The cost implications of the changing population and characteristics of care homes

BACKGROUND: Recent increases in care home closures suggest that homes may not be able to balance pressures to reduce costs against pressures to increase standards. Commissioning requires an understanding of the factors affecting costs and how they change over time. METHODS: A survey of care homes for older people was conducted in 21 local authorities in England in 1996. A complete response was obtained for 618 homes (75%) and 11,900 residents. Findings were compared with surveys conducted in 1986 and 1988. RESULTS: Dependency was significantly related to prices, primarily due to the differential payments to nursing and residential homes. Home characteristics were also related to price, the proportion of single rooms having the largest impact. However, prices were most sensitive to local wage rates, particularly in residential homes. Compared with previous surveys levels of dependency had increased, particularly in voluntary residential homes and nursing homes. Independent homes were more likely to be purpose built, and a higher proportion of beds were in single rooms, although only 30% of private residential, dual registered and nursing homes achieved the proposed level of 80% of beds in single rooms. Staffing ratios appeared to have increased, but price rises were modest, particularly for nursing homes. CONCLUSIONS: Standards of provision have improved over time, although prices appear to have been kept below those expected from increases in costs. Continuing pressures on costs and prices are likely to lead to further closures and a restriction of choice for older people.     

Housing and residential treatment for the mentally ill: Effect on use of inpatient services

This article describes the policy change regarding residential services funded by the public community mental health system, its implementation, and its apparent effect upon the utilization and costs of residential and inpatient services in Cincinnati, Ohio from 1982–1991. The move from supervised to supported housing and funding factors including a housing development grant from the Robert Wood Johnson Foundation (RWJF), introduction of the housing as housing policy of the Ohio Department of Mental Health (ODMH), and the county-wide development and implementation of community support services are discussed.     

Treatment of depression in low-level residential care facilities for the elderly

BACKGROUND: The rate of recognition and treatment of depressed older people in nursing homes is low. Data from the low-level residential care population have not been reported. This study aimed to collect information about the treatment of depression among older persons living in low-level residential care (hostels). METHOD: The participants comprised 300 elderly residents from ten low-level residential care facilities from various suburbs in metropolitan Melbourne. The participants were interviewed by a trained clinical psychologist to determine the presence or absence of major or minor depressive disorder using the Structured Clinical Interview for DSM-IV Axis I Disorder (SCID-I). Each participant was also administered the Standardized Mini-mental State Examination (SMMSE) to determine level of cognitive function. The clinical psychologist then reviewed all cases in consultation with a geropsychiatrist experienced in the diagnosis of depression among older people, prior to assigning a diagnosis of depression. RESULTS: An important finding in this study was the low treatment for currently depressed residents, with less than half of those in the sample who were depressed receiving treatment. However, 61 of the 96 residents out of the sample of 300 who were on antidepressants were not currently depressed. CONCLUSION: There is an under recognition and under treatment of currently depressed older people in low-level residential care facilities (hostels) just as has been reported in studies in nursing homes. However, there are high numbers receiving antidepressants who are not currently depressed.     

The needs and mental health of older people in 24-hour care residential placements

At present one in five men and one in three women who reach the age of 65 in the UK today can expect to require 24-hour residential care. They are assessed according to needs as to the type of placement that is required. Little is known about the changing needs and symptoms of residential clients over 65 with mental health problems. The needs and neuropsychiatric symptoms of older people living in residential, nursing and hospital settings were assessed by standardized questionnaire. Seventy-seven residents were interviewed using the Camberwell Assessment of Needs for the Elderly (CANE) and the Neuropsychiatric Inventory (NPI). The mean CANE for all settings was high. The highest mean CANE was for a residential home and the lowest for a hospital setting. Similar settings had varying NPI and CANE. The data suggests that once placed, subjects needs and neuropsychiatric symptoms do not remain static. It may make both clinical and fiscal sense to reassess subjects. The development of more residential settings, which allow flexibility of degree of care, is recommended.     

