it the norm rather than the exception (Bennett and Humphries, 2013; Royal College of Nursing, 2014). There is a tacit assumption that a shift towards these models will be ‘‘win/win’’ – improving care for individual service users, whilst also saving services from the ‘‘triple threat’’ of population demographics, rising demand and financial austerity (Naylor et al., 2013). Influential health think tanks the King’s Fund and Nuffield Trust (Goodwin et al., 2013a) and professional Bodies such as the Royal Colleges of Physicians (RCP, 2013), General Practitioners (RCGP, 2014) and Nursing (RCN, 2014) have focused increasing efforts on the cause of integration. Whilst my editorial focuses on the UK, other health systems facing similar challenges are increasingly embracing the same agenda (Goodwin et al., 2013a, 2013b, 2014; Ham 2011, Timmins and Ham, 2013). I won’t get drawn into endless, abstruse definitions of what we mean by integrated services. There is a body of literature for those with a niche interest in terminology or who like to close down discussion by saying ‘‘everyone’s talking about it, but no-one can agree what it is’’. I am more concerned by how integration might help support people in need of health and social care and improve their experience and outcomes. We can return to definitions later. Let’s start ‘‘bottom up’’ with people before worrying ‘‘top down’’ about structure and process.

The Flexible Care Service: a third-sector service for older people with mental health needs.

Demographic patterns indicate that by 2030, one in five people in England will be over 65. Together with the fact that as people age they are more likely to suffer from comorbidities, it is of paramount importance that local services are designed to meet the needs of individual older people. The Flexible Care Service is a resource for older people with mental health problems. Through the use of client case studies, the Department of Health's 'six Cs' (care, compassion, competence, communication, courage and commitment) are used as a framework to demonstrate how a third-sector service such as Flexible Care can offer a person-centred approach in order to meet the diverse needs of individual clients. The framework is also used to demonstrate the high level of skills needed by flexible carers in order to provide this support.

Secondary analysis and literature review of community rehabilitation and intermediate care: an information resource

Background and designThis research was based on a reanalysis of a merged data set from two intermediate care (IC) projects in order to identify patient characteristics associated with outcomes [Nancarrow SA, Enderby PM, Moran AM, Dixon S, Parker SG, Bradburn MJ,et al.The Relationship Between Workforce Flexibility and the Costs and Outcomes of Older Peoples’ Services (COOP). Southampton: National Institute for Health Research (NIHR) Service Delivery and Organisation (SDO); 2010 and Nancarrow SA, Enderby PM, Ariss SM, Smith T, Booth A, Campbell MJ,et al.The Impact of Enhancing the Effectiveness of Interdisciplinary Working (EEICC). Southampton: NIHR SDO; 2012]. Additionally, the impact of different team and staffing structures on patient outcomes and service costs was examined, when possible given the data sets, to enable identification of the most cost-effective service configurations and change over time with service provision. This secondary analysis was placed within updated literature reviews focused on the separate questions.Research objectives(1) To identify those patients most likely to benefit from IC and those who would be best placed to receive care elsewhere; (2) to examine the effectiveness of different models of IC; (3) to explore the differences between IC service configurations and how they have changed over time; and (4) to use the findings above to develop accessible evidence to guide service commissioning and monitoring.SettingCommunity-based services for older people are described in many different ways, among which are IC services and community rehabilitation. For the purposes of this report we call the services IC services and include all community-based provision for supporting older people who would otherwise be admitted to hospital or who would require increased length of stay in hospital (e.g. hospital at home schemes, post-acute care, step-up and step-down services).ParticipantsThe combined data set contained data on 8070 patient admissions from 32 IC teams across England and included details of the service context, costs, staffing/skill mix (800 staff), patient health status and outcomes.InterventionsThe interventions associated with the study cover the range of services and therapies available in IC settings. These are provided by a wide range of professionals and care staff, including nursing, allied health and social care.Outcome measures(1) Service data – each team provided information relating to the size, nature, staffing and resourcing of the services. Data were collected on a service pro forma. (2) Team data – all staff members of the teams participating in both studies provided individual information using the Workforce Dynamics Questionnaire. (3) Patient data – patient data were collected on admission and discharge using a client record pack. The client record pack recorded a range of data utilising a number of validated tools, such as demographic data, level of care (LoC) data, therapy outcome measure (TOM) scale, European Quality of Life-5 Dimensions (EQ-5D) questionnaire and patient satisfaction survey.Results(1) The provision of IC across England is highly variable with different referral routes, team structures, skill mix and cost-effectiveness; (2) in more recent years, patients referred to IC have more complex needs associated with more severe impairments; (3) patients most likely to improve were those requiring rehabilitation as determined by levels 3, 4 and 5 on the LoC (> 40% for impairment, activity and participation, and > 30% for well-being as determined on the TOM scale); (4) half of all patients with outcome data improved on at least one of the domains of the TOM scale; (5) for every 10-year increase in age there was a 6% decrease in the odds of returning home. The chance of remaining or returning home was greater for females than males; (6) a high percentage of patients referred to IC do not require the service; and (7) teams including clinical support staff and domiciliary staff were associated with a small relative improvement in TOM impairment scores when compared with other teams.ConclusionsThis study provides additional evidence that interdisciplinary teamworking in IC may be associated with better outcomes for patients, but care should be taken with overinterpretation. The measures that were used within the studies were found to be reliable, valid and practical and could be used for benchmarking. This study highlights the need for funding high-quality studies that attempt to examine what specific team-level factors are associated with better outcomes for patients. It is therefore important that studies in the future attempt empirically to examine what process-level team variables are associated with these outcomes.FundingThe NIHR Health Services and Delivery Research programme.

