Professional perspectives on decision making about the long-term care of older people

With the increasing pressure on social and health care resources, professionals have to be more explicit in their decision making regarding the long-term care of older people. This grounded theory study used 19 focus groups and nine semi-structured interviews (99 staff in total) to explore professional perspectives on this decision making. Focus group participants and interviewees comprised care managers, social workers, consultant geriatricians, general medical practitioners, community nurses, home care managers, occupational therapists and hospital discharge support staff. The emerging themes spanned context, clients, families and services. Decisions were often prompted by a crisis, hindering professionals seeking to make a measured assessment. Fear of burglary and assault, and the willingness and availability of family to help were major factors in decisions about living at home. Service availability in terms of public funding for community care, the availability of home care workers and workload pressures on primary care services influenced decision 'thresholds' regarding admission to institutional care. Assessment tools designed to assist decision making about the long-term care of older people need to take into account the critical aspects of individual fears and motivation, family support and the availability of publicly funded services as well as functional and medical needs.

Costing the hospital-based process of resettling people with learning disability in the community

Objectives: Much has been written about the costs and cost-effectiveness of community care for people with learning disabilities resettled from long stay hospital care. However, comparatively little has been published about the cost of hospital services relating to the preparatory process before eventual resettlement and the disengagement of formal, sustained input from hospital staff. This study describes and costs the input provided by a hospital based multi-disciplinary team into the resettlement of adults with learning disabilities, from long stay wards in Muckamore Abbey Hospital in Northern Ireland between 1996 and 1999 (n = 71).

Resource utilization and cost analyses of home-based palliative care service provision:The Niagara West End-of-Life Shared-Care Project

Background: Increasing emphasis is being placed on the economics of health care service delivery - including home-based palliative care. Aim: This paper analyzes resource utilization and costs of a shared-care demonstration project in rural Ontario (Canada) from the public health care system's perspective. Design: To provide enhanced end-of-life care, the shared-care approach ensured exchange of expertise and knowledge and coordination of services in line with the understood goals of care. Resource utilization and costs were tracked over the 15 month study period from January 2005 to March 2006. Results: Of the 95 study participants (average age 71 years), 83 had a cancer diagnosis (87%); the non-cancer diagnoses (12 patients, 13%) included mainly advanced heart diseases and COPD. Community Care Access Centre and Enhanced Palliative Care Team-based homemaking and specialized nursing services were the most frequented offerings, followed by equipment/transportation services and palliative care consults for pain and symptom management. Total costs for all patient-related services (in 2007 CAN) were 1,625,658.07 - or 17,112.19 per patient/117.95 per patient day. Conclusion: While higher than expenditures previously reported for a cancer-only population in an urban Ontario setting, the costs were still within the parameters of the US Medicare Hospice Benefits, on a par with the per diem funding assigned for long-term care homes and lower than both average alternate level of care and hospital costs within the Province of Ontario. The study results may assist service planners in the appropriate allocation of resources and service packaging to meet the complex needs of palliative care populations. © 2012 The Author(s).

Heterotopias of mental health care: The role of space in experiences of distress, madness and mental health service use.

The change from an institutional to community care model of mental health services can be seen as a fundamental spatial change in the lives of service users (Payne, 1999; Symonds & Kelly, 1998; Wolch & Philo, 2000). It has been argued that little attention has been paid to the experience of the specific sites of mental health care, due to a utopic (idealised and placeless) idea of ‘community’ present in ‘community care’ (Symonds, 1998). This project hence explored the role of space in service users’ experiences, both of mental health care, and community living. Seventeen ‘spatial interviews’ with service users, utilising participatory mapping techniques (Gould & White, 1974; Herlihy & Knapp, 2003; Pain & Francis, 2003), plus seven, already published first person narratives of distress (Hornstein, 2009), were analysed using thematic analysis (Braun & Clarke, 2006). Mental health service sites are argued to have been described as heterotopias (Foucault, 1986a) of a ‘control society’ (Deleuze, 1992), dominated by observation and the administration of risk (Rose, 1998a), which can in turn be seen to make visible (Hetherington, 2011) to service users a passive and stigmatised subject position (Scheff, 1974; 1999). Such visible positioning can be seen to ‘modulate’ (Deleuze, 1992) participants’ experiences in mainstream space. The management of space has hence been argued to be a central issue in the production and management of distress and madness in the community, both in terms of a differential experience of spaces as ‘concordant’ or ‘discordant’ with distress, and with movement through space being described as a key mediator of experiences of distress. It is argued that this consideration of space has profound implications for the ‘social inclusion’ agenda (Spandler, 2007; Wallcraft, 2001).

