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OLDER PEOPLE AND COMMUNITY CARE IN SCOTLAND - A REVIEW OF RECENT RESEARCH
3 ASSESSMENT AND CARE MANAGEMENT
3.1 Assessment and care management are the practices which frame the delivery of community care, and research which helps in the development of joint or integrated practice is of particular interest for this review. Research on hospital discharge is also included in this section on the grounds that the practices involved are, or should be, closely related to assessment and care management as practiced in the community. A brief summary of the English programme of research on outcomes of social care is included because of its potential value for care management practice in Scotland.
ASSESSMENT PRACTICE
3.2 It is surprising given recent interest in single shared assessment procedures that there appears to be a dearth of Scottish research on assessment techniques and how these differ between the professions. Bryans' (2000) study of district nursing assessment practice is therefore of some interest for the current review.
3.3 In a case study of good practice based on a fictitious scenario, Bryans describes the knowledge and skills involved in initial patient assessment by district nurses. The case study presents an illustration of the distinct qualities of good assessment practice. These include "fluent and appropriate use of a practitioner's knowledge base resulting in rapid and accurate recognition of the patient's needs". The practice described is thoroughly patient-focused: "The overall approach involved a fine balance between the patient's agenda and that of the assessor interweaving the nurse-initiated issues while following the patient's cues." The nurse had the explicit aim of getting the patient to identify her own problems. Intensive and thorough questioning about all aspects of the patient's condition was avoided so as not to "put the patient off". This research is highly relevant to the development of single shared assessment in that it illuminates the approach and values which nursing bring to the assessment task.
3.4 Assessment and early diagnosis of dementia is clearly essential to facilitate appropriate treatment and support for people with dementia. An ongoing study 2 is focusing on the memory clinic model in order to understand the future needs of the population and how these might best be met through specialist practice. The most common response to the assessment needs of people with dementia are memory clinics which began to appear in the early 1980s and are now common in UK, US and Europe. A survey of memory clinics across the UK (Wright and Lindesay 1995) described the activities of 20 memory clinics (including 3 in Scotland) and found that, despite broadly similar aims and general operating characteristics, clinics varied considerably in the numbers of people assessed and diagnosed.
Needs assessment and unmet need - older people with schizophrenia
3.5 McNulty et al (2003) present what appears to be an isolated example of research addressing the community care needs of older people with functional mental illness. Using a structured approach to data collection, their study measures the extent of unmet need in a sample of elderly people with schizophrenia in North Lanarkshire. The sample included 10 people in long stay hospital; 11 placed in private nursing homes (under a partnership agreement whereby NHS consultants remain the responsible medical officers); and 37 living in their own homes or with relatives. Problems and needs were assessed in relation to a range of clinical and social areas of functioning. A problem was defined as 'cardinal' if one or more of the following applied in relation to the particular objective problem: the patient was willing to accept help; the caregivers were experiencing severe anxiety, annoyance or inconvenience; the health and safety of the patient or others were put at risk. Needs were then identified as cardinal problems if a suitable intervention existed but had not been given a recent adequate trial.
3.6 Results from the comparison of clinical symptoms showed that people in the community had lower scores on average than those in hospital or partnership homes, with the exception of depression/anxiety for which average scores in the community were significantly higher. In 27 of the 58 cases (48 per cent) there was no social need identified. From 69 cardinal problems identified in areas of social functioning (domestic skills, finance and welfare, transport and amenities, social life, hygiene and dressing) a total of 23 needs were identified. In addition 14 needs related to inappropriate accommodation. Hospital inpatients had considerably more social care needs on average than others in the sample. Those in the partnership homes had the least.
3.7 For the 37 people living in the community, total needs (both social and clinical) were higher for the 17 receiving care from the Community Mental Health Team compared with the 20 who were not. However the authors note the substantial number of needs in those not receiving multi-disciplinary mental health care and that little was currently being done to assist such patients in spite of their having more than 2 cardinal problems each. They conclude that systematic needs assessment is the basis for improving levels of care - a process undermined by shortages of professional staff and local lack of funding in Lanarkshire.
