Urgency coding as a dynamic tool in management of waiting lists for psychogeriatric nursing home care in The Netherlands

Criteria are used to prioritise patients on waiting lists for health care services. This is also true for waiting lists for admission to psychogeriatric nursing homes. A patient's position on these latter waiting lists is determined by (changes in) urgency and waiting time. The present article focuses on the process and outcome of an urgency coding system in a fair selection of patients. It discusses the use of urgency codes in the daily practice of waiting list management and the related waiting times. Patients and their informal caregivers were followed from entry on the waiting list to admission to a nursing home. Caregivers were interviewed during the waiting period and after their relative's admission to a nursing home, and the formal urgency codes on the waiting list were monitored. Seventy-eight of the initial 93 patients were admitted to a nursing home. High urgency codes were commonly assigned and the waiting times were shorter for patients with higher urgency codes. Negative consequences of an urgency coding system, e.g. patients with less urgency not being admitted at all and patients not being admitted to the nursing home of their choice, could not be demonstrated. Patients without higher urgency codes were admitted after a mean waiting time of 28 weeks. It may be questioned whether this long waiting time is problematic, because satisfaction of the caregivers with regard to waiting times was not influenced by the actual waiting times. An urgency coding system enables health care professionals to react to changes in the situation of both patients and caregivers by adjusting urgency codes to influence the length of time until nursing home admission.     

Community care for stroke patients in the last year of life: results of a national retrospective survey of surviving family, friends and officials

The quality of community care received in the last year of life by stroke patients and their informal carers is described. This is secondary analysis of data from the Regional Study of Care for the Dying, in which information was collected on a randomly selected sample of people who died in 1990, in 20 self-selected English health districts that were nationally representative in terms of socio-demographic characteristics and health care provision. The respondents comprised 20 spouses, 48 relatives, three friends or neighbours and 40 officials who had known about the last year of life of 111 people who died of stroke, and had spent some time at home (or in a residential or nursing home) in the last year of life. Two-fifths of those who died were reported to have needed more help with personal care (43%), a quarter to have needed more help with domestic chores (27%), and a third to have needed more financial help (31%). Three-fifths had spent some of their last year in a nursing or residential home (63%). Three quarters of respondents who had borne the brunt of caring reported that caring had restricted their own activities to a fair or severe extent (76%); only a third had found it a rewarding experience (32%). Spouses, and those caring for depressed or anxious stroke patients found caring particularly stressful. Stroke patients living in the community need more help with domestic chores and, in particular, with personal care. Informal carers require better support, especially spouses and for those caring for depressed or anxious stroke patients. Further research is required to identify and evaluate the most effective ways of meeting the needs of these patients and their families, and to explore the effects on their care of the Community Care legislation.     

Staff satisfaction and its components in residential aged care.

OBJECTIVE: The purpose of this study was to assess the direction and magnitude of the effects among the components of staff satisfaction in residential aged care and to examine whether the relationships among satisfaction components vary according to facility type (i.e. nursing homes and hostels). A hostel is a low care facility in which residents are more independent, have a lower level of care needs, and receive personal but not nursing care. DESIGN: A cross-sectional survey design was adopted to collect the required information, and a stratified random sampling approach was utilized to select facilities. Structural equation modeling was used to examine relationships among satisfaction components. SETTING: Seventy residential aged care facilities in Western Australia. STUDY PARTICIPANTS: The sample includes 610 nursing home and 373 hostel care staff. RESULTS: The relationships among satisfaction components are different for nursing home and hostel staff. Professional support is found to have a strong and positive effect on all other aspects of staff satisfaction. CONCLUSION: The findings lead to an improved understanding of the interrelationship among staff satisfaction components, which has important implications through enhancing professional support. This needs to be recognized and emphasized by managers, care providers, and policy makers so as to maintain stable personnel and continuity of care.     

A waiting list model for residential care for the mentally disabled in The Netherlands

We present a model of the waiting list for residential care for the mentally disabled in the Netherlands. The model is a linear stock-flow model and distributes the mentally disabled over different living situations. It includes institutional and semi-institutional care explicitly and ambulatory and other types of care implicitly. Four scenarios are simulated, exploring possible future developments. Scenarios differ in the mortality rate of mentally disabled, the supply and use of ambulatory care and the possible effect of uncertainty in the data. Results show that unless continuous efforts are made to decrease the inflow in the waiting list and to supply extra care as well as extra alternative care, the waiting list for residential care will continue to grow.     

