The role of telematics in assisting family carers and frail older people at home

The overall aim of the ACTION research project (Assisting Carers using Telematic Interventions to meet Older person's Needs) is to maintain or enhance the autonomy, independence and quality of life of frail older and disabled people and their family carers by providing information, advice and support in the home. The authors report on the first phase of evaluation conducted using a case-study approach to test the ACTION system in several family carers' homes in Sheffield, England. The results reflect the realities of conducting an applied research technology project and are discussed with reference to the government's recent national strategy for carers. The authors acknowledge the need for further evaluation studies to explore the key issues raised within this preliminary evaluation phase.     

Developing primary care services for young people

The Cornwall and Isles of Scilly Health Promotion Service and Cornwall Youth Service have been working in partnership to facilitate the planning and promotion of high quality attractive and relevant designated health services for young people. This partnership arose from a joint project in North Cornwall looking at unwanted teenage pregnancies. It involved research with young people about their perspective of health services in their area, and a theatre in education project with the Barbican Theatre working with primary health care teams to raise awareness about the issues relating to health care for young people. The team have presented their work at several conferences, it has won a NHS 50 National Award sponsored by Glaxo-Wellcome, and has attracted much interest locally and nationally from policy makers and practitioners. This paper describes how the team came together, the various stages in the development and execution of the project, the outcomes and recommendations     

Facilitating choice and control for older people in long-term care

The community care reforms enabled some older people with severe disabilities to remain at home with domiciliary care services, as an alternative to institutional admission. This paper explores the extent to which the reforms actually enabled older people receiving domiciliary care to have greater choice and control in their daily lives than older people living in institutions. Findings are reported from a comparative study carried out in Greater Belfast, Northern Ireland, that determined the extent to which the subjective quality of life of older people – particularly autonomy – varied according to the type of setting. The older people were interviewed using a structured interview schedule and subjective autonomy was assessed using a measure of perceived choice. The measure consisted of 33 activities relating to aspects of everyday life such as what time to get up, when to see visitors or friends, and how much privacy was available. Qualitative data were also recorded which informed on the older people's perspectives on their own lives, particularly the extent to which they exercised choice on a daily basis. Two‐hundred and fourteen residents in 45 residential and nursing homes were interviewed, as were 44 older people receiving domiciliary care in private households. The study found that older people living in institutions perceived themselves to have greater decisional autonomy in their everyday lives than did older people receiving domiciliary care. Indeed, it was clear that living at home did not ensure that one's decisional autonomy would be supported. However, living alone may facilitate exercising a relatively higher degree of autonomy when living at home. Whilst the community care reforms have provided some older people who have severe disabilities with the option of receiving care at home, this has not necessarily enabled them to have greater choice and control in their everyday lives than older people admitted to institutions.     

Clinical practice standards and ethical issues applied to a virtual group intervention for spousal caregivers of people with Alzheimer's

Advances in technology have improved access to health and social services by offering more abundant and convenient choices for clients. In particular, the use of technology for delivering services to older adults and their families offers new possibilities for service delivery, by reaching people who are often isolated, and have difficulty accessing traditional services. Despite the continued advances in technology development and its integration into healthcare delivery, health care practitioners need to consider how to adapt and uphold clinical practice standards and address ethical issues in an e-health environment. Given the gap in the literature with respect to discussing these issues, this paper illustrates relevant issues in the context of developing and evaluating an Internet-based intervention for spousal caregivers of persons with dementia. Based on a four year project, a psychotherapeutic group intervention was delivered via the Internet to three groups of spousal caregivers. This article identifies some of the key practice standards and ethical issues that arise when using computer technology to deliver a psychotherapeutic group intervention. The article will also provide examples of relevant issues related to maintaining practice standards and ethical procedures that need to be addressed during the application of a computer-based psychotherapeutic group intervention for spousal caregivers of people with dementia.     

Clinical Practice Standards and Ethical Issues Applied to a Virtual Group Intervention for Spousal Caregivers of People with Alzheimer's

Abstract

Advances in technology have improved access to health and social services by offering more abundant and convenient choices for clients. In particular, the use of technology for delivering services to older adults and their families offers new possibilities for service delivery, by reaching people who are often isolated, and have difficulty accessing traditional services. Despite the continued advances in technology development and its integration into healthcare delivery, health care practitioners need to consider how to adapt and uphold clinical practice standards and address ethical issues in an e-health environment. Given the gap in the literature with respect to discussing these issues, this paper illustrates relevant issues in the context of developing and evaluating an Internet-based intervention for spousal caregivers of persons with dementia. Based on a four year project, a psychotherapeutic group intervention was delivered via the Internet to three groups of spousal caregivers. This article identifies some of the key practice standards and ethical issues that arise when using computer technology to deliver a psychotherapeutic group intervention. The article will also provide examples of relevant issues related to maintaining practice standards and ethical procedures that need to be addressed during the application of a computer-based psychotherapeutic group intervention for spousal caregivers of people with dementia.     

