Long‐term care and hospital utilisation by older people: an analysis of substitution rates

Older people are intensive users of hospital and long‐term care services. This paper explores the extent to which these services are substitutes. A small area analysis was used with both care home and (tariff cost‐weighted) hospital utilisation for older people aggregated to electoral wards in England. Health and social‐care structural equations were specified using a theoretical model. The estimation accounted for the skewed and censored nature of the data. For health utilisation, both a fixed effects instrumental variables GMM model and a generalised estimating equations (GEE) model were fitted, the later on a log dependent variable with predicted values of social care utilisation used to account for endogeneity (bootstrapping was used to derive standard errors). In addition to a GMM model, the social‐care estimation used both two‐part and tobit models (also with predicted health utilisation and bootstrapping). The results indicate that for each additional £1 spent on care homes, hospital expenditure falls by £0.35. Also, £1 additional hospital spend corresponds to just over £0.35 reduction on care home spend. With these cost substitution effects offsetting, a transfer of resources to care homes is efficient if the resultant outcome gain is greater than the outcome loss from reduced hospital use. Copyright © 2009 John Wiley & Sons, Ltd.     

Thoughts on effective falls prevention intervention on a population basis

The prevention of accidental injury associated with falls in older people is a public health target in many countries. Older people make up a large and increasing percentage of the population. As people grow older, they are at increasing risk of falling and suffering injury from falling. Falls are not an inevitable result of ageing, but they are the most serious and frequent home accident among older people. Falls are a major reason for admission to hospital and residential care setting, even when no serious injury has occurred. Falls are therefore costly for society as well as causing considerable suffering, morbidity and mortality. Unless concerted action is taken, the number of falls and injuries is likely to increase even further over the next 25–30 years. A number of strategies and interventions targeted at individuals has been shown to work, but population-based strategies have not been well evaluated. Review of the literature confirms that fall prevention programmes can be effective in reducing the numbers of older people who fall and the rate at which people fall. Targeted strategies aimed at behaviour change and risk modification for those living in the community appear to be most promising. Multidisciplinary multi-factorial intervention programmes that include risk-factor assessment, screening, and appropriate intervention have been shown to be effective. New integrated falls services will help to provide both effective interventions and long-term support to regain mobility, independence and confidence. Health and social care statutory agencies need to work together to prioritise fall prevention as part of their overall strategy for promoting healthy ageing. Coherent multi-disciplinary programmes can be developed at the national level, but these should be implemented with national data collection mechanisms to evaluate interventions. The evidence is still scant for wider population-based approaches to falls prevention. This paper will consider some of the evidence on effectiveness of falls interventions delivered on a population basis.     

Primary health and social care services in the UK: progress towards partnership?

There has been a shift in the theoretical debates around the ways in which organisations deliver the state's objectives of providing health and social care services for its citizens, focusing on issues of welfare governance and the encouragement of partnership working between organisations. This article develops these theories by focusing on developments in primary health and social care policy in the UK, which have undergone a radical change recently. Responsibility for commissioning health care services now falls to primary care groups and trusts (PCG/Ts), run by general practitioners, other primary care practitioners, managers and lay members, and there is some pressure on primary care groups and primary care trusts to engage in partnership working with social services, for example, to cut hospital waiting lists or provide intermediate care services. One policy option is for these organisations to form Care Trusts, integrating the commissioning of health and social care for older people and ending the historical organisational divisions between health and social care in the UK. This paper examines evidence from the first stage of a 3-year longitudinal quantitative and qualitative study of the development of partnership working between PCG/Ts and social services departments in England. It examines whether the evidence suggests that the integration of health and social care is feasible or desirable in older people's services.     

The causes of falls: views of older people with visual impairment

BackgroundSight impairment increases with age and, compared with the general older population, older people with sight impairment are more likely to fall. There is a growing body of evidence on the views and perceptions of older people about falls, but little is published on the views of older people with sight impairment.ObjectiveTo explore what older people with sight impairment believe to be the causes of falls.DesignA qualitative design was used, incorporating focus groups and interviews in which participants discussed falls and falls prevention. Framework analysis was employed to identify themes arising from participants'' discussions of the causes of falls.Setting and participantsFifty‐four community dwelling men and women with sight impairment, aged 65 and over, were recruited from across Greater Manchester, UK.ResultsFive types of factors were identified that were believed to cause falls: (i) health issues and changes in balance caused by ageing; (ii) cognitive and behavioural factors; (iii) the impact of sight impairment on getting around the home; (iv) the impact of sight impairment on negotiating the environment away from home; and (v) unexplained falls.Discussion and conclusionsOlder people with sight impairment reported many researched risk factors previously identified by older people without sight impairment but also described many perceived risks unique to people with sight impairment. There are few interventions to prevent falls aimed at older people with sight impairment, and the results of this study allow further tailoring of such interventions based on views of older people with sight impairment.     

