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.     

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.     

Making choices about support services: disabled adults' and older people's use of information

This paper explores how disabled adults and older people find and use information to help make choices about services. It presents findings from a qualitative longitudinal study in England. Thirty participants had support needs that fluctuated, meaning that additional services might be needed on a temporary basis; and 20 had the sudden onset of support needs resulting from an accident or rapid deterioration in health. Each disabled adult or older person was interviewed three times between 2007 and 2009, using a semi-structured topic guide. They were asked to discuss a recent choice about services, focussing, amongst other things, on their use of information. Interviews were transcribed and coded, then charted according to emergent themes. A wide range of choices and sources of information were discussed. These were dominated by health and to some extent by social care. Key findings are that information was valuable not just in weighing up different service options, but as a precondition for such choices, and that disabled adults and older people with the gradual onset of support needs and no prior knowledge about services can be disadvantaged by their lack of access to relevant information at this pre-choice stage. Timely access to information was also important, especially for people without the support of emergency or crisis management teams. Healthcare professionals were trusted sources of information but direct payment advisers appeared less so. Ensuring that practitioners are confident in their knowledge of direct payments, and have the communication skills to impart that knowledge, is essential. There may be a role also for specialist information advocates or expert lay-advisers in enabling disabled adults and older people to access and consider information about choices at relevant times.     

Responding to rural social care needs: older people empowering themselves, others and their community

Older adult active retirement groups encompass health promotion, social and community psychological potential. However, little is known about the internal dynamics of these groups or their contribution to individual well-being and the community. This paper examines the Third Age Foundation as an example of one such group operating in a rural area in Ireland and explores the various relationships at work internally and externally. Methodology included: structured and semi-structured interviews, focus groups and a postal survey. A substantial contribution to members' well-being and community competence and cohesion was found. Findings are discussed in reference to the importance of individual and community empowerment, sustainability, social entrepreneurship/leadership and the potential of such models to support community-based living in older age.     

Self‐reported health,healthcare service use and health‐related needs: A comparison of older and younger homeless people

The number of older homeless people with a limited life expectancy is increasing. European studies on their health‐related characteristics are lacking. This study compared self‐reported health, healthcare service use and health‐related needs of older and younger homeless people in the Netherlands. It is part of a cohort study that followed 513 homeless people in the four major Dutch cities for a period of 2.5 years, starting from the moment they registered at the social relief system in 2011. Using cross‐sectional data from 378 participants who completed 2.5‐year follow‐up, we analysed differences in self‐reported health, healthcare service use, and health‐related needs between homeless adults aged ≥50 years (N = 97) and <50 years (N = 281) by means of logistic regression. Results show that statistically significantly more older than younger homeless people reported cardiovascular diseases (23.7% versus 10.3%), visual problems (26.8% versus 14.6%), limited social support from family (33.0% versus 19.6%) and friends or acquaintances (27.8% versus 14.6%), and medical hospital care use in the past year (50.5% versus 34.5%). Older homeless people statistically significantly less often reported cannabis (12.4% versus 45.2%) and excessive alcohol (16.5% versus 27.0%) use in the past month and dental (20.6% versus 46.6%) and mental (16.5% versus 25.6%) healthcare use in the past year. In both age groups, few people reported unmet health‐related needs. In conclusion, compared to younger homeless adults, older homeless adults report fewer substance use problems, but a similar number of dental and mental problems, and more physical and social problems. The multiple health problems experienced by both age groups are not always expressed as needs or addressed by healthcare services. Older homeless people seem to use more medical hospital care and less non‐acute, preventive healthcare than younger homeless people. This vulnerable group might benefit from shelter‐based or community outreach programmes that proactively provide multidisciplinary healthcare services.     

Perceptions and attitudes towards exercise among Chinese elders – the implications of culturally based self‐management strategies for effective health‐related help seeking and person‐centred care

Background

Encouraging the uptake of physical activity among a culturally diverse elderly population presents a challenge for health‐care providers across the world. Little is known about the health‐care needs of these populations, for example the increasingly ageing group of Chinese elders in many parts of the world who are now facing later life and increasing challenges to their health.

Objective

This study aimed to explore behaviours and attitudes towards exercise among older Chinese immigrants in the UK to provide insights into the health of Chinese populations in the UK and elsewhere.

Design

A Grounded Theory approach using purposive and theoretical sampling with in‐depth semi‐structured interviews.

Setting and participants

Chinese elders were recruited from Chinese communities in the North West of England. Thirty‐three participants were interviewed face‐to‐face and audio‐recorded.

Results

Participants self‐managed exercise based on cultural perceptions of health and ingrained Chinese values. Professional support and information was lacking and relied on folk norms rather than person‐centred recommendations for healthy living. Inappropriate exercise regimes could act as a substitute for seeking health‐related advice when exercise was often used as a self‐monitored barometer to assess their perceived health status.