The challenges associated with providing community care for people with complex needs in rural areas: a qualitative investigation

The aim of the present study was to explore the experiences of recipients and providers of community care in rural areas in Northern Ireland. Additionally, the authors sought to examine the impact of location, housing and environmental factors on the delivery of community care to older people with complex needs. Individual, semistructured interviews were held with service users (n = 17) and family carers (n = 14). Individual and focus group interviews were conducted with care assistants, health and social care professionals, and senior managers from a large health and social care trust and health and social services board in Northern Ireland. The importance of enabling older people to remain in their own homes and communities was emphasised by all participants. The main challenges associated with care provision in rural areas included: difficulties recruiting care assistants; lack of choice of care assistants; isolation; travel and distance between clients and their care assistants; and poor housing conditions. There was a general consensus among participants that the effectiveness of rural community care was perceived to be reliant upon the goodwill of the community. Additionally, changing demographic trends and the predicted shortfall in the number of formal and informal carers were considered key issues for service planners. A number of creative strategies could be used to address many of the limitations associated with rural isolation. These should involve capitalising on available community networks. However, planners should also acknowledge that additional resources are required to maintain older people in rural communities.     

Partnership working by default: district nurses and care home staff providing care for older people

Older people residents in care homes that only offer residential care rely on primary healthcare services for medical and nursing needs. Research has investigated the demands that care homes staff and residents make on general practice, but not the involvement of other members of the primary healthcare team. This paper describes two consecutive studies completed in 2001 and 2003 that involved focus groups and survey methods of enquiry conducted in two settings: an England shire and inner London. The research questions that both studies had in common were (1) What is the contribution of district nursing and other primary care services to care homes that do not have on‐site nursing provision? (2) What strategies promote participation and collaboration between residents, care home staff and NHS primary care nursing staff? and (3) What are the current obstacles and aids to effective partnership working and learning? A total of 74 community‐based nurses and care home managers and staff took part in 10 focus groups, while 124 care home managers (73% of the171 surveyed) and 113 district nurse team leaders (80% of the 142 surveyed) participated in the surveys. Findings from both studies demonstrated that nurses were the most frequent NHS professional visiting care homes. Although care home managers and district nurses believed that they had a good working relationship, they had differing expectations of what the nursing contribution should be and how personal and nursing care were defined. This influenced the range of services that older people had access to and the amount of training and support care home staff received from district nurses and the extent to which they were able to develop collaborative and reciprocal patterns of working. Findings indicate that there is a need for community‐based nursing services to adopt a more strategic approach that ensures older people in care homes can access the services they are entitled to and receive equivalent health care to older people who live in their own homes.     

Frail bodies, courageous voices: older people influencing community care

Involving frail older users of health and social care services in decision making presents particular challenges for those committed to hearing the voices of service users. Age Concern Scotland initiated a project in Fife, the User Panels project, intended to enable older people who were unable to leave their homes without assistance to meet together to develop a collective voice expressing the needs and experiences of older service users. This paper reports on an evaluation of that project. It considers methodological questions posed by the evaluation of projects which aim to empower users, as well as discussing key findings from the evaluation. Older people were recruited through contacts in service agencies and other local organizations. The largest group was aged between 86 and 90 years and all were experiencing difficulties relating to poor health, physical frailty or disability. The project was based on a belief in the value of meeting together as a means through which people could develop the confidence to express their views. Those who became members of the panels valued this experience and reported intrinsic benefits related to the social contact, opportunities for learning and development of self-esteem. Evidence concerning enhanced capacity to exercise control over key aspects of their lives was less convincing. The work of the panels was generally well received by local social work and health agencies and had influenced local action in some areas. Responses to some issues raised by the panels generated a less positive response and the article considers reasons for this. The model is considered to demonstrate benefits both for the older people who become involved and for officials seeking to improve the sensitivity of services to the needs of older people.     