Trends in residential policies and services for people with intellectual disabilities in Taiwan

Background In Taiwan, 92–95% of people with an intellectual disability (ID) live with their families, with the remaining residing in residential facilities. Instead of funding community‐living alternatives, the Taiwanese Government funds only registered facilities as part of its residential policies and services. The purpose of this study was to evaluate current policies and services trends regarding people with an ID in Taiwan. Methods Both documentary research, such as an analysis of policies, services programmes, official statistics, surveys, reports and funding provision reports, and a mail survey, were conducted to examine current trends and characteristics of the 96 residential settings available for people with an ID in Taiwan. Results During the 1990s in Taiwan, residential programmes for people with an ID showed the biggest growth since 1952. Since the first ‘Community Home’ was launched in 1990, the number of smaller scale residential settings with a unit size of less than 30 has grown significantly, particularly since 2000. However, the rate of institutionalization of people with an ID and who live in the institutions has also risen. Conclusions In Taiwan, unlike in Western societies, residential services for people with an ID provided by formal care systems are tending to grow in number, and these include both large and smaller residential settings.     

Dementia in United States nursing homes: Descriptive epidemiology and implications for long-term residential care

Using data from the 1985 National Nursing Home Survey, the health and functioning of demented and non-demented nursing home residents are compared, and alternate forms of long-term residential care are identified. The 1985 National Nursing Home Survey is a cross-sectional investigation of residents in 1079 nursing and related care homes in the United States. Subjects for comparative analyses include 4622 residents age 65 and older from these facilities. Fifty-one percent had a diagnosis of dementia. Compared with non-demented residents, those with dementia had more impairments in physical and instrumental tasks of daily living, behavioral problems, and psychiatric symptoms, and fewer physical health comorbidities. Although statistically significant, many of the differences were small. Analyses indicate that there is considerable overlap in the health and functional status of nursing home residents with and without dementia. Both groups are heterogeneous in health and functioning and both have members without impairments. The traditional nursing home is one option for providing long-term residential care for these persons. Alternate residential care facilities such as board and care homes, sheltered housing and adult foster care are other options whose use is growing, especially for those not requiring continuous supervision and medical care.     

An observational study to evaluate the impact of a specialist outreach team on the quality of care in nursing and residential homes

Observations of the quality of interaction between staff and residents were made to assess the impact of training and support provided to care staff in nursing and residential homes. Assessments were made before, during and at the end of the training intervention using an adaptation of the Quality of Interactions Schedule (QUIS: Dean et al ., 1993a) modified to avoid the ceiling effect of the original version. A significant increase in the proportion of time staff spent in positive interactions with residents was observed, both in terms of direct care (plessthan 0.002) and social contact (plessthan0.05) at the end of the training schedule. Levels of resident activity were also found to increase immediately after completion of training (plessthan0.001). The results suggest that changes in the quality of interaction between staff and residents can be obtained by providing regular training and support to care workers. These findings suggest that the training schedule used in the present study may have a positive impact on the quality of care provided in nursing and residential homes for the elderly.     

Resettlement in the community: the Priory Court development

SUMMARY. In Avon the district health authorities provide over 1,300 beds for residential care of people with mental handicaps. Government policy is for hospital residents who do not need medical and nursing care to be discharged into community facilities. This paper describes Priory Court, a warden supervised campus development, and its occupants. The role of the consultant psychiatrist in rehabilitation and resettlement is discussed.     

A new version of the geriatric depression scale for nursing and residential home populations: the geriatric depression scale (residential) (GDS-12R)

The objective was to develop a new short-form Geriatric Depression Scale (GDS-12R) suitable for older people living in nursing and residential care settings, including those persons with significant cognitive impairment. A total of 308 newly admitted residents of 30 nursing and residential homes in northwest England were interviewed using the Geriatric Depression Scale (GDS-15), the Mini-Mental State Examination, and the Affect Balance Scale (ABS). A 12-item version of the GDS was shown to have greater internal reliability than the 15-item version, because of the context-dependent nature of the deleted items. There was close agreement between the GDS-12R items and another indicator of depressed mood (a single item from the ABS). Furthermore, moderate to high levels of cognitive impairment did not affect the performance of the new version of the scale. The GDS-12R provides researchers and clinicians with a brief, easy-to-administer depression scale that is relevant to residential and nursing home populations.     

Factors associated with antidepressant treatment in residential care: changes between 1990 and 1997.

