An Evaluation of an Alternative to Long-stay Hospital Care for Frail Elderly Patients: I. The Model of Care
Summary Recent UK government policy has advocated the development of case management to provide more coordinated care at home for vulnerable people. This paper describes a service model whereby case managers, with devolved budgets, employed by the social services department, were located in a geriatric multidisciplinary team to provide an alternative for patients requiring long-stay hospital care. As well as co-ordinating packages of care, case managers were responsible for deploying the time of home care assistants, multi-purpose workers who assisted health care staff and undertook home help tasks. The role of case managers within the multidisciplinary team is explained and the tasks undertaken by home care assistants are identified. Home care assistants undertook a wider range of activities than either home helps or nurses, covering both personal and domestic care tasks.
Introduction In 1983, following a round of consultations and reviews, the UK Government introduced the Care in the Community initiative [1]. As part of the objective of developing community care, this circular funded a series of 28 pilot projects to explore different ways of providing community based services for people discharged from long-stay hospital care [2]. The Darlington Project was one of these, planned to provide home care to physically frail elderly people who would otherwise require long-stay hospital care. A fuller description of the Darlington Project is presented elsewhere [3]. The principal concerns, which led to the development of the Darlington Project, were those of a lack of real choice for and control by
frail elderly people over their care, the multifaceted nature of needs spanning the responsibilities of health and social services, overlap and duplication of services, and inflexible patterns of service delivery. These have all been concerns on a national level too and have been more fully articulated in documents such as the work of the Audit Commission on community care [4], the Griffiths Report [5], and the recent White Paper [6], in which the project is specifically cited (para. 3.3.3). Underlying these concerns is the need to improve the content of services (what kind of care and how it is provided), and to develop the process of case management (more effective individual care planning and co-ordination). The Darlington Project aimed both to improve the content of services through its own home care assistants Age and Ageing 1991.20:236-244
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DAVID CHALLIS, ROBIN DARTON, LYNNE JOHNSON, MALCOLM STONE, KAREN TRASKE
AN ALTERNATIVE TO LONG-STAY HOSPITAL CARE: I
Multidisciplinary working and care planning The project was jointly planned by the Durham County Council Social Services Department and Darlington Health Authority. The project team consisted of a project manager, three service managers whose role was to act as case managers, and a team of home care assistants who were employed by the social services department. The case managers were members of the geriatric multidisciplinary team through which all referrals were directed. The referral, assessment and review of the clients who were to receive the service were undertaken by the geriatric multidisciplinary team, comprising medical staff, hospital and community nursing staff, social workers, paramedical staff and the service managers from the project. In identifying patients suitable for the project, the team took account of the level of dependency and physical impairment, and factors such as personality, motivation, family circumstances and the effects of length of stay in hospital on each individual person. Thus some potential clients were deemed to be unsuitable for the project for reasons such as their carer's refusal to accept help, need for regular nursing care at night, a family unwilling to accept terminal care at home, or poor housing conditions making discharge impossible in the winter months.
Those identified as suitable for the project were re-assessed in detail using information available from the different professionals and co-ordinated by the project service manager. The service manager also visited the family and discussed issues concerning discharge, and in about half the cases a home visit was undertaken with the elderly person, so that the physiotherapist, occupational therapist and service manager could assess the suitability of the person's home environment for their discharge. These procedures usually took place between the first case conference at which a person was identified as potentially suitable for the scheme, and a second conference two weeks later when the additional assessments were considered. It had been planned that a full medical reassessment and review would take place six months after discharge. However, in practice this could not be organized and subsequent medical reviews occurred when initiated by the service manager or other professionals.
Individual case management The main function of the service managers was to ensure that the 'core tasks' of case management were undertaken for their clients. These core tasks, which constitute the key activities of case management, can be described as casefinding, assessment, care planning, and monitoring and review [7]. Whilst in some models of case management the case manager is responsible for undertaking all these tasks, in the Darlington Project some of the tasks were performed by others, and it was the responsibility of the case managers to ensure that these tasks were properly undertaken and co-ordinated. Given the nature of the project, concerned with hospital discharge, case-finding was a task of the multidisciplinary team as a whole, and the principal role of the service managers was screening, to ensure that only clients eligible for the project were accepted. In a community care service, with individuals referred while still at home, in order to prevent admission to longstay settings, the relative importance of their role in case-finding would certainly increase. Following referral, the service managers would
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undertaking a wide range of caring tasks, and to improve co-ordination through the case management function undertaken by the service managers in the project. In this paper we describe a model of care in which case managers, employed by the social services department, were members of a geriatric multidisciplinary team, and in a second paper we present the main findings of an evaluation of that service model. The project built on some of the case management approaches already undertaken in the Kent and Gateshead Projects [7-9]. However, it sought to extend these activities into the realm of a joint health and social services model of provision, based upon a geriatric multidisciplinary team and using multi-purpose care workers to reduce overlap between personnel.