JOINT WORKING MODELS
3.8 Integrated health and social care teams offering intensive support have been in existence in parts of Scotland for some time but joint health and social care teams offering mainstream services are at an early stage of development. Independent evaluations of work in this area which have been published are hard to find. An English evaluation of two integrated teams in a rural area concluded that the features of integration adopted, such as co-location, were insufficient in themselves to produce better outcomes for older people. The authors conclude that more evidence is needed to support the claim that integration is of benefit, but that evaluation in itself is impractical so long as health and social care agencies maintain separate and incompatible information systems. "If the Department of Health wishes to move from benefits in process to benefits to users, then it seems as if it will have to win over the hearts and minds of not only the front-line staff, but the senior managers and politicians charged with making this happen." (Brown et al 2003) The difficulties and expense of conducting comparative research to demonstrate the efficacy of integration are discussed in Levin et al (2002).
3.9 The integrated care model discussed by Foote and Stanners (2002) exemplifies a systems approach to care for older people in which ongoing evaluation is an essential element. Key characteristics of the Elderly Persons Integrated Care System (EPICS) in Marlow, South Buckinghamshire include: the older people are involved in running the service; the response to assessed need is multi-disciplinary without the need for referral from one agency to another; information and 24-hour telephone contact is available from the service base. The evaluation of the original EPICS project (a number of other projects have adopted the same model) shows that the approach was successful in reducing the average length of stay in hospital by 10 days.
3.10 Satisfaction with the EPICS service was monitored through interviews with clients and a survey of referrers. Client satisfaction interviews were conducted with every 16 th person referred by a team of volunteers. An example is given of an improvement to the service made arising from these interviews: the contact number for the project was distributed to all older residents in the area in the form of a label to stick on their telephone. The survey of actual and potential professional referrers recorded that 87 per cent were very satisfied with the service. The reasons given were: the convenience and appropriateness of the service, the immediacy of response, the local community base and the lack of any similar alternative (Foote and Stanners 2002)
CARE MANAGEMENT
3.11 Stalker and Campbell (2002) reviewed how local authorities in Scotland were using care management to sustain people at home in a study commissioned by the Scottish Executive. They conducted a Scotland-wide survey to obtain the views of service managers and care managers about policy and practice in each council area. Four of the 5 detailed case studies of care management practice carried out incorporated a small number of visits to service users or carers.
3.12 The Scotland-wide survey revealed a high degree of variation in the way that care management was perceived, organised and delivered. Most striking was the apparent lack of a shared understanding of the meaning of the term 'care management'. 'Single shared assessment', currently the main vehicle by which the Executive seeks to promote joint working, was also found to be susceptible to varied interpretation. These findings illustrate the difficulty of monitoring the implementation of new policies in social care.
3.13 The lack of a shared understanding of what 'care management' meant was also the case in 1994 when a study of how care management was being implemented in Scotland found widely different interpretations both between and within the four local authorities sampled (Petch et al 1996). The two studies were concerned with broadly the same issues: the nature and practice of care management; the characteristics of care managed cases; the extent to which budgets are devolved; creativity in care planning; and training needs for care managers. However in the commissioning of the later review there was apparently no clear intention to track progress on the basis of the earlier study.
3.14 Case studies were selected purposively in Stalker and Campbell's study for their good practice features including multidisciplinary working, effective screening, effective single shared assessment tools, budgets devolved to care manager level and a high level of user involvement. The study found that predominantly rural authorities were more likely than urban to have adopted creative care management practices and the report suggests that this may not be accidental. Smaller authorities lend themselves to closer working relationships between staff at different levels and in different agencies.
3.15 The study provides some evidence, based on the reports of service and care managers, of the ability of local authorities to sustain people with complex or intensive support needs at home. More detailed data produced by Curtice et al's (2002) study of intensive care is discussed in part 4 of this review.