BACKGROUND: Depression is common among older people living in residential and nursing homes. Detection and treatment of late life depression may be sub-optimal in these settings. AIM: To report the changes in, and factors associated with, antidepressant use among residents in care homes in 1990 and 1997. METHOD: Censuses of those aged 65 years and over in any type of residential care in the county of Leicestershire, UK, on 27 November 1990 and 30 November 1997. Care staff were asked to complete an assessment form for each resident which included a rating of depression and use of antidepressants. RESULTS: The use of antidepressants increased from 11% (484/4415) in 1990 to 18.9% (777/4111) in 1997. Severity of depression as assessed by care staff, gender, younger age, better cognitive functioning, and use of other medications were consistently associated with antidepressant treatment. Antidepressant use was associated with better physical functioning (p = 0.001) in 1990 and frequency of falls in 1997 (p = 0.044). CONCLUSIONS: Increased use of antidepressants appears to be due to the wider range of antidepressant drugs available since 1990. However there is a need for better methods for care staff to detect depression in residents, and for appropriate action to be taken by those responsible for their medical management.     

Psychoanalysis and the early beginnings of residential treatment for troubled youth

One of the intentions of Aichhom, Redl, Wineman, Bettelheim, and Anna Freud in their writings about group care was to advocate for the need to simplify the lives of youths who had known only chaos, to create an atmosphere in which everything has a purpose and predictable positive responses were given unconditionally. Recent efforts, such as those by Greenberg et at, have focused on building community-wide early interventions to forestall later emergence of emotional or behavioral disorders. The efforts also mark a shift away from punishment and exclusion for troubled children at school to more inclusive systems of positive behavioral interventions and support by providing a place to achieve academic and social behavioral success. Contemporary social policy regarding residential care for troubled children reflects the belief that a child's development is inevitably enhanced by residence ina family environment. This belief in the value of home and family, so central to contemporary child welfare policy, has been challenged by the recognition that some family situations are not conducive for growth. Redl and Wineman observed that the children who ended up in residential treatment had used up all community treatment resources and soon became the children that nobody wants. Eventually, the homes that produced them, the communities in which they lived, the schools they attended, and the neighborhoods in which they played were unwilling to tolerate their disruptive and disturbing behavior. The chaotic lives of the parents of these children hindered effective monitoring and management,which limited the family's ability to spend time with children, teach conflict-resolution skills, or communicate consistent behavioral expectations. Walker suggested that divorce, abuse, poverty, drugs, and other forces that interfere with normal parenting increasingly disrupt advantaged and disadvantaged families.Vogel and Bell and Spiegel observed that some troubled young people become the family scapegoat. Within these families, therapeutic efforts directed either at the troubled child or the whole family often fail to resolve conflict. Among these families, placement of a child in a therapeutic milieu provides refuge for children and permits parents to marshal their own resources in an effort to restore their own lives.Although many young persons with severe personality disorders meet the criteria formerly acceptable for residential care, such treatment facilities have proved particularly vulnerable to the effects of funding declines and increasing regulatory demands. Increasing visibility of pediatric pharmacology has lessened the impact of a child's disruptive behavior and may have facilitated decreased length of treatment. If, as Bettelheim maintained, psychological symptoms are a response to a world felt as overwhelming, early return to community in the absence of a young person's enhanced awareness of his or her own situation and impact on others may exacerbate return to care. As Rinsley observed, the pathologic family organization that led to the need for residential treatment is not likely to be significantly ameliorated by short-term, system-focused programs. Traditionally, the efforts of the long-term milieu settings have been aimed at restructuring complex and ingrained pathologic influences that have become embedded in family dynamics and have led to maladaptive behaviors in youngsters. The psychodynamic milieu approach emphasized the nuances of relation-ships and meanings ascertained from every interaction with other young people and with adults. This enhanced awareness of a child's impact on others through the marginal life-space interview, together with enhanced awareness of one's own wishes and thoughts as provided by the milieu and individual therapy, may offer the best means for helping a young person return successfully to the community. Although it is increasingly difficult to support young people in long-term milieu therapy, the concerns initially expressed by Anna Freud and her Viennese colleagues, continued in the work of Bettelheim, Ekstein, and Redl, suggest that attention to a child's understanding of self and experience and focus on the interplay of dynamics between the child and the social milieu continues to offer an important means for therapeutic change. This remains true, even at a time when pressure for "mainstreaming" children with special needs together with financial constraints and reliance on psychopharmacology have altered more traditional understanding of the provision of residential psychodynamic treatment for troubled young people.     