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Table. The client pathway
Geriatric multidisciplinary team (GMDT)
Service managers
Home care assistants (HCAs)
CASE FINDING, SCREENING AND REFERRAL Clarify target criteria with all in geriatric service frail elderly mentally alert patients requiring long-stay care but wishing to return home. Receive referral
Secondary assessment of referred patients, their support network and home circumstances Home visit/assessment by OT and physiotherapist
Discuss referral with patient and describe the nature of the support to be offered. Collate assessment of GMDT. Home visit: assessment, informing, consultation and negotiation with support network. Involve district nursing service. Discuss possible referral with home care assistants and consider suitable HCA for client
Instruct HCA on the ward in respect of the individual needs of the patient
Continued liaison with GMDT and acceptance of patient Construct and finalise care plan. Coordinate formal and informal network, ensuring that each part of the network is aware of the functions of the other pans Familiarise HCAs with support network, formal and informal. Consult patient and tamily on adequacy of support Inform GP.
ASSESSMENT
CARE PLANNING AND DISCHARGE Visit patient on the ward and receive instruction and advice from members of GMDT Meet members of support network.
HOME SUPPORT, MONITORING AND REVIEW Provide treatment and continue to assess needs of patient. Monitor performance of HCA in respect of prescribed tasks Formal review including district nurse at six weeks after discharge and six months.
Progress-chase care plan Support HCAs, ensuring demands are not too great. Call team meetings of HCAs for mutual support Monitor adequacy of support network in consultation with client, carers, HCA and professionals. Refer problems back to GMDT. Take responsibility for resolving problems between client, carers and professionals. Act as advocate on behalf of client. Coordinate review Progress agreed changes in care plan.
Perform tasks prescribed by professionals at a time and in a manner convenient to client Notify professionals and service managers of problems arising, seeking advice and providing feedback Advise informal network of developments. Provide other assistance to client, e.g. contact Social Security Contribute to review.
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Assessment and consideration of treatments and service options tor patients. Referral of suitable patients.
AN ALTERNATIVE TO LONG-STAY HOSPITAL CARE: I
the elderly client, their family, home care assistants and the wider range of services. Each service manager was allocated a budget for their caseload of about 20 clients. The service managers had to cost the service they provided to clients, working, as in previous studies, to an average budget of two-thirds of the cost of institutional care, in this case a longstay hospital bed [7]. A large percentage of this budget was allocated to home care assistant time, but resources were also spent on paying for additional services from members of the community, and the input of other health and social services resources was also costed. This knowledge of the relative costs of different forms of service provision was designed to aid decision-making, as cost comparisons could be made between different possible service inputs intended to achieve similar ends. For example, on occasions other providers, including home help, paid neighbours or volunteers, were used as part of the care plan if these seemed more appropriate. Paid helpers were used to relieve carers, provide night sitting, assist in the general supervision of a client and in recreational activities. However, through much of the life of the project the incentive for interweaving such help was constrained by under-utilization of the
PROJECT TEAM
PROFESSIONALS ACTIVITIES linking consulting coordinating progress-chasing
Project Manager + 3 Service Managers = CASE MANAGEMENT
ACTIVITIES training team building supporting reviewing problem-solving
ACTIVITIES assessment care planning reviewing monitoring counselling advocacy networking
I
I
Chiropodists District Nurses Doctors Occupational Therapists Physiotherapists Speech Therapists
I
HOME CARE ASSISTANTS
ICARERSh
I
ACTIVITIES assessing care planning monitoring reviewing advising
ACTIVITIES training instructing monitoring reviewing advising
|
H CLIENTS |
Figure 1. Darlington Community Care Project: the model of care.
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co-ordinate the assessment of the elderly persons from the different professionals in the multidisciplinary team and would themselves take responsibility for assessing the family and potential support network. The service managers' prime function was, in consultation with the multidisciplinary team, to develop, coordinate and regularly review a package of care, linking together all the necessary resources from a range of different providers, including health, social services, voluntary organizations and informal carers. As well as the tasks of monitoring, liaison and co-ordination, this role also required the service manager to give considerable amounts of emotional support and advice to elderly people and their families, complementing the activities of informal carers, and to provide support to the home care assistants and resolve conflicts in the care network. Thus the service manager had a continuing maintenance function as well as the initial assessment and care planning activities. The Table indicates the 'client pathway' covering the tasks of case management. It indicates the respective roles of the geriatric multidisciplinary team, the service managers and the home care assistants. It can be seen that the service managers were required to work closely with
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Home care assistants Integrating the nursing auxiliary/home help role is not a new development in home care [10, 11]. However, the Darlington Project attempted to move further, by enabling care workers to be instructed and used by a variety of different professionals, in an attempt to integrate much of the work of several different 'hands-on' providers into the activities of one single careworker. Thus the functions of a home help, auxiliary nurse or an aide to an occupational group were combined in one person. The home care assistant was available to, and could contact, consult and be instructed by several different health and social services personnel, according to the differing needs of elderly people. The aim was to give both an extension of service and a reduction in the number of individuals involved in providing care, since activities such as basic physiotherapy or meal provision, usually carried out by staff from several different agencies, could be provided at home through fewer or less specialized personnel. Recruitment and training of home care assistants: The home care assistants were all women