“It's a nice country but it's not mine”: Exploring the meanings attached to home,rurality and place for older lesbian,gay and bisexual adults

An ageing population across European nations, including the United Kingdom, brings with it new challenges for health and social care services and precipitates social policy initiatives targeted at meeting the care and support needs of a rapidly expanding number of older people. Ageing in place is one such policy driver—policy efforts that seek to promote the maintenance of older citizens residing in their own homes for as long as possible with minimal state intervention. Current generations of older lesbian, gay and bisexual (LGB) people have endured homophobia throughout their life histories, and sexual identity can shape perceptions and experiences of ageing, including experiences of home life, community and place. Our objective is to examine the meanings attached to home and place for older LGB adults living independently across three dimensions: rural places as “home,” connections to LGB communities, and social care provision in the home. We present interview findings from a mixed‐methods study on the social inclusion of older LGB adults in Wales. Twenty‐nine LGB‐identifying adults (50–76 years) self‐selected to participate in semistructured interviews between 2012 and 2013. Thematic findings from interviews indicate varying and contradictory meanings attached to home life in rural places, the importance of connection to communities of identity across geographical and online localities, and a high degree of ambivalence towards the prospect of receiving social care services in the home. We argue that a more nuanced understanding of the subjective meanings attached to home, rurality and community for older LGB people is needed to fully support LGB citizens to continue to live independently in their homes.     

Older patients and delayed discharge from hospital

Older people (those aged 65 years and over) are the major users of health care services, especially acute hospital beds. Since the creation of the NHS there has been concern that older people inappropriately occupy acute hospital beds when their needs would be best served by other forms of care. Many factors have been associated with delayed discharge (age, sex, multiple pathology, dependency and administrative inefficiencies). However, many of these factors are interrelated (or confounded) and few studies have taken this into account. Using data from a large study of assessment of older patients upon discharge from hospital in England, this paper examines the extent of delayed discharge, and analyses the factors associated with such delays using a conceptual model of individual and organisational factors. Specifically, this paper evaluates the relative contribution of the following factors to the delayed discharge of older people from hospital: predisposing factors (such as age), enabling factors (availability of a family carer), vulnerability factors (dependency and multiple pathology), and organisational/administrative factors (referral for services, type of team undertaking assessments). The study was a retrospective patient case note review in three hospitals in England and included four hundred and fifty-six patients aged 75 years and over admitted from their own homes, and discharged from specialist elderly care wards. Of the 456 patients in the sample, 27% had a recorded delay in their discharge from hospital of three plus days. Multivariate statistical analysis revealed that three factors independently predicted delay in discharge: absence of a family carer, entry to a nursing/residential home, and discharge assessment team staffing. Delayed discharge was not related to the hypothesised vulnerability factors (multiple dependency and multiple pathology) nor to predisposing factors (such as age or whether the older person lived alone). The delayed discharge of older people from hospital is a topic of considerable policy relevance. Our study indicated that delay was independently related to two organisational issues. First, entry into long-term care entailed lengthy assessment procedures, uncertainty over who pays for this care, and waiting lists. Second, the nature of the team assessing people for discharge was associated with delay (the nurse-coordinated team made the fewest referrals for multidisciplinary assessments and had the longest delays). Additionally, the absence of a family carer was implicated in delay, which underlines the importance of family and friends in providing posthospital care and in maintaining older people in the community. Our study suggests that considerable delay in discharging older people from hospital originates from administrative/organisational issues; these were compounded by social services resource constraints. There is still much to be done therefore to improve coordination of care in order to provide a truly 'seamless service'.     

Resource allocation modelling for home-based health and social care services in areas having differential population density levels: a case study in Northern Ireland.

This project arose from deliberations within the Department of Health and Social Services (DHSS) in Northern Ireland concerning the acceptability of the revenue resource allocation methodology they were using. One problem with the method being used had been the absence of a component that adequately reflected the relative costs associated with the differential population densities of the four health boards into which the Province is divided. This study investigates a particular element of this issue, viz differences in the travelling distances and times of those health and social service professionals who provide visiting services to patients in their own homes. A modelling approach has been developed and used in conjunction with a comprehensive spatial and geographical information system for Northern Ireland. An important outcome of the study has been estimates of the targets that should be set for the annual health and social care travelling distances and times per head of population in the boards, for a range of home-based services. Also, the project has contributed to decisions made by the DHSS in Northern Ireland concerning the annual financial compensations required by boards for costs associated with their relative population densities.     