3.16 In 15 authorities 24-hour care was an option but only on a short term basis or when extra funding was available, and 17 authorities could offer 24-hour emergency cover. In 6 authorities it was said that 24-hour cover was not available at all. Of the 32 care managers interviewed, 19 said that it was possible to find creative ways to support people with rapidly changing needs in their own homes, 3 said it was not easy and 10 said it was difficult. The difficulties commonly mentioned were: lack of resources, budgets not devolved to care managers, inflexible services, lack of transport, lack of direct access for care managers to providers, restrictive local authority guidelines and protocols and waiting lists for services. Some examples are given of methods and resources which helped creativity. Older people were less likely to be offered long-term intensive support than younger disabled people - the high cost of a care package could be the trigger for a nursing home option.
3.17 About half the care managers interviewed did not think there was enough good quality provision locally to give users a choice. Choice for older people was usually limited to a choice between various care homes.
3.18 Findings from a study of care management arrangements in England (Weiner et al 2002) are not dissimilar to those from Scotland: there was considerable variation in care management arrangements; few authorities had differentiated levels of care management; and little evidence emerged of health service staff acting as care managers.
3.19 Service users' views played a central part in another English study which examined experiences of care management at the operational level (Ware et al 2003). Findings are based on analysis of case files as well as in-depth interviews with 55 users, 37 carers and 28 care managers in 7 local authorities. The research found a pronounced emphasis on procedure based practice to the detriment of the fostering of personal relationships with users and carers. Fragmentation of the assessment and care management process could lead to discontinuities in the provision of care.
User satisfaction with assessment and care management
3.20 Ongoing research commissioned by the Scottish Executive ( see Introduction) aims to develop reliable methods, based on research and on existing good practice, to assess service user and carer satisfaction with single shared assessment. The intention is that the resulting toolkit will enable service users across Scotland to express their views using a range of communication modes. Results are expected in late 2004.
3.21 The Department of Health requirement for user and carer satisfaction surveys in England and Wales has prompted considerable debate about approaches to measuring user satisfaction. One approach has been explored using data from a major study entitled 'Evaluating Community Care of Elderly People' (the ECCEP study) (Chesterman et al 2001). Satisfaction was measured using three global questions in interviews with a sample of 418 community-based service users and care managers at time 1, and 224 surviving users 6 months later. The first two questions asked about satisfaction with the assessment (time 1) and with services received (time 2) using a 5 point scale of satisfaction. People with severe cognitive impairment were excluded from this data collection reducing the sample to 326 at time 1 and 206 at time 2. The third question (time 2) asked whether the experience of social services had been 'favourable', 'mixed' or 'unfavourable'. The analysis investigated statistical associations between user satisfaction with services, general life satisfaction and case characteristics relating to the service user, resource inputs and local authority.
3.22 Overall, the researchers concluded that the support provided was not adequately addressing user needs. Being frequently lonely and having arthritis or rheumatism reduced satisfaction at time 2. However, one striking result of the analysis is that users whose care manager was a qualified social worker were more satisfied at time 2 than users whose care manager had been trained as a home help organiser. Furthermore, the greater the number of social worker hours invested in setting up services, the greater the satisfaction at time 2 with the experience of social services.
3.23 The limitations of this method of measuring service user satisfaction are acknowledged by the authors. Expressions of satisfaction may be as much a reflection of user and carer circumstances and characteristics as they are of social care interventions. Interest in user satisfaction surveys is partly a reflection of the general concern of policy makers to ensure Best Value for service users and carers. The idea of a user satisfaction 'measure' for use as a performance indicator has an obvious attraction for managers seeking streamlined quality assurance mechanisms. Whilst the method described by Chesterman et al has some value as a research tool for exploring associations between satisfaction and other characteristics of cases, it may be of limited value to agencies wanting to know how to improve their care management arrangements.
