Community and family contact: an evaluation of small community homes for adults with severe and profound mental handicaps

Two studies examined the frequency of community and family contacts of 10 adults with severe and profound mental handicaps living in small, community-based homes, first with their previous institutional experience and second in comparison with adults with similar handicaps living in larger community units. Adults in the small homes used community amenities significantly more than they did when in institutions and also significantly more than residents of larger community units. They experienced greater family contact than when they lived in more distant institutions, but not significantly more than residents of larger community units which also served local areas. Within the small homes, people newly admitted from their family homes had significantly greater family involvement than those transferred from institutions. The results are related to the characteristics of the residential settings, such as location, staff factors, operational policy, and autonomy of management.     

Service Use and Costs of Support 12 Years after Leaving Hospital

Background There have been major changes in the provision and organization of services for people with intellectual disabilities in England over the last 30 years, particularly deinstitutionalization and the development of the mixed economy of care. The experiences of the people who participated in the Care in the Community Demonstration Programme in the mid‐1980s provide evidence of the immediate and longer‐term effects of the reprovision policy. Methods Cross‐sectional and longitudinal evidence was gathered on service use and costs for over 250 people 12 years after they left long‐stay hospitals for community living arrangements. Comparisons were made with the situation in hospital, and 1 and 5 years after leaving. Relationships between costs after 12 years and individual characteristics assessed before people left hospital were explored. Results Community care at the 12‐year follow‐up remained more expensive than hospital‐based support, although the average cost was lower than at either of the 1‐ or 5‐year community follow‐up points. Service users were living in a wide variety of accommodation settings. Management responsibility fell on National Health Service (NHS) trusts, local authorities, voluntary agencies, or to private organizations or individuals. After standardizing for users’ skills and abilities, costs in minimum support accommodation were significantly lower than those in residential and nursing homes, costs in staffed group homes significantly higher, and costs in hostels slightly lower. When looking at differences between individuals, no relationship was found between costs and outcomes although, overall, people were better off in the community than they had been when in hospital. Conclusions Reprovision planning for hospital and other institutional modes of care requires major and long‐term commitment of resources. Quality of life improvements can be achieved at a cost little different in the long‐run from that for hospital care. The link between needs and costs (reflecting the services intended to meet those needs) would be made stronger through the individualization of care.     

Investigating Organizational Culture: A Comparison of a ‘High’‐ and a ‘Low’‐Performing Residential Unit for People with Intellectual Disabilities

Background This pilot study investigates organizational culture in small community‐based residential services for people with intellectual disabilities, one of the under‐researched determinants of staff behaviour and performance. Staff performance is of primary importance in the provision of quality services. Materials and methods Two matched residential units were assessed using COMPASS: A Multi‐Perspective Evaluation of Quality in Home Life, and identified as ‘high’ and ‘low’ performing. The organizational culture of the units was assessed using the Organizational Culture Inventory in order to investigate any associations. Results The unit with better quality outcomes demonstrated a more positive organizational culture overall, with statistically significant lower scores on three negatively influential cultural styles, namely, oppositional, competitive and perfectionistic. Conclusions There may well be a meaningful relationship between organizational culture and quality outcomes, although the nature of this relationship is far from clear. The continuation of investigations into organizational culture is encouraged.     

Predictors of regular exercise among older residents of long‐term care institutions

The purpose of this study was to apply self‐efficacy theory to explore predictors of regular exercise among older residents of long‐term care institutions. Convenience sampling was used to collect data from 151 older adults residing in three residential care homes in Taiwan. Data collection instruments included a background data sheet, Self Efficacy for Exercise Scale, Outcome Expectations for Exercise Scale and self‐reported regular exercise. Results indicated that older residents who exercised regularly had fewer chronic diseases, better perceived health status and functional status, and higher self‐efficacy expectations and outcome expectations related to exercise. Older residents with a regular exercise habit prior to institutionalization were more likely to engage in regular exercise. Logistic regression analysis indicated past exercise participation and self‐efficacy expectations to be significant positive predictors of regular exercise. To promote regular exercise within this population, these can be potential target areas for interventions. These factors should be targeted in the development and implementation of interventions to promote regular exercise among older residents of long‐term care institutions.     