‘I know they are not trained in dementia’: Addressing the need for specialist dementia training for home care workers

Global population ageing has meant a rapid increase in the numbers of older people with dementia, most of whom live in their own homes. Staying at home is an important determinant of health and well‐being. As care needs increase, the quality of community support which older people receive directly influences their capacity to remain in their own homes. While many are supported informally by family carers, formal support provided by home care workers often enables them to remain at home for longer period. However, providing community‐based care for people with dementia can be challenging. Workers often lack training in dementia‐specific care for clients with increasingly complex needs, and typically work without direct supervision. As the demand for person‐centred home care for people with dementia increases, specialist dementia training for home care workers is urgently needed. In this qualitative study, we used in‐depth interviews of a purposive sample, comprising 15 family carers and four older people with dementia, to understand the experience of receiving community care. Data analysis was guided by Braun and Clarke's approach to thematic analysis and revealed the following five overlapping themes, relating to home care workers’ understanding of dementia, person‐centred care, communication and rapport, mutual collaboration, and the influence of organisational constraints on continuity of care. Although participants acknowledged that service providers operated under challenging circumstances, they were frustrated with home care workers’ lack of dementia knowledge and inconsistent staff rostering. Conversely, an understanding of the lived experience of dementia, effective communication and rapport, and continuity of care contributed significantly to a positive experience of receiving care. The findings of this study will be used to inform the essential elements of a training program aimed at enabling and empowering a skilled, specialist home care workforce to support older people with dementia to live well at home for as long as possible.     

Addressing the nutritional needs of older people in residential care homes

In the UK and Europe, malnutrition in older people is a significant and continuing problem. Malnutrition predisposes to disease, impedes recovery from illness, increases mortality and is costly to society. Despite the high number of older people potentially at risk, malnutrition in care homes has been under explored. There is concern that national guidelines regarding the nutritional care of older people in residential care homes are not always implemented. This qualitative study explored the factors that influence the nutritional care provided to residents in two different types of local authority residential care homes (providing personal care) in Wales. One home had communal dining rooms; the other had eight bedded units with their own kitchen and dining facilities. The sample of 45 participants, comprised 19 staff (managers, care and catering staff), 16 residents and 10 residents' relatives. Data were collected using semi-structured interviews, focus groups, observation and documentary review between August 2009 and January 2010. This paper focuses on how staff assessed and addressed residents' nutritional needs. In both care homes, staff strove to be responsive to residents' dietary preferences, provided person-centred care and worked in partnership with residents and their families to provide nutritious food in a homely environment. Neither home conducted nutritional screening to identify those at risk of malnutrition, contrary to national guidelines, but relied on ad hoc observation and monitoring. The staff's knowledge of special dietary needs was limited. A need for further training for care home staff regarding the importance of nutrition in maintaining health in older people, use of nutritional screening and special dietary needs was identified. Shared nutrition training between health and social care staff needs expansion and policy implications in terms of an enhanced regulatory focus on maintaining nutritional needs in care homes are proposed.     

The mental health status and long term care needs of the Chinese elderly in Hong Kong

This paper examines the mental health status of 945 Chinese older people who are in need of long term care services in Hong Kong. It was found that for those aged respondents who are already waiting for admission to infirmary, over 59.3% were already living in private aged homes, and only as few as 17.8% of these applicants were still living in their own homes. Besides, it was found that the mean SPMSQ score was lowest amongst those living in medical infirmary (1.52) and highest for those living in their own residences (5.99). Analysis of the relationship between GDS scores and residential types reveals that there were higher proportion of respondents residing in their own residences that fell into the highly depressed category. There is a need for the overall revamp of the planning, provision and financing for long term care and psychogeriatric services for Chinese older people in Hong Kong.     

Improving communication between hospitals and care homes: the development of a daily living plan for older people

The present study describes a practice development project that produced a user-led daily living plan (DLP), which was developed in partnership with older people, and staff from health and social care settings. The DLP was designed to facilitate communication of the daily living preferences of older people, ensuring that continuity of care and support could be maintained and that their future care can be planned on an individualised basis when they move from hospital to a care home. In the process of developing and implementing the DLP, more effective person-centred communication between hospitals and care homes was achieved, and some of the hospital staff's ideas about care homes changed.     