Discussion and conclusion

Chinese elders may undertake inappropriate exercise, leading to high‐risk situations, if appropriate professional information is not provided. Health‐care practitioners should devote attention to understanding Chinese elders'' attitudes towards exercise, as this may ultimately lead to successful health promotion activities. A person‐centred approach that acknowledges and works with self‐management practices is advocated.     

Home and community care for older people in urban China: Receipt of services and sources of payment

This study investigates the characteristics of Chinese older people receiving home and community care and the factors associated with the sources of payment for care services. The data come from the Social Survey of Older People in Urban China, which collected information from a random sample of 3,247 older people aged 60 and over in 10 large cities in different regions of China in 2017. Anderson's behavioural model of care utilisation is used to guide the analyses. The study identifies four striking features of the Chinese social care system. First, although disabilities are a significant predictor of receiving home and community care, a large proportion of care recipients do not have disabilities. Second, perceived proximity of care is the most important predictor, which implies high elasticity of demand for care services with regard to perceived distance and the great geographical inequality of care resources in the cities. Third, the government policies support the use of the internet to facilitate care access, but the enabling effect of the internet among older people is limited. Finally, sources of payment for care differ significantly according to people's age, living arrangements, disability and level of education. We argue that the government should consider shifting the focus of financial support from service providers to care recipients in the future.     

Collaboration, facilities and communities in day care services for older people

Collaborative working in care for older people is often seen as a desirable goal. However, there can be problems with this approach. This paper reports on a single blind randomized controlled trial which was carried out to compare outcomes of rehabilitation in two settings: a day hospital and social services day centres augmented by visiting therapists. The subjects were 105 older patients. Principal outcome measures were the Barthel Index, Philadelphia Geriatric Centre Morale Scale and the Caregiver Strain Index. Two aspects of the trial are examined here. Firstly, we investigated whether trial patients were more disabled than regular day centre attendees. Levels of health and well being amongst trial patients were compared with those of a random sample of 20 regular attendees from both of the participating day centres and an additional voluntary sector day centre. Secondly, key staff from the different settings were interviewed to assess how well the day centre model had worked in practice. Trial patients were significantly more disabled than regular day centre attendees according to the Barthel Index (P < 0.001), but this difference was no longer significant after three months of treatment. The day centre model had several problems, principally discharge policy, acceptability, facilities and attitudes of staff and regular attendees. Positive aspects of the day centre model, as well as successful rehabilitation, included shared skills, knowledge and resources. This paper suggests that collaborative working in day centres requires multipurpose facilities. If health staff maintain a permanent presence, benefits can include improved joint working, easier access to health care and the use of rehabilitative therapy as a preventative strategy. Day care settings can be analyzed as representing different types of communities. Allowing older users a greater degree of choice in facilities may increase the acceptability of care.     

New jobs old roles – working for prevention in a whole‐system model of health and social care for older people

The Partnerships for Older People Projects programme provided government funding for local and health authorities to pilot prevention and intervention services in partnership with the voluntary sector and older people between 2006 and 2009. This local evaluation of a pilot in southern England undertaken between 2007 and 2009 used a Theory of Change approach to gathering and reflecting on data with different groups involved in the delivery of this whole‐system based model of prevention. The model was delivered in the same way in seven social services locality areas within a large county authority. The method of data gathering enabled structured reflection on the implementation, development and projected outcomes of the model and a consideration of the key learning of working in a whole‐system way with partners and stakeholders. The whole‐system model, although complex and challenging to implement, was considered overall to have been a success and provided significant learning for partners and stakeholders on the challenges and benefits of working across professional and sectoral boundaries. New posts were created as part of the model. Two of these, recruited to and managed by voluntary sector partners, were identified as ‘new jobs’, but echoed ‘old roles’ within community and voluntary sector based health and social care. The authors reflect on the parallels of these roles with previously existing roles and ways of working and reflect on how the whole‐system approach of this particular pilot enabled these new jobs to develop in particularly appropriate and successful ways.     

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.     

Information‐sharing with respite care services for older adults: a qualitative exploration of carers' experiences

Respite services play an important role in supporting older adults and their carers. When an older person is unable to fully represent themselves, provision of respite care relies on effective information‐sharing between carers and respite staff. This study aimed to explore, from carers' perspectives, the scope, quality and fit of information‐sharing between carers, older people and respite services. An explorative, cross‐sectional qualitative study involving a purposive sample of 24 carers, recruited via carer support groups and community groups in voluntary organisations, was undertaken in North East Scotland. Data were collected from August 2013 to September 2014, with participants taking part in a focus group or individual interview. Data were analysed systematically using the Framework Approach. The multiple accounts elicited from carers identified how barriers and facilitators to information‐sharing with respite services changed over time across three temporal phases: ‘Reaching a point’, ‘Trying it out’ and ‘Settled in’. Proactive information‐sharing about accessibility and eligibility for respite care, and assessment of carers' needs in their own right, were initially important; as carers and older people moved on to try services out, time and space to develop mutual understandings and negotiate care arrangements came to the fore; then, once shared expectations had been established, carers' chief concerns were around continuity of care and maintaining good interpersonal relationships. The three temporal phases also impacted on which modes of information‐sharing were available to, and worked best for, carers as well as on carers' perceptions of how information and communication technologies should be utilised. This study highlights the need for respite staff to take proactive, flexible approaches to working with carers and to make ongoing efforts to engage with carers, and older people, throughout the months and years of them utilising respite services. Information and communication technologies have potential to enhance information‐sharing but traditional approaches will remain important.     

