Food provision for older people receiving home care from the perspectives of home‐care workers

Malnutrition is a significant cause of morbidity and mortality, particularly among older people. Attention has focused on the inadequacies of food provision in institutions, yet the majority suffering from malnutrition live in the community. The aim of this study was to explore barriers and facilitators to food provision for older people receiving home care. It was a qualitative exploratory study using semi‐structured interviews with nine home‐care workers in June 2013 employed by independent agencies in a large city in northern England. Data were analysed thematically, based on the principles of grounded theory. Findings showed that significant time pressures limited home‐care workers in their ability to socially engage with service users at mealtimes, or provide them with anything other than ready meals. Enabling choice was considered more important than providing a healthy diet, but choice was limited by food availability and reliance on families for shopping. Despite their knowledge of service users and their central role in providing food, home‐care workers received little nutritional training and were not involved by healthcare professionals in the management of malnutrition. Despite the rhetoric of individual choice and importance of social engagement and nutrition for health and well‐being, nutritional care has been significantly compromised by cuts to social care budgets. The potential role for home‐care workers in promoting good nutrition in older people is undervalued and undermined by the lack of recognition, training and time dedicated to food‐related care. This has led to a situation whereby good quality food and enjoyable mealtimes are denied to many older people on the basis that they are unaffordable luxuries rather than an integral component of fundamental care.     

Progress and problems in developing outcomes-focused social care services for older people in England

Social care services for adults are increasingly required to focus on achieving the outcomes that users aspire to, rather than on service inputs or provider concerns. This paper reports a study aimed at assessing progress in developing outcomes-focused services for older people and the factors that help and hinder this. It describes the current policy context and discusses the social care service outcomes desired by older people. It then reports on a postal survey that identified over 70 outcomes-focused social care initiatives across England and Wales, and case studies of progress in developing outcomes-focused social care services in six localities. The study found progress in developing outcomes-focused services was relatively recent and somewhat fragmented. Developments in intermediate care and re-ablement services, focusing on change outcomes, were marked; however, there appeared to be a disjunction between these and the capacity of home care services to address desired maintenance outcomes. Process outcomes were addressed across a range of re-ablement, day care and residential services. The paper concludes by discussing some of the challenges in developing outcomes-focused social care services.     

The costs of care: An ethnography of care work in residential homes for older people

The cost of social care, the work conditions experienced by care workers and the quality of care provided by residential homes for older people are all linked, yet we know very little about how this relationship works in practice. Drawing upon an ethnography of two differently priced residential care homes for older people in Southern England, I examine the implications of different financial regimes for care-giving practices. I show how the scheduling and allocation of resources—conveyed, for example, in formal routines and staffing levels—structure the care workers’ time, tasks and activities in each setting. This acts to symbolically demarcate what, or who, is valued. I argue that the availability of resources facilitates and impedes the symbolic culture of care work, shapes care workers’ ability to afford dignity to the individuals in their care and affects how care workers experience, and relate to, their labour. I conclude by discussing how current practices of funding and pricing social care have effects seeping beyond the practical and measurable, and into the realm of the symbolic.     

Evaluating the impact of integrated health and social care teams on older people living in the community

Although it is perceived wisdom that joint working must be beneficial, there is, even at this stage, little evidence to support that notion. The present study is an evaluation of two integrated co-located health and social care teams which were established in a rural county to meet the needs of older people and their carers. This study does identify that patients from the 'integrated teams' may self-refer more and are assessed more quickly. This might indicate that the 'one-stop shop' approach is having an impact on the process of service delivery. The findings also suggest that, in the integrated teams, the initial stages of the process of seeking help and being assessed for a service may have improved through better communication, understanding and exchange of information amongst different professional groups. However, the degree of 'integration' seen within these co-located health and social care teams does not appear to be sufficiently well developed to have had an impact upon the clinical outcomes for the patients/service users. It appears unlikely from the available evidence that measures such as co-location go far enough to produce changes in outcomes for older people. If the Department of Health wishes to see benefits in process progress to benefits to service users, then more major structural changes will be required. The process of changing organisational structures can be enhanced where there is evidence that such changes will produce better outcomes. At present, this evidence does not exist, although the present study does suggest that benefits might be forthcoming if greater integration can be achieved. Nevertheless, until the social services and National Health Service trusts develop more efficient and compatible information systems, it will be impossible to evaluate what impact any further steps towards integration might have on older people without significant external resources.     