Changing the balance of social care for older people: simulating scenarios under demographic ageing in New Zealand

The demographic ageing of New Zealand society, as elsewhere in the developed world, has dramatically increased the proportion of older people (aged 65 years and over) in the population. This has major policy implications for the future organisation of social care. Our objective was to test the effects on social care use, first, of putative changes in the overall disability profile of older people, and second, of alterations to the balance of their care, i.e. whether it was community‐based or residential. In order to undertake these experiments, we developed a microsimulation model of the later life course using individual‐level data from two official national survey series on health and disability, respectively, to generate a synthetic version which replicated original data and parameter settings. A baseline projection under current settings from 2001 to 2021 showed moderate increases in disability and associated social care use. Artificially decreasing disability levels, below the baseline projection, only moderately reduced the use of community care (both informal and formal). Scenarios implemented by rebalancing towards informal care use moderately reduced formal care use. However, only moderate compensatory increases in community‐based care were required to markedly decrease the transition to residential care. The disability impact of demographic ageing may not have a major negative effect on system resources in developed countries like New Zealand. As well as healthy ageing, changing the balance of social care may alleviate the impact of increasing demand due to an expanding population of older people.     

A Social Work Practice Reflection on Issues Arising for LGBTI Older People Interfacing With Health and Residential Care: Rights,Decision Making and End-of-Life Care

This article is a social work practice reflection on issues arising for lesbian, gay, bisexual, transgender, and intersex (LGBTI) older people interfacing with health and residential care in Australia; focusing on clients, families, and carers in relation to rights, decision making, and end-of-life care. The article explores relevant case examples from social work practice in a health and residential care setting that highlight some specific complexities of working with this client group. This article brings greater attention to issues arising for older LBGTI when interfacing with health and residential care and has the potential to improve practice for social workers and other health professionals and improve outcomes for LGBTI older people.     

Involving older people in research: methodological issues

The policy imperative to increase public participation in health and social care research, planning and service delivery raises significant questions about optimum approaches, methods and the extent to which this policy can influence change in practice. This paper highlights the key policy literature on user involvement and participatory research methods to establish the context for a partnership research project exploring perceptions of risk in relation to falls from the perspectives of older people, carers, and health and social care professionals. The paper reports the methods used in developing user involvement in the research at a number of levels, including project management, and a consumer panel working alongside the research team and influencing the dissemination in local falls prevention strategies. The authors draw out the issues related to the context and method of involvement, and discuss the impact on research quality and local service development in health and social care.     

First experiences with a two‐step method for discussing goals with community‐dwelling frail older people

Background

Although frail older people can be more reluctant to become involved in clinical decision making, they do want professionals to take their concerns and wishes into account. Discussing goals can help professionals to achieve this.

Objective

To describe the development of a two‐step method for discussing goals with frail older people in primary care and professionals'' first experiences with it.

Methods

The method consisted of (i) an open‐ended question: If there is one thing we can do for you to improve your situation, what would you like? if necessary, followed by (ii) a bubble diagram with goal subject categories. We reviewed the goals elaborated with the method and surveyed professionals'' (primary care nurses and social workers) experiences, using questions concerning time investment, reasons for not formulating goals, and perceived value of the method.

Results

One hundred and thirty‐seven community‐dwelling frail older people described 173 goals. These most frequently concerned mobility (n = 43; 24.9%), well‐being (n = 52; 30.1%) and social context (n = 57; 32.9%). Professionals (n = 18) were generally positive about the method, as it improved their knowledge about what the frail older person valued. Not all frail older people formulated goals; reasons for this included being perfectly comfortable, not being used to discussing goals or cognitive problems limiting their ability to formulate goals.

Conclusions

This two‐step method for discussing goals can assist professionals in gaining insight into what a frail older person values. This can guide professionals and frail older people in choosing the most appropriate treatment option, thus increasing frail older people''s involvement in decision making.     