A survey of people with intellectual disabilities living in residential aged care facilities in Victoria

Background Australia's national ageing policy recognises that people ageing with intellectual disability (ID) require particular attention, yet there is no policy framework concerning this population. This study describes the distribution and characteristics of people with ID in residential aged care in Victoria, provides insights into the pathways they take into aged care, and gives some indications of how facilities adapt to their needs. Method A postal survey was sent to 826 residential aged care facilities in Victoria, seeking information from directors about their residents with ID. Facilities that responded were fairly representative of all facilities in Victoria. Findings Residents with ID were younger, had entered at an earlier age and remained longer than other residents. Their reported dependency profile was similar to the general aged care population, although the incidence of dementia was lower. Primary areas of concern identified by providers were: inability to fit into the resident community, lack of participation in activities and lack of meaningful relationships. Conclusion This study provides a first glimpse into how older people with ID find their way into aged care and how others view their experiences once there. It suggests that further investigation is required into the accuracy of assessment undertaken prior to entry to more clearly understand whether residents with ID are inappropriately placed in residential aged as a result of a shortage of disability accommodation and inadequate resources to support aging in place for those in such accommodation.     

Analysis of a care planning intervention for reducing depression in older people in residential care

Approximately 40% of older people in residential care have significant symptoms of depression. A training and care-planning approach to reducing depression was implemented for 114 depressed residents living in 14 residential care homes in North Yorkshire, UK. Care staff were offered brief mental health training by community mental health teams for older people. They were then assigned to work individually with residents in implementing the care-planning intervention, which was aimed at alleviating depression and any health, social or emotional factors that might contribute to the resident's depression. Clinically significant improvements in depression scores were associated with implementation of the care-planning intervention as evidenced by changes in scores on the Geriatric Mental State Schedule-Depression Scale. There was evidence of an interaction between the power of the intervention and degree of dementia. These improvements were not accounted for by any changes in psychotropic medication. The training was highly valued by care staff and heads of homes, and they considered that the care-planning intervention represented an improvement in quality of care for all residents, irrespective of levels of dementia. Staff also reported improvements in morale and increased confidence in the caring role as a result of their participation. The limitations of this study are discussed. On the basis of a growing body of evidence, it is argued that there is an urgent need for a suitably powered randomised controlled trial and economic evaluation, to test the cost-effectiveness of personalised care planning interventions aimed at reducing depression in older people in residential care.     

People with learning disabilities in 'out-of-area' residential placements: 1. Policy context

Background A growing shortage of residential care for people with learning disabilities leads to placement funded by one authority in another authority’s area. Such out‐of‐area placements are governed by guidance from different government departments in respect of different funding streams. Method This paper presents an analysis of this guidance and shows that it is inconsistent and incomplete. Results and Conclusion The guidance creates a framework of incentives for health and social services authorities that could lead to people being placed out‐of‐area against their own best interests, with negative consequences for them and for the ‘receiving’ authorities. A companion paper uses interview data to examine the reasons for and effects of out‐of‐area placement.     

Health care needs and residential settings: A national survey and policy perspectives

The relationship between health care needs and residential service placement among older persons with mental retardation is explored. Findings from the 1985–86 Center for Residential and Community Services (CRCS) study of persons over the age of 62 living in residential facilities owned, operated and/or licensed by developmental disabilities agencies are presented. A 10 per cent sample of facilities with one or more persons over the age of 62 was selected, including foster care, group homes, large private facilities (16 or more residents) and state institutions. The final sample consisted of 370 residents in 235 facilities, with an average age of 70 years. Information about the residents was completed by direct careproviders who knew the residents well. For purposes of comparison, findings about persons with mental retardation living in nursing homes and older persons in general living in the community are also presented.