and were predominantly in the 20 to 50 age group, with most aged between 30 and 40. Eighty-three home care assistants were employed over the three years of the pilot project. Of these 83 home care assistants, 64 had previous paid experience in domestic or caring work, 24 had undertaken temporary or fulltime work in residential care homes in the private or public sector, 17 had previously worked as home helps, 13 had worked as domestics in hospital or residential care settings, five had been employed as auxiliary nurses or paramedical helpers, and five were trained nurses. After recruitment, all home care assistants were required to attend an initial full-time training period of two weeks, which was an introduction to basic skills and information about the needs of elderly people. Professional staff from a variety of disciplines in health and social services contributed to this training, and thus became involved in the model of care from the outset. After this initial training the home care assistants were allocated to care for specific clients, and were trained for the particular care tasks needed. The initial training programme was adapted in length and content as the project developed, but core elements included the underlying philosophy of the project, the needs of informal carers, dying and bereavement, and common physical illnesses experienced by elderly people. This was supplemented by observation visits with district nurses and continence advisors, the teaching of practical skills in lifting and transferring disabled people and the use of aids to daily living. Home care assistants and clients: Service managers attempted to match home care assistants to particular clients, considering factors including geographical proximity, personality, attitudes and capacity to cope. Similar factors were seen as important in the Kent and Gateshead studies [7, 8, 12]. Since clients were patients on a hospital ward, the home care assistant was first introduced to a prospective client on the ward, and usually two meetings were arranged to begin to get to know the person, and to be instructed by nursing and therapy staff who were familiar with her particular needs and treatment requirements. These early meetings were also
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service and the service managers had to make full use of available home care assistant time before using other services. The overall service model is summarized in Figure 1, which indicates the relationship between the project team and the multidisciplinary team, and the activities which were undertaken by service managers, both in relation to carers and clients, and in relation to home care assistants. It can be seen from Figure 1 that the activities undertaken by the project team could be performed indirectly through the different professionals, through the home care assistants or directly through interaction with clients and carers. This simplified version of the model of care does not include feedback between carers and home care assistants and the project team, but it demonstrates how the design of the project enabled various health care professionals and the service managers to work either directly with clients and carers, or indirectly through the home care assistants.
AN ALTERNATIVE TO LONG-STAY HOSPITAL CARE: I made possible, travel time was reduced, mutual support and shared working rotas organized, and on occasions home care assistants could become part of a client's immediate social network. Such an arrangement was seen by clients as giving them greater security, knowing that it might be possible to call on a familiar local home care assistant in an emergency. It also made it possible to respond to the needs of caring relatives who might need urgent relief if they found themselves unable to cope in the event of illness or urgent family demands. Of course, this could result in the demands on the home care assistant becoming very great, and it was incumbent on their service manager to monitor such informal arrangements to ensure that the demands did not become excessive or unreasonable. The service manager acted as case manager to between 15 and 18 clients during the pilot phase of the project, although up to 20 was seen as a reasonable caseload. Each service manager was also the manager for a team of approximately 18 home care assistants. A programme of monthly
Sloma care Personal care for carer Speech therapy etc Catheter care Change ol dressings Feeding Bathing Dressings Foot care Care of pressure areas Therapeutic exercises Deal with incontinence Hair/nail care Assist with walking Toileting Litiing/transtering Dressing Washing Administer/supervise medication 20
40
60
80
100
120 140 160 180 200 220
Times performed during survey week
Figure 2. Home care assistants: personal care.
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intended to help ease the transition from hospital to home since the home care assistant had become familiar with the client in hospital. After home care assistants were established in working with a client, they were encouraged to see their role as wider than solely meeting practical care needs. They were encouraged to identify and initiate social and recreational activities that might enhance clients' lives. Inevitably these possibilities for social elements of care were constrained by competing demands on their time, and the sheer amount of practical care required, but both they and the clients had a degree of freedom to make decisions about priorities within the daily and weekly care programme. Service managers and home care assistants: As the project developed, the three service managers each took responsibility for a team of home care assistants within a particular locality. By organizing home care assistants to work in teams within their immediate locality, and care for clients who were also their neighbours, the possibility of flexible, prompt response was
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Shopping with client
Managing affairs
Shopping (alone)
Laundry
Cooking
Housework
20
40
60
60
100
120
140
160
Times performed during survey week
Figure 3. Home care assistants: domestic activities.