Understanding risk of falls in people with cognitive impairment living in residential care

ObjectivesTo better understand fall risk factors in older adults with cognitive impairment living in residential care.DesignA prospective observational cohort study.SettingResidential care homes in South London, UK.ParticipantsResidents older than 60, with cognitive impairment who had a life expectancy of at least 6 months and were not bedbound or recently discharged from hospital.MeasurementsBaseline assessments were undertaken in domains of demographics, medical history, medication use, behavior, affect, gait, balance, sensorimotor performance and neuropsychological function. Participants were followed for 6 months for falls using care home reporting systems.ResultsA total of 109 participants completed baseline assessment and had adequate falls follow-up. Fallers took more medications, were more likely to be taking antidepressants, had more functional impairment, poorer balance and gait, were more impulsive and anxious, exhibited more dementia-related behaviors, and performed worse on cognitive tests involving attention and orientation, memory, and fluency. Logistic regression analysis identified 4 significant and independent predictors of falls: poor attention and orientation, increased postural sway with eyes closed, anxiety, and antidepressant use. The AUC for this model was 0.84 (95% CI 0.76–0.91).ConclusionsThis study identified important risk factors for falls potentially amenable to intervention in older people with cognitive impairment living in residential care. This information may be useful in designing effective approaches to fall prevention in this high-risk population.     

HIV/AIDS Prevention in New York City: Identifying Sociocultural Needs of the Community

This article is a call for those who design social work courses to recognize the complexity and richness of aged care social work in health care and to social workers to shake off ageist attitudes and consider working with older people as a positive option in this rapidly expanding area of social work practice. A mixture of practice experience together with findings from the literature, this article explores social work practice with older people in hospital settings. Social work with older people has both therapeutic and practical components. The importance of integrating a therapeutic approach into all aspects of social work practice with this population cannot be overestimated.     

The cost effectiveness of a home hazard reduction program to reduce falls among older persons

BACKGROUND: The effectiveness of individual components (other than exercise) of multifactorial intervention packages aimed to reduce the incidence of falls in older people is uncertain. There have been no randomised trials of home modifications alone for the prevention of falls. OBJECTIVES: To estimate the cost-effectiveness of just one component of a multifactorial approach to falls prevention, that is, a home hazard reduction program. The study estimates the size and direction of change in resource use within and between the hospital, home and community sectors. METHODS: A randomised trial was conducted to evaluate the effectiveness of home modifications for prevention of falls among older people. An occupational therapist (O/T) with experience in aged care assessed homes for environmental hazards and supervised the necessary home modifications. SUBJECTS: The subjects in this study were people aged 65 years and older and most were recruited during a hospital stay. The cost-effectiveness analysis was based on a randomised trial with a total of 530 subjects. RESULTS: The incremental cost per fall prevented was $4,986. A sensitivity analysis was conducted by removing 12 outlier subjects (6 control and 6 intervention). The incremental cost per fall prevented was $1,921 for all subjects and was cost saving for subjects who had fallen in the 12 months prior to randomisation. CONCLUSIONS & IMPLICATIONS: A single factor home hazard reduction program is more likely to be most cost-effective amongst older people who have a history of falls.     

Community care staff attitudes towards delivering a falls prevention exercise intervention to community care clients

Millions of older people world-wide receive community care services in their home to assist them to live independently. These services often include personal care, domestic assistance and social support which are delivered by non-university trained staff, and are frequently long term. Older people receiving community care services fall 50% more often than individuals of similar age not receiving services. Yet, few ongoing community care services include exercise programs to reduce falls in this population. We conducted an earlier study to examine the feasibility of community care staff delivering a falls prevention program. A critical finding was that while some of the assessment and support staff responsible for service delivery delivered the falls prevention exercise program to one or two clients, others delivered to none. Therefore, the aim of this qualitative sub-study was to understand reasons for this variation. Semi-structured interviews were conducted with 25 participating support staff and assessors from 10 community care organisations. Staff who had successfully delivered the intervention to their clients perceived themselves as capable and that it would benefit their clients. Older clients who were positive, motivated and wanted to improve were perceived to be more likely to participate. Staff who had worked at their organisation for at least 5 years were also more likely to deliver the program compared to those that had only worked up to 2 years. Staff that did not deliver the intervention to anyone were more risk averse, did not feel confident enough to deliver the program and perceived their clients as not suitable due to age and frailty. Experienced staff who are confident and have positive ageing attitudes are most likely to deliver falls prevention programs in a home care organisation.     