From success to capability for healthy ageing: shifting the lens to include all older people

The ‘successful’ ageing model has been an important influence on research, intervention and public policy around ageing for three decades. Over this time, critiques of the model have grown until the shortcomings of the approach are now generally recognised in gerontology and beyond. This paper provides a summary of these critiques with empirical support for their unintended negative effects on the well-being of older people through oppressive policies, a focus on individual responsibility and denial of death. The limitations of attempts to overcome these shortcomings are then briefly surveyed before suggesting how the ‘capability approach’ will address each of these problems and provide a new socially oriented framework for research, policy and intervention that will support the development of health and well-being for all older people.     

Buying Time I: a prospective, controlled trial of a joint health/social care residential rehabilitation unit for older people on discharge from hospital

The study's objective was to determine the effectiveness of a joint NHS/Social Services rehabilitation unit (a form of intermediate care) for older people on discharge from community hospital, compared with 'usual' community services. This was a controlled clinical trial in a practice setting. The intervention was 6 weeks in a rehabilitation unit where individuals worked with care/rehabilitation assistants and occupational therapists to regain independence. Controls went home with the health/social care services they would ordinarily receive. Participants were from two matched geographical areas in Devon: one with a rehabilitation unit, one without. Recruitment was from January 1999 to October 2001 in 10 community hospitals. Study eligibility was assessed using the unit's inclusion/exclusion criteria: 55 years or older and 'likely to benefit from a short-term rehabilitation programme' ('potential to improve', 'realistic and achievable goals' and 'motivation to participate'). Ninety-four people were recruited to the intervention and 112 to the control. The mean (standard deviation) age was 81.8 (8.0) years. The main outcome measure was prevention of institutionalisation assessed by the number of days from baseline interview to admission to residential/nursing care or death ('survival-at-home time'). Secondary outcome measures were time to hospital re-admission over 12 months, quality of life and coping ability. There were no significant differences between the groups on any outcome measure. Adjusted hazard ratio (95% CI) for 'survival-at-home time' was 1.13 (0.70-1.84), and 0.84 (0.53-1.33) for 'time to hospital re-admission'. However, attending the unit was associated with earlier hospital discharge. Median (interquartile range) days in hospital for the intervention graph was 27 (20, 40), and for the control graph was 35 (22, 47) (U = 4234, P = 0.029). These findings suggest a stay in a rehabilitation unit is no more effective than 'usual' care at diverting older people from hospital/long-term care. Alternative service configurations may be as effective, having implications for tailoring services more specifically to individual need and/or user preferences. However, the unit did appear to facilitate earlier discharges from community hospital.     

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.     

The impact of community care services on the preference for ageing in place in urban China

This paper examines the relationship between community care services and ageing in place in urban China. Using data from the 2010 Sample Survey on Aged Population in Urban/Rural China, and within the framework of a revised version of Andersen's model, the paper applies multilevel models and analyses the effects of community care on the preference between ageing in place and institutional care, and reveals that ageing in place is preferred even in urban China. However, the existence of community care services had no significant effect on the preference for ageing in place. The paper concludes by arguing that China needs to develop its community care services and promote the idea of community care in both culture and policy. Realising ageing in place also requires a multidisciplinary approach. A model of shared care, between family and state, is particularly appropriate for China.     

Health outcomes associated with participating in community care centres for older people in Taiwan

Community care centres (CCCs) are widespread across Taiwan and have provided health promotion and social activities for older people in communities since 1995. The purpose of this study was to describe the status of the delivery and management of CCCs for older people, and to explore the effects of individual factors and the organisational factors on the health‐related outcome of older people's participation in CCCs. The sample was taken from participants at CCCs in Taichung, Taiwan. Twenty‐five CCCs participated in the study. The managers and the elderly participants of CCCs underwent face‐to‐face interviews. In total, 417 elderly participants and 25 chiefs completed the face‐to‐face interviews. The participants reported that self‐reported health, sleep quality, memory, family relationships, care for health, and health literacy improved after they participated in the programme. There were no consistent organisational factors related to the outcomes. However, management style was related to sleep quality improvement and staffing getting paid was related to family relationship improvement. Policy recommendations are provided.     

Means without ends: justifying supportive home care for frail older people in Canada, 1990-2010

The challenges associated with ageing populations are very much on the policy and research agenda of many nations, with significant discussions focused on establishing appropriate, acceptable parameters of home care for those who are older and frail. This paper develops an analysis of changing justifications of home care in Canada (1990-2010) through examination of governmental and non-governmental home care policy documents and position papers, as well as observations from recent fieldwork in home care. Boltanski and Thévenot's sociology of justification provides a framework for analysis of these situations where competing and irreducible pluralities of goods complicate discussions of the 'right' way to proceed.     