180
200
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support sessions was introduced, in which each respective roles of the family carers and the home care assistant met individually with her home care assistant. service manager, in addition to contacts on a The group whose role was most affected and more ad hoc basis. These formal meetings were who were required to come to terms with and used for problem solving, for identifying suc- use these untested workers as auxiliaries were cesses and problems experienced in coping with the district nurses. Some experienced difficulparticular clients. ties in gaining confidence in the home care Care tasks and assisting professionals: The assistant and, on occasions, over the policy of range of staff for whom the home care assistants whether a patient should be discharged to their acted as auxiliaries included district nurses, own home. None the less, district nurses did physiotherapists, occupational therapists and gain familiarity with individual home care asspeech therapists, as well as the continence sistants through participating in their training advisor, dietician and stoma therapist. No rigid which, over time, helped to resolve difficulties. rules were laid down as to what would and A common response was a degree of reassurance would not be a suitable task for delegation to about the common sense and practical abilities home care assistants, rather it was the responsi- of the home care assistants. Initial concern bility of the instructing service provider to among general practitioners about greater satisfy themselves that the particular home care workloads was not substantiated. assistant was competent to perform the task. As might have been expected, the range of The work of home care assistants as auxiliar- tasks delegated was extended as professionals ies to several different staff undoubtedly ran the gained confidence in the ability of home care risk of conflict. Problems with clients and their assistants to follow instructions correctly, and families were relatively rare, and were mainly seek advice or information if they encountered associated with excessive demands made by the difficulties. In September 1987, when the proelderly person or with the need to clarify the ject had been running for about two years, a
AN ALTERNATIVE TO LONG-STAY HOSPITAL CARE: I
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survey of activities undertaken in one week was posed in the Griffiths Report [5] and in the carried out. At the time, 53 part-time home care recent White Paper [6]. In addition it brings assistants were caring for 45 clients, and all together the two key agencies, health and social participated in the survey, representing 238 services, through case managers located in a working days in all. The data provide a fre- geriatric multidisciplinary team. The service quency count of tasks undertaken over the also deployed multi-purpose community carers survey week, without giving any weighting for as proposed by Griffiths. Such a model is the time taken. Thus, although administration applicable to a broader context than the immeof medication was the most frequently per- diate one of discharging long-stay patients from formed task it would not have been as time hospital offering one means of providing conconsuming as a less frequently performed task tinuing care in the community. Here we have such as bathing. Nonetheless, it is noteworthy described the structure and inputs of the serthat the most frequently performed tasks in the vice. In a later paper [15] we consider the costs personal care field were toileting, transfer, and benefits of this approach compared with management of medication, dressing and wash- long-stay hospital care. ing (Figure 2), Housework, cooking and laundry were the most frequently performed domestic care tasks (Figure 3) indicating a very Acknowledgements substantial overlap with the home help service. We should like to thank a number of staff in The social contact activities undertaken, such as Darlington and Durham Health Authorities and providing companionship, were predominantly Durham Social Services Department for their coactivities which took place during the perfor- operation and also the elderly people and their mance of more instrumental activities, but also relatives. The patients were under the care of Drs P. included 'sitting-in' to give a carer relief or Carr, P. Earnshaw, P. Suri and I. Wandless, whom we should also like to thank. taking the elderly person out. Comparing the activities of home care assistants and those of community nurses reported by References Dunnell and Dobbs [13], and those of home 1. DHSS. Care in the community, HC (83)6, LAC helps reported by Latto [14], showed that the (83)5, London: HMSO, 1983. home care assistants undertook a wider range of 2. Renshaw J, Hampson R, Thomason C, Darton R, Judge K, Knapp M. Care in the community: activities and tasks than either home helps or the first steps. Aldershot, Hants: Gower, 1988. nurses. Although home care assistants under3. Challis D, Darton R, Johnson L, Stone M, took a similar proportion of personal care Traske K, Wall B. The Darlington Community activities as the district nurses, about 4 1 % Care Project: Supporting frail elderly people at albeit with few technical tasks, they spent less home. Personal Social Services Research Unit, time travelling than district nurses or auxiliarUniversity of Kent, Canterbury, 1989. ies. Home care assistants undertook markedly 4. Audit Commission. Making a reality of commufewer domestic tasks than the home helps, 25% nity care. London: HMSO, 1986. compared with 78%. Given that this is a 5. Griffiths R. Community care: agenda for action. comparison with a substantially extended home London: HMSO, 1988. help service, the difference might be greater 6. Cm. 849. Caring for people: community care in the next decade and beyond. London: HMSO, 1989. compared with other home help services. Thus 7. Challis D, Davies B. Case management in commuit appears that, to a substantial extent, the nity care. Aldershot, Hants: Gower, 1986. activities of home care assistants were overcom8. Challis D, Chessum R, Chesterman J, Luckett ing the barriers of role demarcation and reducR, Woods R. Community care for the frail ing task duplication. This is described in more elderly: an urban experiment. Br J Soc Work, detail by Challis et al. [3]. 1988; 18(Suppl): 13-42. The Darlington Project provides a model of 9. Davies B, Challis D. Matching resources to needs care which includes case managers with in community care. Aldershot, Hants: Gower, devolved budgets, based upon similar case 1986. management models elsewhere [7, 8], as pro- 10. Ferlie E. Sourcebook of innovation in community
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11.
12.
14. 15.
care of the elderly. Discussion Paper 271, Personal Social Services Research Unit, University of Kent, Canterbury, 1982. Salvage A. Domiciliary care schemes for the elderly: provision by local authority social services departments. Research Team for the Care of the Elderly, University of Wales College of Medicine, 198S. Qureshi H, Challis D, Davies B. Helpers in casemanaged community care. Aldershot, Hants: Gower, 1989. Dunnell K, Dobbs J. Nurses working in the community. London: HMSO, 1980. Latto S. The Coventry home help project. Coventry Social Services Department, 1982. Challis D, Darton R, Johnson L, Stone M, Traske K. An evaluation of an alternative to
long-stay hospital care for frail elderly patients: II. Costs and effectiveness. Age Ageing 1991;20:245-54. Authors' addresses D. Challis, R. Darton, L. Johnson*, K. Traske Personal Social Services Research Unit, University of Kent at Canterbury, Canterbury, Kent M. Stone Information and Development Officer, Darlington District Health Authority * Present address: South Tyneside Social Services Department Received in revised form 6 February 1991
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13.