Staff perceptions of end-of-life care in long-term care

OBJECTIVE: Although residential care/assisted living facilities and nursing homes have increasingly become a significant site of death for older Americans, little is known about staff perceptions of end-of-life care, perceived need for improvement in care, and differences by type of setting. DESIGN, SETTING, AND PARTICIPANTS: Ninety-nine staff provided their perceptions of end-of-life care for 99 decedents from 74 residential care/assisted living facilities and nursing homes in four states as part of a larger cohort study. Staff were interviewed retrospectively regarding care provided during residents' last month of life. MEASUREMENTS: Staff reported on 11 areas of end-of-life care, describing the importance of each area and the level of improvement they felt was indicated. Weighted "need for change" scores were calculated as the product of perceived importance and need for improvement. RESULTS: Both residential care/assisted living and nursing home staff reported a need for more staff education and nursing assistant time, as well as more use of volunteers. The two lowest ranked items for both facility types were involvement of hospice and encouragement for staff to attend funeral services. Nursing home staff perceived a greater need for improvement than residential care/assisted living staff in all 11 areas. CONCLUSION: Results underscore the staffing demands of end-of-life care across facility types, and staff desires to be able to provide quality care throughout the dying process.     

The continuing care guidelines and primary and community health services

The confirmation of NHS responsibilities for continuing health care has important implications for primary and community health services. In early 1996, during the period of consultation on draft local policies and eligibility criteria, exploratory interviews were carried out with general practitioners (GPs), community nursing managers, primary care development officers and social services purchasers in three health authority areas. The interviews indicated that few GPs had responded to local consultation and were only slowly becoming aware of the implications for the provision and purchasing of primary and community health services. Moreover, local continuing care policies had apparently not addressed two issues which GPs and community nursing staff indicated were currently highly problematic: their responsibilities in relation to independent sector residential and nursing home patients; and the consequences for primary health and community nursing services of hospital discharge decisions. The need for purchasers and commissioners of health services, whether health authorities or GPs, to begin collecting information on patients' potential needs for continuing care services was widely recognised as an urgent priority.     

The use of acute hospital services by elderly residents of nursing and residential care homes

The objective of this study was to compare hospitalisation rates by cause of admission, hospital death rates and length of stay for residents from nursing and residential care homes with those in the community. This is a retrospective study of acute hospital emergency admissions in one health district, Merton, Sutton and Wandsworth between April 1996 and March 1997. Data linkage and manual look up were used to derive emergency hospital admissions for residents of care homes aged 65 and over. Admission rates were calculated for cause, length of stay and hospital death for residents of care homes and in the community with relative risks. The relative risk of emergency admission from a care home compared with the community was 1.39 for all diagnoses, 2.68 for all injuries, and 3.96 for fracture of neck of femur. The relative risk of dying in hospital for care home residents was 2.58 overall, and 3.64 in the first 48 hours of a hospital stay (all P-values <0.0001). Admission rates were higher from residential than from nursing homes. There was some increase in admissions from homes during holiday periods and over Christmas. In conclusion, there are major difficulties in monitoring admissions from nursing and residential care homes due to poor quality recording and inaccuracies in NHS coding. This was compounded by an absence of data on the age and sex profile and healthcare needs of the resident population in care homes. Prospective studies are required to ascertain when admission is avoidable and when it is appropriate. The information strategy needs to ensure that routine data sources are capable of monitoring the use of hospital services by residents of care homes.     