3.24 Qureshi and Rowlands (forthcoming) outline an alternative to the method proposed by Chesterman et al, one which is designed to address issues which are meaningful and relevant to service users and using cognitive testing as a method of validation. They also present a clear exposition of the different functions of user satisfaction surveys from an organisational viewpoint. They highlight the tension between the goals of performance measurement and performance improvement and argue that a different approach is required depending on which goal is pursued.
Research on outcomes of social care
3.25 In 2001 the Social Policy Research Unit (SPRU) at York University completed a five year Department of Health funded research programme on outcomes of social care. The work aimed to develop and test practical ways for agencies to collect and use information about outcomes of services for three groups of people: older people, carers and disabled adults of working age. Methods for outcomes focused practice developed by SPRU have been adapted for use by a number of Social Services Departments in England including Bradford and Derbyshire.
3.26 The SPRU research is valuable because of its focus on changing practice: the development of tools and methods for measuring outcomes was treated as a stepping stone to the creation of what they call "… a complete feedback loop in which relevant and useful information is collected, correctly interpreted and acted on". (Qureshi et al 1998). The outcomes under discussion were 'final outcomes' i.e. the ultimate effect of an intervention on the user, rather than 'intermediate outcomes' such as delivery of a particular service.
3.27 The first stage of the programme explored the views of service users, carers and staff in one social services department to identify what outcomes were relevant. Older people, for example, were consulted using group and individual interviews, with groups meeting on more than one occasion to allow people time to form considered opinions on the issues. Amongst the older people consulted were people with dementia, users of social day care services and people from minority ethnic groups.
3.28 The consultation process provided the basis for a practical framework for understanding outcomes which distinguished three different kinds of outcomes:
- maintenance of quality of life in terms of, for example, acceptable standards of comfort, social contact, activity and control over daily life;
- change, for example, improving confidence, reducing risk, increased mobility and recovery of skills;
- impacts of service process, for example, feeling valued and respected, services fitting in with personal preferences and other sources of help (Qureshi et al 1998).
3.29 Unlike change outcomes, where measurement is required at more than one point in time, maintenance and service process outcomes are assessed by comparing them with a defined standard. The researchers argue that, given that deteriorating health is a common characteristic of older and disabled people requiring social care, judging social care activity solely on evidence of improvement in the individual's functioning would be unhelpful (Qureshi 2001).
3.30 In the second stage, a range of practice tools and guidance was developed in partnership with two local authorities. The aim was to introduce a greater focus on outcomes into care management practice (at both assessment and review stages), and to collect feedback from service users and carers. Three separate applications of the outcomes approach were developed and piloted, one of which was concerned with assessment of older people. Rather than produce yet another set of assessment procedures, the project's intention was to insert a new stage between assessment and care planning which made intended outcomes explicit and therefore made the measurement of success possible. In practice, the research team identified how this stage would fit into existing procedures through discussion with managers and practitioners.
3.31 A two page summary sheet was designed for recording intended outcomes and how they should be achieved. The sheet was intended to be completed by the assessor and passed on to service providers. Service users and carers were not involved in the working groups at this stage as it was apparent from the first stage of the project that they were not greatly interested in details of procedures and case recording. However, as Qureshi reminds us (2001, p 27), literature written from the perspective of service users has argued for a greater focus in assessment on the aims of intervention rather than 'needs', impairments and deficits. This point is particularly pertinent when information is shared with service users and carers.
3.32 The pilot implementation involved 12 staff from both community and hospital settings, including 7 social worker/care managers, 2 senior practitioners and 3 home care organisers. A total of 30 assessment summaries and 17 staff diary sheets were completed by these staff and analysed by the SPRU team. The analysis showed that the ease with which staff adopted the outcomes concept was quite variable and that training resources were needed. Some staff clearly had benefited from being involved in the workshops while others were able to formulate outcomes appropriately without any training. For staff involved in the development process, discussion of the complexities of assessment helped to make explicit the underlying negotiation between users' and carers' needs on the one hand and agency resources on the other. Evaluation of the pilot was compromised, albeit for sound management reasons as the report explains, by the fact that the use of the outcomes summary was introduced at the same time as other changes to the assessment process (Qureshi 2001).