D. CHALLIS ET AL.
Summary Recent UK government policy has advocated the development of case management to provide more coordinated care at home for vulnerable people. This paper describes a service model whereby case managers, with devolved budgets, employed by the social services department, were located in a geriatric multidisciplinary team to provide an alternative for patients requiring long-stay hospital care. As well as co-ordinating packages of care, case managers were responsible for deploying the time of home care assistants, multi-purpose workers who assisted health care staff and undertook home help tasks. The role of case managers within the multidisciplinary team is explained and the tasks undertaken by home care assistants are identified. Home care assistants undertook a wider range of activities than either home helps or nurses, covering both personal and domestic care tasks.
Introduction In 1983, following a round of consultations and reviews, the UK Government introduced the Care in the Community initiative [1]. As part of the objective of developing community care, this circular funded a series of 28 pilot projects to explore different ways of providing community based services for people discharged from long-stay hospital care [2]. The Darlington Project was one of these, planned to provide home care to physically frail elderly people who would otherwise require long-stay hospital care. A fuller description of the Darlington Project is presented elsewhere [3]. The principal concerns, which led to the development of the Darlington Project, were those of a lack of real choice for and control by
frail elderly people over their care, the multifaceted nature of needs spanning the responsibilities of health and social services, overlap and duplication of services, and inflexible patterns of service delivery. These have all been concerns on a national level too and have been more fully articulated in documents such as the work of the Audit Commission on community care [4], the Griffiths Report [5], and the recent White Paper [6], in which the project is specifically cited (para. 3.3.3). Underlying these concerns is the need to improve the content of services (what kind of care and how it is provided), and to develop the process of case management (more effective individual care planning and co-ordination). The Darlington Project aimed both to improve the content of services through its own home care assistants Age and Ageing 1991.20:236-244
Downloaded from http://ageing.oxfordjournals.org/ at Columbia University Libraries on February 1, 2015
DAVID CHALLIS, ROBIN DARTON, LYNNE JOHNSON, MALCOLM STONE, KAREN TRASKE
AN ALTERNATIVE TO LONG-STAY HOSPITAL CARE: I
Multidisciplinary working and care planning The project was jointly planned by the Durham County Council Social Services Department and Darlington Health Authority. The project team consisted of a project manager, three service managers whose role was to act as case managers, and a team of home care assistants who were employed by the social services department. The case managers were members of the geriatric multidisciplinary team through which all referrals were directed. The referral, assessment and review of the clients who were to receive the service were undertaken by the geriatric multidisciplinary team, comprising medical staff, hospital and community nursing staff, social workers, paramedical staff and the service managers from the project. In identifying patients suitable for the project, the team took account of the level of dependency and physical impairment, and factors such as personality, motivation, family circumstances and the effects of length of stay in hospital on each individual person. Thus some potential clients were deemed to be unsuitable for the project for reasons such as their carer's refusal to accept help, need for regular nursing care at night, a family unwilling to accept terminal care at home, or poor housing conditions making discharge impossible in the winter months.
Those identified as suitable for the project were re-assessed in detail using information available from the different professionals and co-ordinated by the project service manager. The service manager also visited the family and discussed issues concerning discharge, and in about half the cases a home visit was undertaken with the elderly person, so that the physiotherapist, occupational therapist and service manager could assess the suitability of the person's home environment for their discharge. These procedures usually took place between the first case conference at which a person was identified as potentially suitable for the scheme, and a second conference two weeks later when the additional assessments were considered. It had been planned that a full medical reassessment and review would take place six months after discharge. However, in practice this could not be organized and subsequent medical reviews occurred when initiated by the service manager or other professionals.
Individual case management The main function of the service managers was to ensure that the 'core tasks' of case management were undertaken for their clients. These core tasks, which constitute the key activities of case management, can be described as casefinding, assessment, care planning, and monitoring and review [7]. Whilst in some models of case management the case manager is responsible for undertaking all these tasks, in the Darlington Project some of the tasks were performed by others, and it was the responsibility of the case managers to ensure that these tasks were properly undertaken and co-ordinated. Given the nature of the project, concerned with hospital discharge, case-finding was a task of the multidisciplinary team as a whole, and the principal role of the service managers was screening, to ensure that only clients eligible for the project were accepted. In a community care service, with individuals referred while still at home, in order to prevent admission to longstay settings, the relative importance of their role in case-finding would certainly increase. Following referral, the service managers would
Downloaded from http://ageing.oxfordjournals.org/ at Columbia University Libraries on February 1, 2015
undertaking a wide range of caring tasks, and to improve co-ordination through the case management function undertaken by the service managers in the project. In this paper we describe a model of care in which case managers, employed by the social services department, were members of a geriatric multidisciplinary team, and in a second paper we present the main findings of an evaluation of that service model. The project built on some of the case management approaches already undertaken in the Kent and Gateshead Projects [7-9]. However, it sought to extend these activities into the realm of a joint health and social services model of provision, based upon a geriatric multidisciplinary team and using multi-purpose care workers to reduce overlap between personnel.