Carers' reflections on nursing home and NHS long-stay care for elderly patients

The aim of this study was to compare the perceptions of carers of elderly long-stay care patients who are now in nursing homes in three health districts in a former Regional Health Authority and in remaining long-stay geriatric National Health Service (NHS) wards. One hundred and ninety-eight nursing home carers (78%) and 128 NHS carers (83%) were interviewed by telephone, using a semi-structured questionnaire and open questions. The impact of caring at home was shown to be greater on NHS than on nursing home carers. Most were satisfied with the care, staff and atmosphere of the nursing home or hospital. Nursing homes were perceived to offer better ‘hotel’ facilities and a more pleasant environment. They were seen as better at respecting patients' privacy. The NHS was regarded as superior in offering clinical and rehabilitative services. Most participants thought the institution was the right place for their relative, although in general, it was thought to be better to care for elderly people at home. ‘Care in the community’ was supported, but carers were realistic about alternatives when informal care ceased to be a reasonable option. There was little ‘choice’ between public and private sector care. For many patients, entry into the institution followed directly from an acute hospital admission. The only choice was between care in a long-stay facility or remaining at home, with the patient becoming increasingly dependent and the carer becoming increasingly unable to cope. The formal aspect of community care should be to be organized rationally and accepted as a valid response to the needs of some dependent elderly patients and their carers.     

Why are some care homes better than others? An empirical study of the factors associated with quality of care for older people in residential homes in Surrey,England

This paper reports an empirical study that investigated associations between the quality of care received by older people in residential settings and features of the care homes in which they live. Data were gathered from the first announced inspection reports (2002–2003) of all 258 care homes for older people in one county of England (Surrey). The number of inspected standards failed in each home was used as the main indicator of quality of care. Independent variables (for each home) were: size, type, specialist registration, on‐site nursing, ownership, year registered, location, maximum fee, vacancies, resident dependency, whether the home took publicly funded residents, care staff qualifications and managerial quality. Quality of care was modelled using a Poisson count maximum likelihood method based on 245 (91%) of the inspected homes for which relevant data were available. The results showed that quality of care (as defined by failures on national standards) was statistically associated with features of care homes and their residents. A higher probability of failing a standard was significantly associated with being a home that: was a for‐profit small business (adjusted risk ratio (RR) = 1.17); was registered before 2000 (adj. RR = 1.22), accommodated publicly funded residents (adj. RR = 1.12); was registered to provide nursing care (adj. RR = 1.12). Fewer failures were associated with homes that were corporate for‐profit (adj. RR = 0.82); held a specialist registration (adj. RR = 0.91); charged higher maximum fees (adj. RR = 0.98 per 100 pound sterling unit). A secondary analysis revealed a stronger model: higher scores on managerial standards correlated with fewer failures on other standards (r = 0.65, P < 0.001). The results of this study may help inform future policy. They are discussed in the context of alternative approaches to measuring quality of residential care, and in terms of their generalisability.     

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.     

Revealing regional differences in the institutionalization of adult patients in homes for the elderly and nursing homes: results of the Belgian network of sentinel GPs

OBJECTIVES: The aim of this study was, firstly, to determine the number of institutionalizations in homes for the elderly and nursing homes and, secondly, to learn about regional differences in the placement procedure and the pre-existing problems and diseases. METHODS: Data were recorded during 1994 by the 143 GPs of the network of sentinel practices, which is representative of Belgian GPs. All placements of adult patients in homes for the elderly and nursing homes were registered. RESULTS: During 1994, Belgian sentinel GPs placed 297 patients in a nursing home or a home for the elderly. Most of them were women and patients who lived alone. At the time of institutionalization, motor function impairment and dementia were the most common diseases. The institutionalizations were motivated mostly by a need for assistance with daily living activities and nursing assistance. An interim hospitalization was necessary in 60% of all institutionalizations. Two-thirds of all patients were on a waiting list. The average length of these waiting lists was shorter in the southern (Walloon) region than in the northern (Flemish) region. Home care services were consulted in 16% of all institutionalizations. In the southern region, home care services were consulted more often than in the northern region. CONCLUSIONS: Motor function impairment and dementia were the most common pre-existing impairments. Placements were often hampered by long waiting lists and interim hospitalization. In the southern region, waiting lists were shorter and home care services consulted more often. Some placements could be avoided or delayed by a better organization and promotion of the possibilities of professional home care services.     