3.33 In her concluding comments, Qureshi (2001) argues that the assessment of outcomes through systematic recording and review is effectively the same as adopting standards for social care which in turn can be operationalised as eligibility criteria.
HOSPITAL DISCHARGE
3.34 Taraborrelli et al's literature review (1998) commissioned by the Scottish Executive assesses the actual and potential contribution of current UK and European research to approaches to the discharge of frail older people (including those with dementia) from acute, geriatric and psycho-geriatric wards. The literature is discussed under four headings: pre-admission; following admission; preparing for the return home; and future research. While broad agreement was found within the literature on many aspects of discharge practice, weaknesses identified in methodology lead to suggestions for further research. Case studies of four Scottish NHS Trusts indicate diversity in discharge arrangements, reflecting both local variation in the needs of frail older users, and local differences in the pace of development of discharge policies. A number of innovative local discharge arrangements were in place in some Trusts with other agencies involved; but problems with funding, and lack of communication or involvement with other key personnel were also identified.
3.35 McGinley's (2001) survey gathered views and experiences about hospital discharge from people contacted through carers' organisations. This study was linked to a UK-wide study (Holzhausen 2001). It highlights problems which carers' experience in relation to hospital discharge: having their caring contribution taken for granted; not being consulted about discharge arrangements; and patients being discharged before they are well enough. The findings are linked to policy recommendations which include taking account of the interests and needs of carers within the Delayed Discharge Learning Network 3.
3.36 Reed et al's (2002) appreciative enquiry project referred to earlier aimed to address the multi-agency nature of successful hospital discharge. The researchers were successful in developing a collaborative approach to tackling complexities. The carrying out of the action plans was only limited by lack of engagement in the process of managers at a sufficiently high level within organisations involved. An example of practice-based research in Liverpool involved a 'tracker nurse' team formed in 2000. The team conducted a review to establish the factors which lead to emergency readmissions of patients aged 65+ and to try to prevent this (Rosbotham-Williams 2002).
SUMMARY
3.37 Research on assessment practice is scarce. Analysis of how different professions approach assessment is potentially valuable in the development of multi-disciplinary assessment practice.
3.38 There is, equally, little published research on models of joint and integrated working in Scotland. Collaborative and multi-agency research has met with some success in England in actually promoting joint working. In one example, an action plan to improve hospital discharge was the outcome. In another, an integrated care system was developed employing a 'whole systems' approach with monitoring and evaluation playing an integral part.
3.39 Evidence of unmet need and of inadequate practice continues to emerge from research. Unmet needs for social support in older people with schizophrenia in one NHS Board area were found to be significant and attributable to a failure to provide multi-disciplinary assessment.
3.40 A Scotland-wide review of care management has revealed a high degree of variation in the way care management is organised and differing interpretations of what it is. Social Work Departments also appear to offer very different levels of service. 24-hour cover was available in almost all areas but only as an emergency or short term service. Managers from about half of the authorities did not think there was adequate choice for service users.
3.41 The policy agenda has focused attention on user satisfaction research. This has progressed in different directions depending on whether the aim is to measure or to improve performance. In English research, using global measures of satisfaction, assessment by a social worker, as opposed to a home care manager, was found to influence satisfaction in a positive way. However, such measures are of limited use for identifying what aspects of a service people find satisfactory or what needs to be changed.
3.42 An alternative approach focuses on outcomes of social care for individuals. Three different kinds of outcomes have been distinguished related to: maintenance of quality of life, change, and the process of service delivery. Researchers propose that agreeing outcomes with service users as a stage between assessment and care planning provides care managers with a tool to monitor standards of care.
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