Older persons mental health in rural Australia: testing a model for integration

Introduction and problem: There is significant unmet need for mental health care for older persons in Australia, with those living in rural communities particularly disadvantaged in terms of availability and access to services. Linkages and collaboration between health and social services has been advocated in national policies, though integrated primary mental health care for older people in the Australian context remains problematic. Purpose and theoretical basis: A participatory research project is being undertaken (October 2013-January 2015) to test a network model to plan and manage the development of integrated primary mental health care for older people, with one rural region in South Australia as a case study. The theoretically informed model [1,2] consists of components (linkages and enablers) and processes (facilitated reflective practice) with the aim to optimize problem solving in situ. The testing of the model is to ascertain if the process of facilitated reflection can help participating organizations to improve integration. Method: A mixed methods case study approach included analysis of the policy context and Organizational Network Analysis to determine the structure and function of links between services, and barriers and enablers to effective linkages. Consumers and their carers will also be interviewed to explore client journeys to care. Meetings are being held over the course of the project for stakeholders (champions and managers) from a range of relevant organizations to reflect on the data. World Congress on Integrated Care 2014, Sydney, November 23-26, 2014. International Journal of Integrated Care – Volume 14, 8 December – URN:NBN:NL:UI:10-1-116607– http://www.ijic.org/ Findings and Conclusion: Early results suggest that the reflective process is effective in engaging stakeholders in identifying problems in the network and participating in the development of solutions at the local level. Formalized processes to support integration however are lacking, with a fragmented policy and funding context creating an unsupportive authorizing and resourcing environment. Three levels appear to impact on how the network is functioning: 1. Local level linkages; 2. Management level linkages; 3. Policy and funding. Implications of emerging findings on the development of sustainable integration of services for older people with mental health issues will be discussed.

Client satisfaction as a driver of quality improvement in services for older people: a Western Australian case study.

This paper aims to describe a practical example of the use of adapted versions of a resident satisfaction questionnaire for quality improvement purposes in a large aged care service organisation. Residential care and home care questionnaires each covered 11 aspects, the 'housing' questionnaire nine. Each aspect included Likert scale-type satisfaction questions. Questionnaires were distributed for completion by residents or by a friend/family member where a resident was unable to self-complete (e.g. because of dementia). Over the six separate customer satisfaction surveys conducted by the organisation since 1999, the analysis scheme has been refined and forms the basis of a report to the Board highlighting major findings and making recommendations regarding future actions. Most recently, the Board has decided to focus on three main areas, with actions identified for each, namely satisfaction with staff (e.g. enhanced staff training), social activities and involvement (e.g. increased occupational therapy), and opportunities for enhanced feedback.