Health and quality of care from older peoples' and formal caregivers' perspective

Aim: The overall aim of this thesis was to gain a deeper understanding of older people's view of health and care while dependent on community care. Furthermore to describe and compare formal caregivers' perceptions of quality of care, working conditions, competence, general health, and factors associated with quality of care from the caregivers' perspective. Method: Qualitative interviews were conducted with 19 older people in community care who were asked to describe what health and ill health((I), good and bad care meant for them (II). Data were analyzed using content analysis (I) and a phenomenological analysis (II). The formal caregivers; 70 nursing assistants (NAs) 163 enrolled nurses (ENs) and 198 registered nurses (RNs), answered a questionnaire consisting of five instruments: quality of care from the patient's perspective modified to formal caregivers, creative climate questionnaire, stress of conscience, health index, sense of coherence and items on education and competence (III). Statistical analyses were performed containing descriptive statistics, and comparisons between the occupational groups were made using Kruskal-Wallis ANOVA, Mann-Whitney U-test and Pearson's Chi-square test (III). Pearson's  product moment correlation analysis and multiple regression analysis were performed studying the associations between organizational climate, stress of conscience, competence, general health and sense of coherence with quality of care (IV). Results: The older people's health and well-being were related to their own ability to adapt to and compensate for their disabilities and was described as negative and positive poles of autonomy vs. dependence, togetherness vs. being an onlooker, security vs. insecurity and tranquility vs. disturbance (I).  The meaning of good care (II) was that the formal caregivers respected the older people as unique individuals, having the opportunity to live their lives as usual and receiving a safe and secure care. Good care could be experienced when the formal caregivers had adequate knowledge and competence in caring for older people, adequate time and continuity in the care organization (II). Formal caregivers reported higher perceived quality of care in the dimensions medical-technical competence and physical-technical conditions than in identity-oriented approach and socio-cultural atmosphere (III). In the organizational climate three of the dimensions were close to the value of a creative climate and in seven near a stagnant climate. The formal caregivers reported low rate of stress of conscience. The RNs reported to a higher degree than the NAs/ENs a need to gain more knowledge, but the NAs and the ENs more often received training during working hours. The RNs reported lower emotional well-being than the NAs/ENs (III). The formal caregivers' occupation, organizational climate and stress of conscience were associated with perceived quality of care (IV). Implications: The formal caregivers should have an awareness of the importance of kindness and respect, supporting the older people to retain control over their lives. The nursing managers should employ highly competent and adequate numbers of skilled formal caregivers, organize formal caregivers having round the clock continuity. Improvements of organizational climate and stress of conscience are of importance for good quality of care.

The care crunch: changing work, families and welfare in Australia

Structural shifts in labour markets and in households are impacting on the capacity of households and families to deal with risk. In Australia the post-Federation and post-war social settlement, based on the gendered assumptions underpinning the male breadwinner/female carer model, is no longer viable in an era of increasingly precarious employment, diverse family forms and deepening inequalities. Labour market and industrial relations changes, when combined with major demographic shifts such as divorce and population ageing, and increasing expectations for community care are contributing to a 'care crunch'. The article canvasses the challenge of developing a social risk protection framework that balances caring, work and quality of life.

The interface of acute and aged care: the role of the nurse in provincial area

Objective: This study was to investigate issues that arose from pre-admission to post-discharge, for people in Toowoomba, Queensland over the age of 65 admitted to an acute facility. This paper concentrates on a significant concern that emerged from the latge amount of data collected during this project, that is, the role of the nurse in the continuum of health care involving elderly people.

Method: The study involved a multi-site, multi-agency and multi-method (qualitative and quantitative) approach. Data was collected from regional service providers, the Department of Health and Aged Care (DHAC), the Australian Bureau of Statistics (ABS), Home and Community Care (HACC), the Aged Care Assessment Team (ACAT), elderly people who had been discharged from regional hospitals and their carers, residents of regional aged care facilities, area health professionals and elderly regional hospital inpatients.

Results: The data indicated that nurses in this provincial area currently play a limited role in preadmission planning, being mostly concerned with elective surgery, especially joint replacements. While nurses deliver the majority of care during hospitalisation, they do not appear to be cognizant of the needs of the elderly regarding post-acute discharge.

Conclusion: The recent introduction of the model of nurse case management in the acute sector appears to be a positive development that will streamline and optimise the health care of the elderly across the continuum in the Toowoomba area. The paper recommends some strategies, such as discharge liaison nurses based in Emergency Departments and the expansion of the nurse case management role, which would optimise care for the elderly person at the interface of care.