Pain prevalence and characteristics in three Dutch residential homes

Background: In Anglo‐Saxon countries, high prevalence rates of pain have been reported for elderly living in nursing homes, residential homes and for community‐dwelling elderly. No information on pain prevalence is available for elderly living in Dutch residential homes. Methods: We performed an explorative study on pain prevalence, characteristics and treatment in three residential homes in Rotterdam, the Netherlands. Residents were interviewed using a standardized pain questionnaire. Results: The overall prevalence of pain was 69%. In case of pain, it was chronic in 93% of residents. Present pain and mean pain during the preceding week were substantial (numeric rating scale ≥4) in 68% and 85% of residents, respectively. Of the residents with pain, 22% did not receive any analgesics and only 3% was prescribed a strong opioid. When analgesics were prescribed, they were given only ‘as needed’ in 31% of residents. In a majority of residents, pain interfered with daily living and mood. Almost 60% of the elderly was convinced that pain is a part of ageing, 70% indicated that they did not always report their pain to the caregivers. Thirty‐seven percent was satisfied with the caregivers’ and 39% with the doctors’ attention towards pain. Conclusions: The pain prevalence rate in Dutch residential homes is similar to rates found in other Anglo‐Saxon countries. Furthermore, they are also comparable to rates reported from European nursing homes. Pain treatment is insufficient and although pain interferes with daily activities and mood, elderly tend to accept pain as an unavoidable part of aging.     

The Oldest Old and Personal Activities of Daily Living

The aim of this study was to evaluate the actual function of the personal activities of daily living in old people living in nursing homes and in the community. Another purpose was to evaluate and document the nursing load. The assessments were made over a four-week period. Two groups of individuals, aged 80 years or older, were compared with respect to ability to perform activities of daily living. The first group comprised old people who had been resident in nursing homes for at least six months, while those in the other group lived alone in the community and received some kind of assistance from the home service providers. The subjects in the latter group were less disabled than those residing in nursing homes. Age group comparisons among nursing-home residents showed no significant differences in the capacity of residents to function in activities of daily living, nor in the case of those living in the community. The nursing staff in the nursing-home setting had a heavier work-load than those working in the community concerning performance of personal activities of daily living. Caring for old people in institutions as well as in the community creates substantial challenges for the care personnel.     

Social Ecology of a Residential Special School for Young People with Challenging Behaviours: A Preliminary Report

Background Little is known about the social ecology of residential schools. This study examined staff/student interaction and student activity in a traditional residential unit and an ‘independent living unit’ (ILU) in a school for students with intellectual disabilities and challenging behaviour. Method Staff and student behaviours were observed for 23 students aged 8–16 years, five from the ILU and 18 from the traditional unit. Results Students received staff assistance to complete activity for under 6% and 1% of time, and were constructively engaged for under 50% and 20% of time, in the traditional unit and ILU respectively. Few differences were found between the units. Conclusions Despite higher staffing ratios, levels of staff assistance and attention and resident activity in the school resemble mean levels in comparable adult community services. Further research into outcomes in residential schools seems warranted.     

DO SMALLER HOMES RESULT IN INCREASED INTEGRATION?

One of the best publicised consequences of the policy of community care is the resettlement of people with a mental handicap from large institutions into homes in the community. Normalisation dictates that smaller residences have greater potential for integration than larger ones. The aim of this study was to investigate whether there is a difference in the number of community contacts made by residents with a mental handicap living in small and large community units. Community contacts of 40 individuals with a mental handicap were recorded by care staff for a period of four weeks. Twenty one of the subjects lived in three flats, with seven, ten and eight beds respectively and the remaining 19 lived in a large unit with 24 beds. Results show that people residing in the smaller units experienced significantly more community contacts than those in the large unit (p < 0.05). Areas for further study are identified.     

Predictors of Job Satisfaction among Staff in Residential Settings for Persons with Intellectual Disabilities: A Comparison between Three Residential Models

Background This cross‐sectional study aims to assess whether there are differences in staff job satisfaction, including organizational and individual characteristics, between three residential models for adults with intellectual disabilities (small residential home, group home and institution) and to investigate the organizational and individual variables associated with staff job satisfaction. Methods A standardized self‐administered questionnaire (Job Satisfaction Survey) was distributed together with demographic questions between April 2007 and June 2007. In total, 1301 staff members completed the questionnaire. Results We found that staff working at small homes had a significantly higher level of job satisfaction than staff from the other two models. Logistic regression revealed that the characteristics of the organizations at which they were employed rather than the staff’s individual characteristics were strongly associated with job satisfaction. Conclusion This study suggests that the residential model and the provider sector of the residential setting are the factors of concern when ensuring staff job satisfaction.     

Factors associated with residential placement in an assertive community treatment program

Assertive community treatment (ACT) programs originated to meet the needs of the severely mentally ill (SMI) for multiple psychosocial supports necessary for community living. Housing has been prominent among these needs and research to date on ACT programs has addressed residential outcomes, principally reduced homelessness and maintenance in some form of stable housing. However, limited studies have examined variables that might predict particular types of residential placements, which range from unsupervised to highly structured environments. The purpose of this study was to identify factors related to residential placement for the subjects in a model ACT program. Of multiple variables assessed, two were significantly related to residential placement. Chronic respiratory illness was strongly associated with placement in supervised group homes. Team assignment was associated with placement, with clients in one of three teams significantly more likely to live more independently. Clients assigned to this team showed higher psychosocial functioning than others in terms of functional ratings on the Multnomah Community Ability Scale. However, higher function alone was not significantly associated with placement, suggesting a role for clinical judgement and a need for future research in this area.     