237
D. CHALLIS ET AL
Table. The client pathway
Geriatric multidisciplinary team (GMDT)
Service managers
Home care assistants (HCAs)
CASE FINDING, SCREENING AND REFERRAL Clarify target criteria with all in geriatric service frail elderly mentally alert patients requiring long-stay care but wishing to return home. Receive referral
Secondary assessment of referred patients, their support network and home circumstances Home visit/assessment by OT and physiotherapist
Discuss referral with patient and describe the nature of the support to be offered. Collate assessment of GMDT. Home visit: assessment, informing, consultation and negotiation with support network. Involve district nursing service. Discuss possible referral with home care assistants and consider suitable HCA for client
Instruct HCA on the ward in respect of the individual needs of the patient
Continued liaison with GMDT and acceptance of patient Construct and finalise care plan. Coordinate formal and informal network, ensuring that each part of the network is aware of the functions of the other pans Familiarise HCAs with support network, formal and informal. Consult patient and tamily on adequacy of support Inform GP.
ASSESSMENT
CARE PLANNING AND DISCHARGE Visit patient on the ward and receive instruction and advice from members of GMDT Meet members of support network.
HOME SUPPORT, MONITORING AND REVIEW Provide treatment and continue to assess needs of patient. Monitor performance of HCA in respect of prescribed tasks Formal review including district nurse at six weeks after discharge and six months.
Progress-chase care plan Support HCAs, ensuring demands are not too great. Call team meetings of HCAs for mutual support Monitor adequacy of support network in consultation with client, carers, HCA and professionals. Refer problems back to GMDT. Take responsibility for resolving problems between client, carers and professionals. Act as advocate on behalf of client. Coordinate review Progress agreed changes in care plan.
Perform tasks prescribed by professionals at a time and in a manner convenient to client Notify professionals and service managers of problems arising, seeking advice and providing feedback Advise informal network of developments. Provide other assistance to client, e.g. contact Social Security Contribute to review.
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Assessment and consideration of treatments and service options tor patients. Referral of suitable patients.
AN ALTERNATIVE TO LONG-STAY HOSPITAL CARE: I
the elderly client, their family, home care assistants and the wider range of services. Each service manager was allocated a budget for their caseload of about 20 clients. The service managers had to cost the service they provided to clients, working, as in previous studies, to an average budget of two-thirds of the cost of institutional care, in this case a longstay hospital bed [7]. A large percentage of this budget was allocated to home care assistant time, but resources were also spent on paying for additional services from members of the community, and the input of other health and social services resources was also costed. This knowledge of the relative costs of different forms of service provision was designed to aid decision-making, as cost comparisons could be made between different possible service inputs intended to achieve similar ends. For example, on occasions other providers, including home help, paid neighbours or volunteers, were used as part of the care plan if these seemed more appropriate. Paid helpers were used to relieve carers, provide night sitting, assist in the general supervision of a client and in recreational activities. However, through much of the life of the project the incentive for interweaving such help was constrained by under-utilization of the
PROJECT TEAM
PROFESSIONALS ACTIVITIES linking consulting coordinating progress-chasing
Project Manager + 3 Service Managers = CASE MANAGEMENT
ACTIVITIES training team building supporting reviewing problem-solving
ACTIVITIES assessment care planning reviewing monitoring counselling advocacy networking
I
I
Chiropodists District Nurses Doctors Occupational Therapists Physiotherapists Speech Therapists
I
HOME CARE ASSISTANTS
ICARERSh
I
ACTIVITIES assessing care planning monitoring reviewing advising
ACTIVITIES training instructing monitoring reviewing advising
|
H CLIENTS |
Figure 1. Darlington Community Care Project: the model of care.
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co-ordinate the assessment of the elderly persons from the different professionals in the multidisciplinary team and would themselves take responsibility for assessing the family and potential support network. The service managers' prime function was, in consultation with the multidisciplinary team, to develop, coordinate and regularly review a package of care, linking together all the necessary resources from a range of different providers, including health, social services, voluntary organizations and informal carers. As well as the tasks of monitoring, liaison and co-ordination, this role also required the service manager to give considerable amounts of emotional support and advice to elderly people and their families, complementing the activities of informal carers, and to provide support to the home care assistants and resolve conflicts in the care network. Thus the service manager had a continuing maintenance function as well as the initial assessment and care planning activities. The Table indicates the 'client pathway' covering the tasks of case management. It indicates the respective roles of the geriatric multidisciplinary team, the service managers and the home care assistants. It can be seen that the service managers were required to work closely with
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Home care assistants Integrating the nursing auxiliary/home help role is not a new development in home care [10, 11]. However, the Darlington Project attempted to move further, by enabling care workers to be instructed and used by a variety of different professionals, in an attempt to integrate much of the work of several different 'hands-on' providers into the activities of one single careworker. Thus the functions of a home help, auxiliary nurse or an aide to an occupational group were combined in one person. The home care assistant was available to, and could contact, consult and be instructed by several different health and social services personnel, according to the differing needs of elderly people. The aim was to give both an extension of service and a reduction in the number of individuals involved in providing care, since activities such as basic physiotherapy or meal provision, usually carried out by staff from several different agencies, could be provided at home through fewer or less specialized personnel. Recruitment and training of home care assistants: The home care assistants were all women