Carer satisfaction with end-of-life care in Powys, Wales: a cross-sectional survey

A cross-sectional postal survey of bereaved carers was conducted in order to examine levels of satisfaction with services provided for people in their last year of life in the rural county of Powys, Wales, UK. A self-complete questionnaire, using a modified version of the Views of Informal Carers - Evaluation of Services instrument was sent to all bereaved carers of all those people dying of cancer in Powys between 1 April 1999 and 30 June 2001. Eight hundred and five (out of a possible of 815 people) were contacted and 407 agreed to receive the questionnaire. Out of these 407 individuals, 301 (74% of those who agreed to receive a questionnaire and 37% of the 815 contacted) returned a completed questionnaire. A single reminder letter was sent to non-responders. It was found that the majority of those who received help from district nurses or practice nurses (90%) said that they were excellent or good. However, nearly 40% of respondents reported needing more nursing help. More help was also needed from social care services. For 103 out of the 301 respondents, it was known that the deceased person wanted to die at home; only 44 did so. Only one-fifth of respondents had the opportunity to talk to someone from health and social services after their bereavement; a large majority (four-fifths) found this helpful. One-tenth of respondents reported untreated pain at home; however, there was evidence for an increasing proportion of those treated having received good pain relief. Although there are high levels of satisfaction with care and services received by Powys residents, deficits exist in relation to: symptom control, nursing help, assistance from social services with transport and bathing, communication, and bereavement support.     

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.     

Measuring job satisfaction in residential aged care.

BACKGROUND: Staff satisfaction has received increasing recognition as an important factor influencing service quality and in particular the quality of residents' lives in residential aged care facilities, where staff typically have a long-term and close relationship with residents. Consequently, a valid and reliable instrument is required to assess staff satisfaction in this particular context. OBJECTIVE: This paper aims to assess the factor structure, reliability, and validity of the Measure of Job Satisfaction (MJS) instrument when used in residential aged care facilities. DESIGN: A cross-sectional survey design was used to collect the required information, and a stratified random sampling method was utilized to select facilities. Exploratory and confirmatory factor analyses were conducted to assess the factor structure of staff satisfaction via the MJS. SETTING: Both high and low care residential aged care facilities in Western Australia. STUDY PARTICIPANTS: Nine hundred and eighty-three staff (including the Director of Nursing, manager, registered nurses, enrolled nurses, nursing assistants, and therapists) in 70 residential aged care facilities. RESULTS: An acceptable five-factor (22-item) measurement model was derived. The Cronbach's alpha reliability levels range from 0.86 to 0.95. Convergent and discriminant validity are also satisfactory. CONCLUSION: This investigation has confirmed that a modified MJS is a reliable and valid instrument for assessing staff satisfaction in residential aged care settings.     

Modelling decisions of a multidisciplinary panel for admission to long-term care

This paper describes a modelling study of a multidisciplinary review panel which is responsible for matching levels of long-term care to the needs of older people. The study aims to understand the decision making process of the review panel and to predict placement decisions based on an applicant's attributes. Data were collected from cases notes presented to the London Borough of Merton review panel. A model predicting placement of an individual to residential home, nursing home or long-stay nursing care was built using logistic regression, and correctly predicts 78% of placement decisions. The model can be used as a means of checking the consistency of the review panel's placement decisions.     

Work satisfaction,stress, quality of care and morale of older people in a nursing home

The aim in the present study, which was carried out in one nursing home for older people, was to determine the feasibility of working with care workers and very frail service users to investigate links between the levels of work satisfaction and stress of the staff, and the quality of care and morale of the residents. Most of the 44 care staff (70%) and 22 cognitively intact residents (82%) participated willingly in completing rating scales through self-completion questionnaire or by interview. Well-validated scales were used to measure job satisfaction, work stress, organisational commitment, perceived quality of care, and morale and mental health. The findings revealed a staff group with a fairly high level of job dissatisfaction and stress, who were, nevertheless, very committed to the nursing home. The morale of the residents was good although the residents rated the home atmosphere lower than the staff did. Significant correlations emerged, in the expected direction, between satisfaction, commitment, stress and quality of care perceived by staff. The correlations between home atmosphere perceived by residents, and their morale and mental health were low; further investigation is needed with a larger sample. This feasibility study supports the need for further research using a case-study approach in a small number of homes because of the labour-intensive nature of the data collection and the importance of triangulating data from many sources.     