The findings highlight the importance of using the older population in general as a referent, as well as challenging the assumption of medical need among the vast majority of persons residing in nursing facilities. Many of the changes found in the older population of persons with mental retardation were similar to those noted for older persons in general, and there was considerable overlap in the characteristics of persons with mental retardation living in nursing homes and residents of facilities operated by developmental disabilities agencies. Many of the differences found between persons living in community residential facilities and persons living in state institutions and/or nursing homes were in areas such as level of retardation and independent living skills, which may increase assistance needs, but which do not necessarily increase the need for medically intensive services. Greater system flexibility is needed in order for this group to remain successfully in the community.     

Policy and organizational changes in state mental health systems

State mental health authorities are currently the primary locus of service policy and funding decisions. In assuming increased authority and responsibility for service delivery, many states are emphasizing program development and funding for the severely acutely and chronically mentally ill while deemphasizing consultation/education, prevention, and evaluation activities. Funding mechanisms are moving towards greater accountability and funding levels are relatively stable. State authorities are exercising more control through regulations, but state-center relations are viewed as generally supportive and positive. There were few other consistent trends regarding changes in state/local relations, funding or regulatory patterns, or policy shifts except that almost all of the states interviewed reported instituting increased accountability mechanisms.Jeanette M. Jerrell is Associate Research Scientist and Judith K. Larsen is Senior Research Scientist at COGNOS Associates. This research was supported by NIMH grant # 5-R01-MH38069-02, Division of Biometry and Epidemiology. Requests for reprints should be sent to Dr. Jerrell at 111 Main St., Suite 5, Los Altos, CA 94022.     

A randomized trial of early psychiatric intervention in residential care: impact on health outcomes

BACKGROUND: The prevalence of psychological and behavioral disturbances among older adults living in residential care facilities is high, and it has been shown previously that people with such symptoms have poorer health outcomes. This study was designed to assess the efficacy of an early psychiatric intervention on the 12-month health outcomes of older adults admitted to residential care facilities in Perth, Western Australia. We hypothesized that subjects in the intervention group would have better mental and physical health outcomes than controls. METHODS: The study was designed as a randomized, single-blinded, controlled trial. All subjects aged 65 years or over admitted to one of the 22/26 participating residential care facilities of the Inner City area of Perth were approached to join the study and were allocated randomly to the intervention or usual care group. Demographic and clinical information (including medications and use of physical restraint) was gathered systematically from all participants at baseline, and at 6 and 12 months. At each assessment, the Geriatric Depression Scale (GDS), the Health of the Nation Outcome Scales for older adults (HoNOS 65+), the Mini-mental State Examination (MMSE) and the Neuropsychiatric Inventory (NPI) were administered. Subjects in the intervention group who screened positive at the baseline assessment for psychiatric morbidity were reviewed within a 2-week period by the Inner City Mental Health Service of Older Adults (ICMHSOA). If clinically appropriate, mental health services were introduced without the involvement of the research team. RESULTS: One hundred and six subjects and their next of kin consented to participate in the study (53 in each group). Mental health screening and early referral to a psychogeriatric service did not significantly change the average number of medical contacts, self-rated health, use of psychotropic or PRN medication, use of physical restraint, 12-month mortality, or mental health outcomes, as measured by the GDS-15, HoNOS 65+ and NPI (p > 0.05 for all relevant outcomes). CONCLUSION: Systematic mental health screening of older adults admitted to residential care facilities and early clinical intervention does not change 12-month health outcomes. More effective interventions to improve the health outcomes of older adults with psychological and behavioral disturbances admitted to residential care facilities are needed.     

Nonhospital alternatives for acute psychiatric care in California

In California multiple social forces and financial constraints are leading to the rapid development of local alternatives not only to state hospitals but to general hospital psychiatric units as well. Two dissimilar patterns of acute-care services are emerging: the use of skilled nursing facilities with additional staff to provide mental health services and the development of a wide range of primarily nonmedical facilities under the licensing category of "residential care facility." The author summarizes characteristics of both kinds of programs and describes how they draw on all available sources of revenue before using state and county mental health funds. He also describes Santa Clara County's plan for local acute-care services in which a 54-bed residential building and a 15-bed psychiatric unit in a county hospital will replace two county-hospital psychiatric wards.