Experiences of disability consumer-directed care users in Australia : results from a longitudinal qualitative study

The rapidly growing body of literature suggests that Consumer-directed Care (CDC) has the potential to empower consumers and improve the flexibility and quality of care. However, reports highlighting quality and risk concerns associated with CDC focusing on a longer time frame have been few. This paper presents the findings from a qualitative longitudinal evaluation of an Australian CDC programme. Focusing on the period between 2003 and 2008, it reports on the experiences of 12 families caring for a dependent family member. It is based on two external evaluations completed 6 and 36 months after enrolment, and one internal evaluation completed 48 months after enrolment. The findings were triangulated with internal memos, reports and minutes of meetings, as well as with the theoretical literature. The study demonstrates that CDC harbours considerable benefits for people with disabilities and their carers. However, the study also suggests that, over time, carers may experience an increased sense of isolation and lack of support as a result of their involvement in the CDC programme. The paper argues that the development of safeguards addressing these weaknesses is crucial for the sustainability of CDC programmes in contexts where risk cannot be simply transferred onto consumers.

Is phase-specific, community-oriented treatment of early psychosis- an economically viable method of improving outcome?

Objective: The Early Psychosis Prevention and Intervention Centre (EPPIC) provides a comprehensive 'real-world' model of early intervention to young people experiencing an emerging psychotic disorder. A prospective study has already provided evidence of improved clinical outcome at 12 months after entry. The present study examined whether the service was also cost-effective.

Method: A cost-effectiveness analysis compared EPPIC with its immediate precursor service, from the perspective of the government funding agency. Only direct costs were included.

Results: EPPIC proved to be more cost-effective. The weighted average cost per patient for the first 12 months was cheaper (by äD 7110 per patient), while treatment outcomes were superior. The savings were due to the marked reduction in in-patient costs outweighing substantial increases in the costs of community care.

Conclusion: These results, while encouraging in terms of the further development of integrated, phase-specific intervention programmes for early psychosis, are not conclusive, and further research is required.

An evaluation of a wellness guide for older carers living in the community

Objective: To assess the usefulness and effectiveness of a wellness guide and to identify whether its use by a group of older ‘‘new’’ carers would make them healthier and knowledgeable of community resources. Design and Sample: Pretest, posttest measures of physical and mental health and a questionnaire with associated focus groups. A purposive sample of 21 older carers who were ‘‘new’’ carers was selected for the study. Measures: Locus of control (LOC), Short Form 12, depression anxiety stress scale, and questionnaire. Results: Participants embraced the wellness guide as an excellent resource. It
changed their behavior and improved their health on LOC measures, although changes in physical and mental health were not statistically significant. Conclusions: The wellness guide assisted carers’ preparedness for their role and enhanced their sense of personal control over demanding situations.

An evaluation of the beyondblue depression training program for aged care workers

Background: The prevalence of depression among older people receiving care is high, yet the rate of treatment of this disorder is low. One way to improve the pathway to care is to train care staff to recognize the symptoms of depression and raise their confidence in responding to them. In this study we evaluated the efficacy of the beyondblue Depression Training Program to achieve this aim.
Methods: Staff (N=148) from low level care facilities and community care facilities in metropolitan Melbourne completed the beyondblue Depression Training Program, while staff in other facilities (N = 96) acted as controls. Pre-program, post-program and follow-up questionnaire data were collected and referrals for depression by staff were recorded.
Results: Training improved carers’ knowledge about depression, their self-efficacy in responding to signs of depression and their attitudes towards working with depressed aged care recipients. In addition, training increased the number of referrals for depression made by carers.
Conclusion: Training aged care staff in depression can improve the pathways to care for depressed care recipients, and has the potential to improve the quality of life of older people.

Detecting and managing depressed patients : palliative care nurses' self-efficacy and perceived barriers to care

Background: Depression is a highly prevalent yet under-recognized and under-treated psychiatric illness in patients receiving palliative care. Nurses are the front-line health care professionals in these settings and are well-positioned to detect depressive symptoms and initiate pathways to care. Previous research suggests, however, that nurses' confidence and skills in relation to this task are low, and there appear to be a number of barriers within these settings that may impede nurses' engagement in this process.

Methods: To further investigate these factors, a quantitative study was carried out with 69 palliative care nurses from three palliative care services in Australia.

Results: A number of issues were identified, including the need for further training in the signs and symptoms of depression, issues around discussing depression with patients and their family members, and difficulty differentiating depressive symptoms from grief.

Conclusion: These findings provide insight into specific areas in which palliative care nurses would benefit from further training to improve detection rates for depression in this vulnerable population.

Assessing and managing old age psychiatric disorders in community practice

A shortage of specialised facilities means that general practitioners have a prominent role in community care of the elderly with mental illness.