Burden of delayed admission to psychogeriatric nursing homes on patients and their informal caregivers

OBJECTIVE: To assess the deleterious effects of waiting for admission to a nursing home on the state of health of patients and their informal caregivers, and on the burden of caring. DESIGN AND PARTICIPANTS: Prospective longitudinal study consisting of interviews with informal caregivers during the period on the waiting list and after admission of the patient to a nursing home. Analysis of patients' files on diagnosis, date of registration on the waiting list, and date of admission to nursing home. SETTING: Ninety three patients registered on waiting lists for admission to a psychogeriatric nursing home in two regions of Amsterdam. RESULTS: Seventy eight of the 93 patients were admitted to a nursing home. The burden on the caregivers declined after admission of the patient but depressive symptoms did not. After 6 months a subgroup of 19 caregivers whose relatives were still waiting to be admitted were interviewed. The health of these patients remained stable during this waiting period and only problems in activities of daily living increased. The burden on these 19 informal caregivers and their state of health remained stable during the waiting period. CONCLUSIONS:A decline in the state of health and a rise in the burden on caregivers during the waiting period did not occur. However, a decrease in the burden and an improvement in mental health could have started earlier if patients had been admitted earlier.     

Perspectives of elderly people receiving home help on health, care and quality of life

From a nursing perspective it is important to have information about the type of care needed, the reasons care is needed and quality of life among the most elderly people living in their own homes, in order to support their independence and maximise their quality of life. Thus a study was performed to investigate people aged 75 years and older dependent on care from professionals and/or a next of kin, their functional health, diseases, and complaints in relation to quality of life as perceived by themselves. The sample (n = 448) comprised those who, in an age-stratified randomised sample of adults living in their own homes, responded that they were dependent on help from others. The questionnaire covered sex, age, living conditions, civil status and number of children and cohabitation, respondents' health, diseases, quality of life, help from another person, and the type and amount of help received. The number of elderly persons dependent on help ranged from 18.5 to 79.1% in the different age groups. The help came mainly from informal carers (84.1%), and, in 53.1% of cases, from the home help service and home nursing care. Help from formal caregivers was given in combination with that from a next of kin in 38.8% of the cases. More next of kin than formal carers helped in all Instrumental Activities of Daily Living (IADL) and Personal Activities of Daily Living (PADL) tasks, with the exception of cleaning the house and providing a bath/shower. Although the respondents received help themselves, they also helped another person in 6.5% of cases. The elderly reported a median of three diseases and ten different complaints of which pain and impaired mobility were the most frequent. Between 20 and 40% of the respondents in the different age groups reported restricted ability to be alone and one third of them reported low or very low quality of life. Multiple linear regression analysis showed the number of complaints, restricted ability to be alone, living alone and age to have a significant relationship on low quality of life.     

The meaning of urgency in the allocation of scarce health care resources; a comparison between renal transplantation and psychogeriatric nursing home care

In the juridical and ethical literature on patient selection criteria it is an unargued premise that those who are most urgently in need of treatment or care will be given priority. The aim of this study is to gain insight into the medical practice of waiting list problems and patient selection at the microlevel, especially with respect to urgency. Thus, the study intends to contribute to the medical ethical discussion on patient selection for scarce resources. The results of qualitative research into the meaning and occurrence of urgency in two health care services, renal transplantation and psychogeriatric nursing home care, are discussed. In the first sector, patients are seldom considered urgent. Criteria for urgency are technical dialysis problems or severe psychological burden due to protracted dialysis treatment. In contrast, psychogeriatric patients are often considered urgent, with the principal criterion being too heavy a care load for informal carers. Both health care services show variation in assigning urgency codes. It appears that the exact meaning of urgency is not self-evident and that admission of urgent patients to nursing homes can be negotiated by professionals or informal carers. This points to the necessity of a discussion within these services as to the actual content matter of urgency. Further, professionals involved in renal transplantation raise several moral and practical arguments against giving patients priority, even if they need treatment urgently. It shows that distributive justice cannot always be applied. Occasionally non-urgent patients are rated urgent as they have been waiting very long due to specific allocation procedures. In these cases urgency is granted in an unexpected way that is ultimately in accordance with the notion of procedural justice.