配子捐赠指征界定与伦理思考

新兴发展的辅助生殖技术（ART）为不孕不育者带来了福音,亦为遗传病患者与高龄女性带来了为人母的希望。由于ART所涉及的不仅有不孕不育夫妇的利益,尚有家庭、后代及社会问题,因此伴随着供精、供卵等新的ART衍生技术的实施,相关伦理问题日益突出,ART的应用与发展面临新的挑战。探讨卵子捐赠以及几种特殊情况下供精指征。     

Characteristics and Outcomes of Ethics Consultations on a Comprehensive Cancer Center’s Gastrointestinal Medical Oncology Service

The goal of this paper is to review and describe the characteristics and outcomes of ethics consultations on a gastrointestinal oncology service and to identify areas for systems improvement and staff education. This is a retrospective case series derived from a prospectively-maintained database (which includes categorization of the primary issues, contextual ethical issues, and other case characteristics) of the ethics consultation service at Memorial Sloan Kettering Cancer Center. The study analyzed all ethics consultations requested for patients on the gastrointestinal medical oncology service from September 2007 to January 2016. A total of 64 patients were identified. The most common primary ethical issue was the DNR order (39%), followed by medical futility (28%). The most common contextual issues were dispute/conflict between staff and family (48%), dispute/conflict intra-family (16%), and cultural/ethnic/religious issues (16%). The majority of ethical issues leading to consultation were resolved (84%); i.e., the patient, surrogate, and/or healthcare team followed the recommendation of the ethics consultant. 22% had a DNR order prior to the ethics consult and 69% had a DNR order after the consult. In this population of patients on a gastrointestinal oncology service, ethics consultations are most often called regarding patients with advanced cancers and the most common ethical conflicts arose between families and the health care team over goals of care at the end of life, specifically related to the DNR order and perceived futility of continued/escalation of treatment. Ethics consultations assisted with conflict resolution. Conflicts might be reduced with improved communication about prognosis and earlier end of life care planning.     

The Mental Health Status and Long Term Care Needs of the Chinese Elderly in Hong Kong

ABSTRACT

This paper examines the mental health status of 945 Chinese older people who are in need of long term care services in Hong Kong. It was found that for those aged respondents who are already waiting for admission to infirmary, over 59.3% were already living in private aged homes, and only as few as 17.8% of these applicants were still living in their own homes. Besides, it was found that the mean SPMSQ score was lowest amongst those living in medical infirmary (1.52) and highest for those living in their own residences (5.99). Analysis of the relationship between GDS scores and residential types reveals that there were higher proportion of respondents residing in their own residences that fell into the highly depressed category. There is a need for the overall revamp of the planning, provision and financing for long term care and psychogeriatric services for Chinese older people in Hong Kong.     

Health Care Professionals and Bedbugs: An Ethical Analysis of a Resurgent Scourge

Many health care professionals (HCPs) are understandably reluctant to treat patients in environments infested with bedbugs, in part due to the risk of themselves becoming bedbug vectors to their own homes and workplaces. However, bedbugs are increasingly widespread in care settings, such as nursing homes, as well as in private homes visited by HCPs, leading to increased questions of how health care organizations and their staff ought to respond. This situation is associated with a range of ethical considerations including the duty of care, stigmatization, vulnerability, confidentiality, risks for third parties, and professional autonomy. In this article, we analyze these issues using a case study approach. We consider how patients whose living environments are infested with bedbugs can receive care in the community setting in a manner that supports their well-being, is consistent with fairness in care provision, and takes into account risks for HCPs and third parties. We also discuss limits and obstacles to the provision of care in these situations.     

The feasibility and acceptability of a specialist health and social care team for the promotion of health and independence in 'at risk' older adults

Population ageing, escalating costs in pensions, health-care and long-term care have prompted a new policy agenda for active ageing and quality of life in old age across the European Union and other developed countries. In England, the National Service Framework for Older People (NSF OP) explicitly demands for the first time that the NHS and local authorities, in partnership, agree programmes to promote health ageing and to prevent disease in older people. These programmes are expected to improve access for older people to mainstream health promotion services and also to develop multiagency initiatives to promote health, independence and well-being in old age. This paper describes the evaluation of one interagency project team established to test out mechanisms for addressing health promotion for older people through primary care. A mixed methodology was used to understand the processes of service development, the impact of the team's intervention, and the primary and secondary outcomes for older people. The project demonstrated that multi-agency partnerships have the potential to improve the quality of the lives of older people deemed 'at risk' by their general practitioners, particularly through income generation but also in the identification of medical problems such as unrecognised hypertension, hearing loss and visual loss. It also offered some key learning points for other multi-agency groups developing similar services.