An overlooked resource? Public libraries’ work with older people – an introduction

Purpose – The purpose of this paper is to highlight work with older people being undertaken by public libraries. Design/methodology/approach – The paper draws on responses from libraries working with older people, outlining their approaches, and also on the report, “Library services for older people – good practice guide”. Findings – There is a large and varied programme of work being delivered by public libraries and their partner organisations. However, much of it is “under the radar”, so, when spending cuts are made, the knock-on effects are often not recognised. Practical implications – Highlights examples of work that other library services could replicate. Also highlights work that potential partner organisations may not know about, and therefore can use this paper as a “way in” to libraries. Stresses the importance of recognising the wide range of people under the umbrella term, “older people”. Social implications – This paper aims to draw attention to a key area of work which may not be well known outside libraries themselves, with the potential to bring other partners and funders on board. Originality/value – The paper draws together examples of different initiatives developed by public libraries, all of which have an enormous impact on the older people (and their families) involved.

Meeting unmet needs? The role of a rural mental health service for older people

Background: Rural and remote residents have been identifi ed as a group with limited access to mental health services. Older rural people may experience additional problems due to lack of access to transport, limited opportunities for social engagement and the stigma attached to mental illness. Aim: To explore the extent to which service providers, carers and consumers view the Older Persons’ Mental Health Service (OPMHS) as meeting the needs of older people with mental health problems in rural South Australia. Methods: Semi-structured interviews were conducted at 3 case study sites with 22 key informants from mental health teams and organisations providing care to older people and with 4 consumers and 5 carers. Results: The establishment of OPMHS clinicians at the sites studied led to increased access to specialist services for older people leading to earlier assessment and treatment of consumers. It has also led to greater service integration and knowledge sharing about older persons’ mental health. Participants identify ongoing service needs particularly for remote, CALD and Aboriginal populations and for after-hours crisis care. Conclusion: The localization of services and attachment of specialist older persons’ clinicians to rural mental health teams has enhanced service delivery for older people through enabling case management within rural communities. There are however, ongoing service needs which need to be resolved.

Speaking out.

DAVID OLIVER has been liberated. As a former national clinical director for older people's services, he adapted to the limitations imposed on clinicians who take on a government role. Now, though, he is free to speak his mind and does so frequently online and in print, often pointing out the contradictions and inconsistencies in the way older people's care is organised - or, in some cases, disorganised.

Mental health services for older people.

Mental health services for older people.

‘All elderly people have important service needs’: a study of discourses on older people in parliamentary discussions in Finland

ABSTRACTThis study examines discursive constructions of older people by analysing the talk of members of parliament in parliamentary discussions in Finland. While the perceptions of older people that are constructed in various public and private arenas have been relatively widely examined, the talk of political decision makers has not been studied to any large extent. However, decision makers' understandings of older people are likely to influence the ways in which service systems are developed and services organised for older people. The parliamentary discussions examined in this study were related to the process of enacting legislation to secure services for older people. Using discourse analysis, three ways of constructing older people – as ‘the dependent’, ‘the active’ and ‘the deserving’ – are identified. Although the results are to some extent in accordance with previous findings, indicating that older people are constructed as either totally dependent and passive or extremely active, this study also breaks this dichotomous view and highlights the overlap between those constructions. Nonetheless, the picture of older people remains fairly one-dimensional. There was an absence of recognition of diversity among older people, which might inhibit the development of a customer-oriented service system.

Not too late: Fortnightly short term dynamic therapy with older people

I describe a short-term dynamic therapy of 12–14 fortnightly sessions developed whilst working in a specialist mental health service for older people. Vignettes are given of this therapy with two women suffering from long histories of depression who experienced considerable benefit. They both showed an impressive capacity to reflect on and hold the therapy in mind during the fortnightly intervals and the longer breaks. To their surprise and relief, they did not become depressed during the period of therapy. They were especially pleased to discover an unexpected resilience. Less intensive frequency of sessions with fortnightly intervals offers the advantage of not encouraging a regression in the transference and, whilst recognising the importance of difficulties in early life, can galvanise adult capacities and resources developed over a long life. Particular influences in this work are discussed in the use of play from Winnicott, as described by Smith, and the importance of reaching hopeful and positive aspects of the personality described by Music.