What is the impact of day care on older people with long-term conditions: A systematic review

There is a lack of robust evidence regarding outcomes for day care use among older people living with long-term conditions (LTCs). Day care is provided by independent, private and voluntary and charitable sectors. This systematic review aims to establish current evidence of outcomes for older people with LTCs attending day care services and outcomes on carers, across all service models. Narrative synthesis of quantitative and qualitative data was undertaken. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic literature search was carried out across eight electronic databases and reference lists of key journals between 2004 and October 2020 were searched. Searches returned 1,202 unique titles. Forty-five articles from 16 countries met the criteria on review of title, abstract and full article. There is limited evidence suggesting improved levels of perceived psychological health, quality of life, perceived general health, physical health and functioning for older people attending day care who have LTCs. The respite function of day care resulted in positive outcomes for carers. Studies evaluating outcomes for participants or carers were limited in quantity and quality. There is limited information regarding outcomes for day care attendance for older people with multiple LTCs from existing literature. Further research focusing on LTCs and day care attendance would benefit this field.     

Drawing the line: the boundaries of volunteering in the community care of older people

Volunteers can play important roles in the provision of support and care to frail or confused older people living in their own homes. There are conflicting expectations as to what these roles should be since there are unclear boundaries with those of paid care and with informal care. The present article explores some of these boundaries, drawing on material from a study of 14 volunteer schemes in England. The aim of the research was to explore the roles played by volunteers in the overall care division of labour. The main method used was that of semistructured interviews with organizers and volunteer coordinators of the schemes involved. The findings presented here relate to the limitations on the type of cases taken on, and to the boundaries with professional care, paid manual work and informal care. It concludes that the ways in which these boundaries are established and maintained depends not only on legal and policy constraints at the level of the state, but also on negotiation between organizations and individuals at a local level. The issues raised are of importance not only to research in the area, but to anyone planning similar schemes in the future.     

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.     

Meeting the health needs of older people with intellectual disabilities: exploring the experiences of residential social care staff

Older people with intellectual disabilities often experience high levels of health needs and multiple morbidities but they may be supported by residential care staff with little or no previous experience of identifying and meeting health needs. Little is known regarding how they undertake this health‐related role and this exploratory study seeks to address this gap. A purposive sample of 14 managers of supported living accommodation in Wales were interviewed in 2014 to determine their experiences of supporting tenants in relation to age‐related health needs. The semi‐structured interviews were transcribed and thematically analysed. Three of the emerging themes are reported in this paper: meeting health needs, the consequences of ageing and relationships. Findings indicate that residential care staff support older people with intellectual disabilities with complex and multiple health needs: they monitor health status, support access to healthcare, provide additional support arising from changing health needs and advocate for tenants in the context of healthcare. However, their role is often not understood by healthcare professionals. The importance of staff having a long‐term relationship with those they support was identified as being important to identifying any health‐related changes. The need to develop effective relationships with healthcare staff was also noted. It is concluded that there is a need for better understanding among health staff of the role of residential social care workers and for further research regarding health‐related communication.     

Exploring the impact of social network change: Experiences of older adults ageing in place

Social networks are sources of support and contribute to the well‐being of older adults who are ageing in place. As social networks change, especially when accompanied by health decline, older adults’ sources of support change and their well‐being is challenged. Previous studies predominantly used quantitative measures to examine how older adults’ social networks change. Alternatively, this study explores the impact of changing social networks on older adults’ lives by examining their personal experiences. We held four focus groups, two with a total of 14 older adults who are ageing in place and receiving home care and two with a total of 20 home‐care nurses from different regions and organisations in the Netherlands. Subsequently, an expert team of home‐care professionals and managers discussed and verified the results. Procedures for grounded theory building were used for analysis. We revealed four themes of high‐impact experiences: (a) struggling with illness/death of the spouse; (b) working out a changing relationship with (grand)children; (c) regretting the loss of people they have known for so long and (d) feeling dependent and stressed when helpers enter the network. Also, network dynamics were found to follow three consecutive stages: (a) awareness of social network change; (b) surprise when social network change actually occurs and (c) acceptance and adjusting to new circumstances. Together, the four themes of experiences and three stages of network change form an integrative model of the role of social network dynamics for older adults’ lives when ageing in place.     