and were predominantly in the 20 to 50 age group, with most aged between 30 and 40. Eighty-three home care assistants were employed over the three years of the pilot project. Of these 83 home care assistants, 64 had previous paid experience in domestic or caring work, 24 had undertaken temporary or fulltime work in residential care homes in the private or public sector, 17 had previously worked as home helps, 13 had worked as domestics in hospital or residential care settings, five had been employed as auxiliary nurses or paramedical helpers, and five were trained nurses. After recruitment, all home care assistants were required to attend an initial full-time training period of two weeks, which was an introduction to basic skills and information about the needs of elderly people. Professional staff from a variety of disciplines in health and social services contributed to this training, and thus became involved in the model of care from the outset. After this initial training the home care assistants were allocated to care for specific clients, and were trained for the particular care tasks needed. The initial training programme was adapted in length and content as the project developed, but core elements included the underlying philosophy of the project, the needs of informal carers, dying and bereavement, and common physical illnesses experienced by elderly people. This was supplemented by observation visits with district nurses and continence advisors, the teaching of practical skills in lifting and transferring disabled people and the use of aids to daily living. Home care assistants and clients: Service managers attempted to match home care assistants to particular clients, considering factors including geographical proximity, personality, attitudes and capacity to cope. Similar factors were seen as important in the Kent and Gateshead studies [7, 8, 12]. Since clients were patients on a hospital ward, the home care assistant was first introduced to a prospective client on the ward, and usually two meetings were arranged to begin to get to know the person, and to be instructed by nursing and therapy staff who were familiar with her particular needs and treatment requirements. These early meetings were also
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service and the service managers had to make full use of available home care assistant time before using other services. The overall service model is summarized in Figure 1, which indicates the relationship between the project team and the multidisciplinary team, and the activities which were undertaken by service managers, both in relation to carers and clients, and in relation to home care assistants. It can be seen from Figure 1 that the activities undertaken by the project team could be performed indirectly through the different professionals, through the home care assistants or directly through interaction with clients and carers. This simplified version of the model of care does not include feedback between carers and home care assistants and the project team, but it demonstrates how the design of the project enabled various health care professionals and the service managers to work either directly with clients and carers, or indirectly through the home care assistants.
AN ALTERNATIVE TO LONG-STAY HOSPITAL CARE: I made possible, travel time was reduced, mutual support and shared working rotas organized, and on occasions home care assistants could become part of a client's immediate social network. Such an arrangement was seen by clients as giving them greater security, knowing that it might be possible to call on a familiar local home care assistant in an emergency. It also made it possible to respond to the needs of caring relatives who might need urgent relief if they found themselves unable to cope in the event of illness or urgent family demands. Of course, this could result in the demands on the home care assistant becoming very great, and it was incumbent on their service manager to monitor such informal arrangements to ensure that the demands did not become excessive or unreasonable. The service manager acted as case manager to between 15 and 18 clients during the pilot phase of the project, although up to 20 was seen as a reasonable caseload. Each service manager was also the manager for a team of approximately 18 home care assistants. A programme of monthly
Sloma care Personal care for carer Speech therapy etc Catheter care Change ol dressings Feeding Bathing Dressings Foot care Care of pressure areas Therapeutic exercises Deal with incontinence Hair/nail care Assist with walking Toileting Litiing/transtering Dressing Washing Administer/supervise medication 20
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Figure 2. Home care assistants: personal care.
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intended to help ease the transition from hospital to home since the home care assistant had become familiar with the client in hospital. After home care assistants were established in working with a client, they were encouraged to see their role as wider than solely meeting practical care needs. They were encouraged to identify and initiate social and recreational activities that might enhance clients' lives. Inevitably these possibilities for social elements of care were constrained by competing demands on their time, and the sheer amount of practical care required, but both they and the clients had a degree of freedom to make decisions about priorities within the daily and weekly care programme. Service managers and home care assistants: As the project developed, the three service managers each took responsibility for a team of home care assistants within a particular locality. By organizing home care assistants to work in teams within their immediate locality, and care for clients who were also their neighbours, the possibility of flexible, prompt response was
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Shopping with client
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Figure 3. Home care assistants: domestic activities.