Social work with older people in a hospital setting

This article is a call for those who design social work courses to recognize the complexity and richness of aged care social work in health care and to social workers to shake off ageist attitudes and consider working with older people as a positive option in this rapidly expanding area of social work practice. A mixture of practice experience together with findings from the literature, this article explores social work practice with older people in hospital settings. Social work with older people has both therapeutic and practical components. The importance of integrating a therapeutic approach into all aspects of social work practice with this population cannot be overestimated.     

Combining paid work with eldercare: the implications for social policy

Government policy relies upon the continued provision of unpaid care from informal carers to groups such as elderly people. The majority of carers of elderly people are in employment and the number of people who combine care and work is likely to rise as the proportion of women and older workers in the labour force increases. However, recent public policy statements make little mention of the impact of informal care on employment and the difficulties associated with combining care and work. Likewise this issue has been ignored in the policy debate about the promotion of equal opportunities in employment, and in discussion of social policies for older workers, who among workers below pension age are the main providers of care for elderly people. This paper reviews the evidence concerning the relationship between employment and care of the elderly. It suggests an agenda of policy issues that need to be addressed, taking account of the fact that carers of elderly people are not a homogeneous group. A range of policy measures are discussed which would enable more carers to remain in employment, and allow other carers to return to the labour market, and hence reduce some of the financial and other costs associated with loss of employment.     

Older fallers attended to by an ambulance but not transported to hospital: a vulnerable population at high risk of future falls

Objective : This prospective cohort study describes older non‐transported fallers seen by the Ambulance Service of New South Wales (ASNSW), quantifies the level of risk and identifies predictors of future falls and ambulance use. Methods : Participants were 262 people aged 70 years or older with a fall‐related ASNSW attendance who were not transported to an emergency department. They completed a questionnaire about health, medical and physical factors previously associated with falling. Falls were monitored for six months after ambulance attendance with monthly fall calendars. Results : Participants had a high prevalence of chronic medical conditions, functional limitations and past falls. During follow‐up, 145 participants (58%) experienced 488 falls. Significant predictors of falls during follow‐up were three or more falls in the past year, being unable to walk more than 10 minutes without resting, and requiring assistance for personal‐care activities of daily living (ADLs). Sixty‐two participants (25%) required repeat, fall‐related ambulance attendance during the study. Predictors of repeat ambulance use were: 3+ falls in past year, requiring assistance for personal‐care ADLs and having disabling pain in past month. Conclusions : Older, non‐transported fallers seen by the ASNSW are a vulnerable population with high rates of chronic health conditions. Implications : Onward referral for preventive interventions may reduce future falls and ambulance service calls.     

Implementing falls prevention research into policy and practice: an overview of a new National Health and Medical Research Council Partnership Grant

Preventing falls and fall-related injuries among older people is an urgent public health challenge. This paper provides an overview of the background to and research planned for a 5-year National Health and Medical Research Council Partnership Grant on implementing falls prevention research findings into policy and practice. This program represents a partnership between key Australian falls prevention researchers, policy makers and information technology companies which aims to: (1) fill gaps in evidence relating to the prevention of falls in older people, involving new research studies of risk factor assessment and interventions for falls prevention; (2) translate evidence into policy and practice, examining the usefulness of new risk-identification tools in clinical practice; and (3) disseminate evidence to health professionals working with older people, via presentations, new evidence-based guidelines, improved resources and learning tools, to improve the workforce capacity to prevent falls and associated injuries in the future.     

The burden of fall-related injury among older persons in New South Wales

Objective: To develop a comprehensive estimate of the burden of fall‐related injury among older people in New South Wales. Methods: Fall injuries in 2006/07 were estimated using information from several datasets and the literature. Healthcare costs were calculated using Australia‐Refined – Diagnostic‐Related Group costs for hospital episodes of care and average costs for Emergency Department presentations, ambulance transport and residential aged care (RAC). Ratios of the cost of inpatient care relative to other health services, derived from the literature, were used to estimate the costs associated with these services. Results: In 2006/07, in NSW, there were almost 143,000 falls, among older people, resulting in injuries requiring medical treatment. The total cost of healthcare associated with these falls was estimated at $558.5 million. Although accounting for only 6% of the NSW population aged 65 years and older, persons in RAC accounted for 15% of the total cost of falls injury and 21% of hospital inpatient costs. Conclusion and implications: This study demonstrates the extremely high economic cost of falls in older persons and highlights the disproportionate impact of falls in RAC. The study underscores the urgent need for significant investment in fall‐injury prevention efforts in both the community and RAC settings.     

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.     

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.