The health, social care and housing needs of lesbian, gay, bisexual and transgender older people: a review of the literature

This paper reports the findings of a literature review of the health, social care and housing needs of older lesbian, gay, bisexual and transgender (LGBT) adults undertaken in 2006 for the Welsh Assembly Government. Peer-reviewed literature was identified through database searches of BNI, PubMed, CINAHL, DARE, ASSIA and PsychInfo. Follow-up searches were conducted using references to key papers and journals as well as specific authors who had published key papers. A total of 187 papers or chapters were retrieved, of which 66 were included in the study; major themes were identified and the findings synthesised using a meta-narrative approach. The main themes that emerged from the review were isolation, health behaviours, mental health and sexual health behaviours. The literature indicates that the health, social care and housing needs of LGBT older people is influenced by a number of forms of discrimination which may impact upon the provision of, access to and take up of health, social care and housing services. Understanding of the health, social care and housing needs of older LGBT people is limited and research in this area is scarce. The research which exists has been criticised for using small samples and for tending to exclude participants from less affluent backgrounds. The focus of research tends to be on gay men and lesbians; consequently, the needs of bisexual and transgender people remain largely unknown. Additionally, research which does exist tends to focus on a narrow range of health issues, often related to the health needs of younger LGBT people. Discrimination in various forms has a major impact on needs and experiences, leading to marginalisation of LGBT people both in the provision of health and social care services and neglect of these groups in public health research.     

Loneliness and social support of older people in China: a systematic literature review

Loneliness is a serious problem for older people, which can be alleviated by social support. The dramatic population ageing together with social and economic change in China increases the likelihood of loneliness and the availability of different sources of social support of older people. The aim of this review was to identify the prevalence of loneliness and its related factors and sources of social support of older people in China. Electronic literature searches were conducted in September 2011 using Web of Science, PsycINFO, MEDLINE, PubMed, CINAHL, China Academic Journal and VIP Database for Chinese Technical Periodicals. Twenty‐six papers were identified and reviewed. The prevalence of loneliness varied across the studies, reflecting the different measurements and samples. Marital status, gender, age, educational level, economic level, living arrangements, health status and social support were significant factors related to loneliness. The family was the most important source of social support followed by friends. The receipt of family support improved subjective well‐being and mental health, but the effects of support from friends were inconsistent. Chinese older people received relatively little support from neighbours, governmental or other social organisations. Further well‐designed studies are needed to identify additional factors related to loneliness and to understand the support from friends, neighbours, formal organisations and other sources.     

Exploring the mealtime experience in residential care settings for older people: an observational study

Improving the mealtime experience in residential care can be a major facilitator in improving care, well‐being and QoL. Evidence suggests that, despite guidance on the subject of food, nutrition and hydration, there are still concerns. Although there is a range of methods to research and assess the quality of food provision, there is a challenge in capturing the experiences of those residents who are unable or unwilling to describe their feelings and experiences because of frailty, impaired communication or other vulnerability. The aim of this exploratory study was to capture and describe individual residents’ mealtime experience. In spring 2011, a small‐scale, observational study was carried out in seven dining settings in four residential care homes in Manchester. An adapted dementia care mapping tool was used alongside field notes. Observations showed two major differences in the way the mealtimes were organised: ‘pre‐plated’ and ‘family‐style’ (where either bowls of food are placed in the centre of the table or food is served directly from a hotplate by a chef). These two styles of service are discussed in relation to the emerging themes of ‘task versus resident‐centred mealtimes’, ‘fostering resident independence’ and ‘levels of interaction’. Although improving mealtimes alone is not enough to improve quality of life in care homes, findings showed that relatively small changes to mealtime delivery can potentially have an impact on resident well‐being in these homes. Observation is a useful method of engaging residents in care settings for older people who may not otherwise be able to take part in research.     

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.     

Conducting an advance care planning group among older adults living in residential care homes: An initiative of social workers in Hong Kong

This study aimed to examine the effects of an advance care planning (ACP) group which was developed by social workers in Hong Kong for older adults. A quasi-experimental study was conducted. Participants were recruited from 14 residential care homes. The ACP intervention group included 59 participants for analyses, and the control group 58. Three major outcomes were measured at two time points: (a) Quality-of-life concerns, (b) End-of-life preference and (c) Advance directive (AD)-related outcomes (awareness of AD, AD completion, willingness to complete AD and communication with family members about AD). Findings indicate that the ACP group enhanced participants’ awareness of AD compared with the control group. Participants were also more willing to complete AD, and more participants communicated with family members about AD after participating in the ACP group. No significant difference was found in other outcomes. This study demonstrates the efforts of social workers in promoting ACP in Hong Kong and the effectiveness of an ACP group for enhancing older adults’ awareness of AD. Findings support the role of social workers in promoting ACP for deprived groups, like frail older adults. The ACP group could be considered a first step in enhancing older adults’ awareness of and willingness to discuss end-of-life issues. Further follow-up is required to develop individualised ACP for older adults.