THE EFFECT OF INDIVIDUAL AND ENVIRONMENTAL CHARACTERISTICS ON OUTCOMES IN RESIDENTIAL SERVICES

Research over a number of years has shown the damaging and dehumanising effects of institutional living on people with learning disabilities (e.g. King, Raynes & Tizard, 1971), and has exposed the fact that the quality of life experienced in such settings is not solely a consequence of having a learning disability, but is as much a consequence of the nature of the service offered. Increasingly, evidence has suggested that smaller, community based facilities are ‘better’ than large institutions. This study builds on this evidence; it uses data from some London residential services to not only compare the outcomes for clients of different types of residential service, but also to investigate the actual factors and processes which produce those outcomes.     

FACTORS ASSOCIATED WITH RESIDENTIAL PLACEMENT IN AN ASSERTIVE COMMUNITY TREATMENT PROGRAM

Assertive community treatment (ACT) programs originated to meet the needs of the severely mentally ill (SMI) for multiple psychosocial supports necessary for community living. Housing has been prominent among these needs and research to date on ACT programs has addressed residential outcomes, principally reduced homelessness and maintenance in some form of stable housing. However, limited studies have examined variables that might predict particular types of residential placements, which range from unsupervised to highly structured environments. The purpose of this study was to identify factors related to residential placement for the subjects in a model ACT program. Of multiple variables assessed, two were significantly related to residential placement. Chronic respiratory illness was strongly associated with placement in supervised group homes. Team assignment was associated with placement, with clients in one of three teams significantly more likely to live more independently. Clients assigned to this team showed higher psychosocial functioning than others in terms of functional ratings on the Multnomah Community Ability Scale. However, higher function alone was not significantly associated with placement, suggesting a role for clinical judgement and a need for future research in this area.     

AN EXAMINATION OF THE RELATIONSHIP BETWEEN STAFF BEHAVIOUR AND STRESS LEVELS IN RESIDENTIAL CARE

This paper examines the relationship between levels of stress and the observed performance at work of direct care staff in one community unit and two group homes for people with learning disabilities. Staff completed a questionnaire which measured their levels of stress and factors which they perceived could have influenced them. Staff were observed in detail at work and asked to report on levels of stress during these observation periods. No significant differences in levels of stress were found between the staff in group homes and community units. There was greater staff/resident interaction in the group homes, suggesting that quality improvements in residential environments can be achieved without affecting staff stress. A number of factors, particularly relationships with other staff and management, are discussed as of vital importance in influencing stress levels.     

Residential and home-based postacute rehabilitation of individuals with traumatic brain injury: a case control study

OBJECTIVES: To compare the outcomes of severely brain-injured individuals treated in a postacute residential rehabilitation program with a matched sample of individuals receiving limited services in their homes or on an outpatient basis. DESIGN: Controlled study using a matched design in a before-and-after trial and a 1-year follow-up trial. SETTING: A postacute community-based residential rehabilitation program or in the homes of patients. PATIENTS AND OTHER PARTICIPANTS: The treatment group included all persons admitted consecutively for rehabilitation to the postacute residential program over a 3-year period (n = 23). All subjects had severe traumatic brain injury. The comparison group was selected from the roster of a support group on the basis of a systematic matching procedure. Matching variables included gender, age, length of coma, time since injury, and level of disability. Subjects of the two groups were matched on an individual basis. MAIN OUTCOME MEASURES: A functional assessment instrument (modified Health andActivity Limitations Survey [HALS]) and the Community Integration Questionnaire (CIQ). RESULTS: Individuals with traumatic brain injury who received residential-based postacute rehabilitation displayed a statistically significant increase in functional abilities when compared with a traditional (home-based) service group. More specifically, treatment subjects showed significantly greater improvement in motor skills and cognitive abilities. Treatment subjects also showed greater improvement in community integration, although this may have been accounted for by initial group differences. CONCLUSIONS: Postacute rehabilitation appears to be effective in improving function for individuals with severe brain injury. Residential-based services appear to produce greater functional improvement, whereas home-based services are more effective at maintaining community integration.     

An ethnographic study of independent living alternatives.