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support sessions was introduced, in which each respective roles of the family carers and the home care assistant met individually with her home care assistant. service manager, in addition to contacts on a The group whose role was most affected and more ad hoc basis. These formal meetings were who were required to come to terms with and used for problem solving, for identifying suc- use these untested workers as auxiliaries were cesses and problems experienced in coping with the district nurses. Some experienced difficulparticular clients. ties in gaining confidence in the home care Care tasks and assisting professionals: The assistant and, on occasions, over the policy of range of staff for whom the home care assistants whether a patient should be discharged to their acted as auxiliaries included district nurses, own home. None the less, district nurses did physiotherapists, occupational therapists and gain familiarity with individual home care asspeech therapists, as well as the continence sistants through participating in their training advisor, dietician and stoma therapist. No rigid which, over time, helped to resolve difficulties. rules were laid down as to what would and A common response was a degree of reassurance would not be a suitable task for delegation to about the common sense and practical abilities home care assistants, rather it was the responsi- of the home care assistants. Initial concern bility of the instructing service provider to among general practitioners about greater satisfy themselves that the particular home care workloads was not substantiated. assistant was competent to perform the task. As might have been expected, the range of The work of home care assistants as auxiliar- tasks delegated was extended as professionals ies to several different staff undoubtedly ran the gained confidence in the ability of home care risk of conflict. Problems with clients and their assistants to follow instructions correctly, and families were relatively rare, and were mainly seek advice or information if they encountered associated with excessive demands made by the difficulties. In September 1987, when the proelderly person or with the need to clarify the ject had been running for about two years, a
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survey of activities undertaken in one week was posed in the Griffiths Report [5] and in the carried out. At the time, 53 part-time home care recent White Paper [6]. In addition it brings assistants were caring for 45 clients, and all together the two key agencies, health and social participated in the survey, representing 238 services, through case managers located in a working days in all. The data provide a fre- geriatric multidisciplinary team. The service quency count of tasks undertaken over the also deployed multi-purpose community carers survey week, without giving any weighting for as proposed by Griffiths. Such a model is the time taken. Thus, although administration applicable to a broader context than the immeof medication was the most frequently per- diate one of discharging long-stay patients from formed task it would not have been as time hospital offering one means of providing conconsuming as a less frequently performed task tinuing care in the community. Here we have such as bathing. Nonetheless, it is noteworthy described the structure and inputs of the serthat the most frequently performed tasks in the vice. In a later paper [15] we consider the costs personal care field were toileting, transfer, and benefits of this approach compared with management of medication, dressing and wash- long-stay hospital care. ing (Figure 2), Housework, cooking and laundry were the most frequently performed domestic care tasks (Figure 3) indicating a very Acknowledgements substantial overlap with the home help service. We should like to thank a number of staff in The social contact activities undertaken, such as Darlington and Durham Health Authorities and providing companionship, were predominantly Durham Social Services Department for their coactivities which took place during the perfor- operation and also the elderly people and their mance of more instrumental activities, but also relatives. The patients were under the care of Drs P. included 'sitting-in' to give a carer relief or Carr, P. Earnshaw, P. Suri and I. Wandless, whom we should also like to thank. taking the elderly person out. Comparing the activities of home care assistants and those of community nurses reported by References Dunnell and Dobbs [13], and those of home 1. DHSS. Care in the community, HC (83)6, LAC helps reported by Latto [14], showed that the (83)5, London: HMSO, 1983. home care assistants undertook a wider range of 2. Renshaw J, Hampson R, Thomason C, Darton R, Judge K, Knapp M. Care in the community: activities and tasks than either home helps or the first steps. Aldershot, Hants: Gower, 1988. nurses. Although home care assistants under3. Challis D, Darton R, Johnson L, Stone M, took a similar proportion of personal care Traske K, Wall B. The Darlington Community activities as the district nurses, about 4 1 % Care Project: Supporting frail elderly people at albeit with few technical tasks, they spent less home. Personal Social Services Research Unit, time travelling than district nurses or auxiliarUniversity of Kent, Canterbury, 1989. ies. Home care assistants undertook markedly 4. Audit Commission. Making a reality of commufewer domestic tasks than the home helps, 25% nity care. London: HMSO, 1986. compared with 78%. Given that this is a 5. Griffiths R. Community care: agenda for action. comparison with a substantially extended home London: HMSO, 1988. help service, the difference might be greater 6. Cm. 849. Caring for people: community care in the next decade and beyond. London: HMSO, 1989. compared with other home help services. Thus 7. Challis D, Davies B. Case management in commuit appears that, to a substantial extent, the nity care. Aldershot, Hants: Gower, 1986. activities of home care assistants were overcom8. Challis D, Chessum R, Chesterman J, Luckett ing the barriers of role demarcation and reducR, Woods R. Community care for the frail ing task duplication. This is described in more elderly: an urban experiment. Br J Soc Work, detail by Challis et al. [3]. 1988; 18(Suppl): 13-42. The Darlington Project provides a model of 9. Davies B, Challis D. Matching resources to needs care which includes case managers with in community care. Aldershot, Hants: Gower, devolved budgets, based upon similar case 1986. management models elsewhere [7, 8], as pro- 10. Ferlie E. Sourcebook of innovation in community
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care of the elderly. Discussion Paper 271, Personal Social Services Research Unit, University of Kent, Canterbury, 1982. Salvage A. Domiciliary care schemes for the elderly: provision by local authority social services departments. Research Team for the Care of the Elderly, University of Wales College of Medicine, 198S. Qureshi H, Challis D, Davies B. Helpers in casemanaged community care. Aldershot, Hants: Gower, 1989. Dunnell K, Dobbs J. Nurses working in the community. London: HMSO, 1980. Latto S. The Coventry home help project. Coventry Social Services Department, 1982. Challis D, Darton R, Johnson L, Stone M, Traske K. An evaluation of an alternative to
long-stay hospital care for frail elderly patients: II. Costs and effectiveness. Age Ageing 1991;20:245-54. Authors' addresses D. Challis, R. Darton, L. Johnson*, K. Traske Personal Social Services Research Unit, University of Kent at Canterbury, Canterbury, Kent M. Stone Information and Development Officer, Darlington District Health Authority * Present address: South Tyneside Social Services Department Received in revised form 6 February 1991
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