Methodological development of the interactive INTERLINKS Framework for Long-term Care.

There is increasing international research into health and social care services for older people in need of long-term care (LTC), but problems remain with respect to acquiring robust comparative information to enable judgements to be made regarding the most beneficial and cost-effective approaches. The project 'INTERLINKS' ('Health systems and LTC for older people in Europe') funded by the EU 7th Framework programme was developed to address the challenges associated with the accumulation and comparison of evidence in LTC across Europe. It developed a concept and method to describe and analyse LTC and its links with the health and social care system through the accumulation of policy and practice examples on an interactive web-based framework for LTC. This paper provides a critical overview of the theoretical and methodological approaches used to develop and implement the INTERLINKS Framework for LTC, with the aim of providing some guidance to researchers in this area. INTERLINKS has made a significant contribution to knowledge but robust evidence and comparability across European countries remain problematic due to the current and growing complexity and diversity of integrated LTC implementation.

An examination of assessment arrangements and service use for older people in receipt of care management.

With anticipated greater demand for formal care services globally, this article examines the sociodemographic and health characteristics of frail older people in receipt of community support. Data were collected from audits of case files of older people receiving care management at two time points during which two government policy initiatives were implemented to promote greater standardization in health and social care provision for older people in England. Findings at Time 2 revealed that there were higher levels of physical and mental impairment and more health care assessments undertaken. There was a slight decrease in home care receipt but a marginal increase of more intensive home care provision. Service users living with a carer were less likely to receive home care but more likely to receive respite care or day care than those living alone. The policy goal of widening access to specialist health and social care services for older people with mental health problems was achieved. Guidance that focused eligibility criteria on the identification of older people with complex needs required the availability of appropriate support and services. Irrespective of policy initiatives, the sociodemographic characteristics of older people and the availability of informal support are principal determinants of service provision.

Promoting family-focused approaches within adult drug services: The potential of the ‘Senses Framework’

BackgroundPolicies across countries promote family-focused engagement with adult drugs services however this is rarely offered routinely and relationships with carers are often poor. Research in mental health and older people's services suggests that improving the relationships between carers and service providers is fundamental to enhancing the quality of services. One example is the Senses Framework which assesses the extent to which services are relationship-centred and provides deeper insight into the areas that require further improvement. The aim of this paper is to establish the extent to which relationship-centred care, as defined by the Senses Framework, is expressed in the interactions between carers, services providers and policy makers in adult drug service settings. MethodsA qualitative study, involving 8 focus groups and 32 individual interviews, was undertaken to explore carers’, service providers’ and policy makers’ experiences and understandings of family and carer involvement with drug services in Scotland, United Kingdom. ResultsTensions exist between carers, service providers and policy makers however there are also areas of commonality in which participants shared experiences and understandings of family and carer involvement with services. Our findings go beyond existing research which focuses largely on describing of the poor quality of relationships between carers, service providers and policy makers by providing a deeper theoretical insight into the nature of these relationships. In so doing, by focusing on the senses of belonging, continuity, security, achievement, purpose and significance, we present the possibility of resolving such tensions. ConclusionsWe think that implementing relationship-centred approaches to care, such as that in the Senses Framework, would provide a greater sense of therapeutic and strategic direction for those delivering and commissioning adult drug services in many countries.

The Executive Interview (EXIT25) as a tool for assessing executive functioning in older medical and surgical inpatients referred to a psychiatry service: feasibility of creating a brief version