Whistle‐blowing and workplace culture in older peoples' care: qualitative insights from the healthcare and social care workforce

Inquiries in the UK into mistreatment of older people by healthcare employees over the last 30 years have focused on introducing or supporting employee whistle‐blowing. Although whistle‐blowers have made an important contribution to patient safety it remains a controversial activity. The fate of whistle‐blowers is bleak, often resulting in personal and professional sacrifices. Here we draw on the views of healthcare and social care employees working with older people to explore perceptions of whistle‐blowing as well as alternative strategies that may be used to raise concerns about the mistreatment of patients by co‐workers. Whistle‐blowing was perceived as a negative term. Managers said they promoted open cultures underpinned by regular team meetings and an open‐door ethos. Others described workplace norms that were somewhat at odds with these open culture ideals. Whistle‐blowing was considered risky, and this led to staff creating informal channels through which to raise concerns. Those who witnessed wrongdoing were aware that support was available from external agencies but preferred local solutions and drew upon personal ethics rather than regulatory edicts to shape their responses. We argue that the importance of workplace relationships and informal channels for raising concerns should be better understood to help prevent the mistreatment of vulnerable groups.     

Dignity and the capabilities approach in long‐term care for older people

The ageing populations of the Western world present a wide range of economic, social, and cultural implications, and given the challenges posed by deteriorating maintenance ratios, the scenario is somewhat worrying. In this paper, I investigate whether Martha C. Nussbaum's capabilities approach could secure dignity for older people in long‐term care, despite the per capita decreases in resources. My key research question asks, ‘What implications does Nussbaum's list of central human capabilities have for practical social care?’ My methodology combines Nussbaum's list with ethnographic data gathered from a Finnish sheltered home for older people. On the basis of this study, it seems that the capabilities approach is a plausible framework for the ethics of care because it highlights differences in the ability to function and thus differences in opportunities to pursue a good life. The ideas presented in this article could assist social policy planners and executives in creating policies and practices that help old people to maintain their dignity until the end of their days.     

The experiences of neighbour,volunteer and professional support‐givers in supporting community dwelling older people

Public policy increasingly emphasises the importance of informal support networks to meet the needs of the ageing population. Evidence for the types of support neighbours provide to older people and how neighbours collaborate with formal support‐givers is currently insufficient. Our study therefore explored (i) types of informal neighbour support and (ii) experiences of neighbours, volunteers and professionals providing support. Interviews with nine Dutch neighbour support‐givers, five volunteers and 12 professionals were conducted and subjected to latent content analysis. Findings indicate that commitment occurred naturally among neighbours; along with providing instrumental and emotional support, neighbour support seems to be a matter of carefully ‘watching over each other’. Neighbour support‐givers, however, are often frail themselves and become overburdened; they furthermore lack support from professionals. Neighbour, volunteer and professional support‐givers seem to operate in distinct, non‐collaborative spheres. Findings suggest that policy‐makers should consider the opportunities and limitations of neighbour and volunteer support. Professionals have an indispensable role in providing back‐up and accountable, specialised support. They may be trained to adopt a visible and proactive attitude in neighbourhoods to facilitate, cooperate with and mediate between neighbour and volunteer support‐givers.     

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.     

Understanding help‐seeking in older people with urinary incontinence: an interview study

The prevalence of urinary incontinence (UI) increases with age and can negatively affect quality of life. However, relatively few older people with UI seek treatment. The aim of this study was to explore the views of older people with UI on the process of seeking help. Older people with UI were recruited to the study from three continence services in the north of England: a geriatrician‐led hospital outpatient clinic (n = 18), a community‐based nurse‐led service (n = 22) and a consultant gynaecologist‐led service specialising in surgical treatment (n = 10). Participants took part in semi‐structured interviews, which were transcribed and underwent thematic content analysis. Three main themes emerged: Being brushed aside, in which participants expressed the feeling that general practitioners did not prioritise or recognise their concerns; Putting up with it, in which participants delayed seeking help for their UI due to various reasons including embarrassment, the development of coping mechanisms, perceiving UI as a normal part of the ageing process, or being unaware that help was available; and Something has to be done, in which help‐seeking was prompted by the recognition that their UI was a serious problem, whether as a result of experiencing UI in public, the remark of a relative, the belief that they had a serious illness or the detection of UI during comprehensive geriatric assessment. Greater awareness that UI is a treatable condition and not a normal part of ageing is needed in the population and among health professionals. Comprehensive geriatric assessment appeared an important trigger for referral and treatment in our participants. Screening questions by healthcare professionals could be a means to identify, assess and treat older people with UI.