The purpose of this ethnographic study was to compare 12 settings in which housing, attendant assistance, and transportation were shared by clusters of young adults with physical disabilities during the early years of the independent living movement. The settings that were studied were (a) a demonstration independent living program established by a medical rehabilitation facility, (b) a university dormitory, (c) four apartment clusters, and (d) six nursing homes. Data were gathered with ethnographic interviews of 109 subjects as well as by participant observation in each setting. Independent living alternatives are compared in terms of their ability to support residents' engagement in school, work, and leisure activities and their social and cultural similarities and differences. Findings are also reported on how residents viewed their experience in clustered living arrangements and how they believe these experiences shaped their future. Implications of the findings are discussed in terms of public policy issues, including the need for community-based support services, alternative models for organizing such services, and better planning of transitions from institutions to the community.     

Outcomes of Cardiac Arrest in Residential Care Homes for the Elderly in Hong Kong

Objective: Studies done in the 1990's suggested nursing home residents with cardiac arrest had minimal chance of survival and resuscitation was not recommended. More recent studies showed opposing results. In Hong Kong, the proportion of elderly living in the residential care homes for the elderly is increasing. There is no study of out-of-hospital cardiac arrest outcomes in this population. This study aimed at evaluating the prognosis of out-of-hospital cardiac arrest occurring in the residential care homes for the elderly. It is hoped that the findings may inform the local emergency medical service concerning the issue of futility of resuscitating the residents with cardiac arrest in the residential care homes. Methods: This study was a retrospective analysis of a database of all patients aged 65 years or above with atraumatic out-of-hospital cardiac arrest and who were attended by the emergency medical service in a 12-month period. Data in the database were prospectively collected by the emergency medical service. The characteristics of patients and cardiac arrests, timeliness of the emergency medical service, and survival were analyzed. Comparison was made between elderly living in and not living in the residential care homes. Predictors of survival were evaluated with logistic regression. Results: 3919 patients aged ≥ 65 years were analyzed. There were 1506 cases of cardiac arrest occurring in the residential care homes for the elderly. Resuscitation was discontinued at the emergency department in over 70% of these cases. The survival to hospital admission rate and the 30-day survival rate were 9.6% and 0.3% respectively. Both were lower than patients not residing in the residential care homes. Younger age, witnessed arrest, bystander defibrillation, and shorter call to ED interval were associated with higher chance of surviving to hospital admission. Conclusion: Elderly suffering from cardiac arrest in residential care homes had a poor chance of survival. Except age, witnessed arrest, bystander defibrillation, and call to ED interval are modifiable predictors of survival. It is inappropriate to declare that resuscitating elderly in residential care homes is futile unless those factors have been fully addressed.     

Effect of the environmental factor of coexistence on the physical condition of people with mild and moderate intellectual disabilities

Background

The main objective of this study was to compare the physical condition of people with intellectual disabilities living in residential homes (RH; restricted residential environment) versus independent homes (IH; family houses while performing paid work). The effect of gender on physical condition was also evaluated separately for each group.

Method

Sixty individuals with mild to moderate intellectual disability, 30 living in RH and 30 living in IH, participated in this study. The RH and IH groups were homogeneous in terms of gender distribution (17 males and 13 females) and intellectual disability level. Body composition, postural balance, and static and dynamic force were considered as dependent variables.

Results

The IH group performed better in the postural balance and dynamic force tests compared to the RH group, but no significant differences between the groups were observed for any body composition or static force variable. Women in both groups tended to have better postural balance than men, while men presented higher dynamic force.

Conclusions

The IH group presented a higher physical fitness compared to RH group. This result emphasises the need to increase the frequency and intensity of the physical activity sessions commonly programed for individuals living in RH.     

A Comparison of Activity Levels Among Adults with Intellectual Disabilities Living in Family Homes and Out‐of‐Family Placements

Background The quality of life of adults with intellectual disabilities living in the family home is an under‐researched area. The current study compared indicators of household and community activity between adults living in family homes and those in out‐of‐family placements. Methods Four datasets were merged to produce information on the household participation and social and community activities of 721 adult participants living independently (n = 30) or in family (n = 142) or staffed homes (n = 559). Data on age, gender, adaptive and challenging behaviour, and social impairment were also available. Participant characteristics and household and community activity indicators were compared across places of residence. In addition, for those living in family or staffed homes, multiple regression was used to examine the association between the activity indicators and place of residence after controlling for participant characteristics. Results People living independently had higher household participation. People living in staffed housing had higher household participation and did more community activities more frequently than people living in family homes. Place of residence was a significant factor after controlling for participant differences. Conclusions Interpretation should take account of the limited nature of the activity indicators. However, the comparison adds weight to other recent research suggesting that adults living in family homes may have fewer activity opportunities than those living in supported accommodation.