Most neuropsychological tests of executive function are time-consuming and otherwise unsuitable for routine bedside assessment, particularly in older people admitted to a general hospital. After introducing the Executive Interview (EXIT25) in our routine clinical practice, we hypothesized that it would be possible to shorten it for easier administration in our group of patients while maintaining or improving properties of the scale. The EXIT25 was applied in 122 clinically stable medical and surgical inpatients aged 65 years and over referred to the Liaison Psychiatry Service for Older People. Individual items were initially tested for floor and ceiling effects, inter-rater and test-retest reliability, and item-total correlations. Items were then selected for retention in the brief scale on the basis of adequate item-total correlation and inter-rater and test-retest reliability. The construct validity of the original and brief versions of the EXIT25 scale was assessed. The original EXIT25 scale was found to lack desirable scaling properties either as a classical or hierarchical scale. The study confirmed a possibility to reduce the number of items to nine out of the original 25 while improving internal consistency, test-retest and inter-rater reliability, and maintaining high correlation with the original EXIT25 score, and moderate inverse correlation with the Mini-Mental State Examination score. There is potential to abbreviate the original EXIT25, and improve internal consistency and hierarchical scaling properties. Future research is necessary to focus on piloting these brief measures of executive function in relevant clinical settings, when administered en bloc, rather than with items interspersed in the original longer version.

Adult protection training for community nurses: evaluating knowledge following delivery using participant-favoured training methods

Purpose – The purpose of this paper is to measure nurses’ knowledge about Adult Support and Protection (Scotland) Act 2007 before and after a one-day training course using participants’ favoured methods of training activities. Design/methodology/approach – A repeated measures design was used to evaluate the impact of a one-day Adult Support and Protection training on pre-training knowledge of community nurses across one NHS area. Participants’ favoured methods of training activities were used in the training. Participants were community nurses working in learning disability, mental health, older people's services, acute services, substance misuse, and accident and emergency. All completed a training needs analysis and training preferences study. Individual and group scores on an Adult Support and Protection knowledge questionnaire were analysed pre- and post-training. Findings – There was a statistically significant increase in scores post-training (Wilcoxon's signed-ranks test). Individual increases ranged from 2.5 to 27.5 per cent, with a mean score of 15 per cent. Evaluation of the impact of nationally approved Adult Support and Protection training is needed and training should take account of participants’ existing knowledge and preferred methods of training delivery to improve the transfer of learning into practice. Research limitations/implications – Participants were self-selecting. Existing knowledge was not controlled for in the sample. No longitudinal follow up to measure retention of any improvements in knowledge. No control group. Training methods used were based on the expressed preferences of 40 nursing staff, but only 18 of these staff participated in the training day. Originality/value – There is a dearth of research in evaluating the impact of the adult protection training on staff knowledge and understanding. Designing training activities and content to take account of participant preferences, and areas where knowledge is weakest may enhance the effectiveness of training in this area. This research was funded as a Queens Nursing Institute Community Project. It builds on a pilot project

Social counselling for older people—between advice and therapy

In Europe, social counselling services increasingly follow the guiding principle active ageing. Active ageing policies help people recognise and use their physical, social and mental potential in order to participate in society according to their individual needs and capacities. Counselling the heterogeneous target group—‘older people’—implies that services should be prepared to address individual risks and resources. This article discusses the largely unclear position of social counselling for older people within social work in Europe. An empirical perspective is established with a German online survey, conducted among social counselling professionals nationwide (N = 1050). Their services were studied in terms of service provision, target groups, counsellor qualification and applied methods. The aim was to describe and classify the existing counselling provision. The study revealed that social counselling is located somewhere between advice and psychotherapy, and as such primarily focused on helping with age-related deficits and problems. A considerable proportion of client contacts results from acute crises. Still, only a third of the respondents followed a specific, defined concept in their work, and even fewer stated having gerontological qualification. Primary achievements of the study were to help classify existing social counselling services for older people and to develop basic gerontological training for counsellors.

Integrated and Seamless Services for Active Aging, a Model for Zhuhai

The Aging Tsunami as it is often quoted to describe the worrying situations of rapidly aging in China has not met with detail planning in facilities upgrade and careful consideration in service models. Broad brushed central policies categorizes services into home care, community care and institutional care and set policy goals at 90-6-4, representing the percentage of older people in receiving respective care. This leaves local officials helpless on how these ideals can be actualized. Some cities have inclined to build huge older people homes and pour resources into institutional care, forgetting the need for older people to be connected with the society. This paper reviews the historical developments of older people services in Hong Kong and recommends an integrative model of social work services connecting institutional, community and home care into a seamless network. The city of Zhuhai will be presented as a perfect experimental city on how its existing facilities can be converted and developed according to the model. Survey on the situations of the 16 public older people homes will be used to illustrate the potentials of an integrative model.