Care management has become a key component in the development of community-based care in many countries, and this paper examines the different care management arrangements for older people's services that are now emerging. It has been United Kingdom government policy since that the providers of social services develop care management systems, as confirmed in the White Paper, Modernising Social Services. The paper opens with the background to the policy changes and a discussion of the role of care management in the British social care system. Secondly, evidence from the early phases of care management development is examined ; and thirdly, the evidence from a major national study of care management arrangements for older people on the patterns of variation on key dimensions is considered. Weiner, Stewart, Hughes, Challis and Darton et al. ; Challis , a). This latter was particularly associated with two important factors. Enhanced home care for vulnerable people was seen as requiring the degree of individualisation and co-ordination associated with care management. Furthermore, the degree of fragmentation of service provision both within and between social and health care agencies necessitated their co-ordination.It became British government policy in for local authority social services departments, the main agencies for the provision of social care, to develop care management systems. This was introduced as part of the wider community care reforms embodied in the White Paper Caring for People (Cm ) and leading to the National Health Service and Community Care Act, which was implemented in . The policy was driven principally by the budgetary pressures of an ageing population and by funding anomalies. These anomalies had produced a bias in favour of the placement of older people in institutional care rather than the pursuit of a long-standing policy objective to provide care at home (Challis ). New levels of funding and responsibilities were given to social services departments. They were made responsible for undertaking assessments of need, the design and packaging of services tailored to meet such needs, and for the provision of care managers to monitor, review and act as a single point of contact for those receiving services. The more recent social services White Paper reiterated the importance of care management through its emphasis on promoting both independence and user-centred and individually tailored services (Cm ). Care management antecedents
BackgroundThe rising number of older people with mental health problems makes the effective use of mental health resources imperative. Little is known about the clinical effectiveness and/or cost-effectiveness of different service models.AimsThe programme aimed to (1) refine and apply an existing planning tool [‘balance of care’ (BoC)] to this client group; (2) identify whether, how and at what cost the mix of institutional and community services could be improved; (3) enable decision-makers to apply the BoC framework independently; (4) identify variation in the structure, organisation and processes of community mental health teams for older people (CMHTsOP); (5) examine whether or not different community mental health teams (CMHTs) models are associated with different costs/outcomes; (6) identify variation in mental health outreach services for older care home residents; (7) scope the evidence on the association between different outreach models and resident outcomes; and (8) disseminate the research findings to multiple stakeholder groups.MethodsThe programme employed a mixed-methods approach including three systematic literature reviews; a BoC study, which used a systematic framework for choosing between alternative patterns of support by identifying people whose needs could be met in more than one setting and comparing their costs/outcomes; a national survey of CMHTs’ organisation, structure and processes; a multiple case study of CMHTs exhibiting different levels of integration encompassing staff interviews, an observational study of user outcomes and a staff survey; national surveys of CMHTs’ outreach activities and care homes. A planned randomised trial of depression management in care homes was removed at the review stage by the National Institute for Health Research (NIHR) prior to funding award.ResultsBoC: Past studies exhibited several methodological limitations, and just two related to older people with mental health problems. The current study suggested that if enhanced community services were available, a substantial proportion of care home and inpatient admissions could be diverted, although only the latter would release significant monies. CMHTsOP: 60% of teams were considered multidisciplinary. Most were colocated, had a single point of access (SPA) and standardised assessment documentation. Evidence of the impact of particular CMHT features was limited. Although staff spoke positively about integration, no evidence was found that more integrated teams produced better user outcomes. Working in high-integration teams was associated with poor job outcomes, but other factors negated the statistical significance of this. Care home outreach: Typical services in the literature undertook some combination of screening (less common), assessment, medication review, behaviour management and training, and evidence suggested intervention can benefit depressed residents. Care home staff were perceived to lack necessary skills, but relatively few CMHTs provided formal training.LimitationsLimitations include a necessary reliance on observational rather than experimental methods, which were not feasible given the nature of the services explored.ConclusionsBoC: Shifting care towards the community would require the growth of support services; clarification of extra care housing’s (ECH) role; timely responses to people at risk of psychiatric admission; and improved hospital discharge planning. However, the promotion of care at home will not necessarily reduce public expenditure. CMHTsOP: Although practitioners favoured integration, its goals need clarification. Occupational therapists (OTs) and social workers faced difficulties identifying optimal roles, and support workers’ career structures needed delineating. Care home outreach: Further CMHT input to build care home staff skills and screen for depression may be beneficial. Priority areas for further study include the costs and benefits for older people of age inclusive mental health services and the relative cost-effectiveness of different models of mental health outreach for older care home residents.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
Since the community care reforms of the early 1990s, care management in the United Kingdom has become the usual means of arranging services for even the most straightforward of social care needs. This paper presents data from a diary study of care managers' time use, from a sample of social services commissioning organizations representing the most common forms of care management practiced in England at the end of the 20th century. It compares the working practices of care managers in community mental health service settings to the practices of those situated in older people's services. Evidence is provided to suggest that while the former follow a more clinical model of care management, those working with older people take an almost exclusively administrative approach to their work. In addition, the multidisciplinary nature of mental health service teams appears to facilitate a more integrated health and social care approach to care management compared to the approach to older people's services. Further enquiry is needed as to the comparative effectiveness of these different modes of working in each service setting.
Background Assessment was identified as one of the ‘cornerstones’ of community care. This study presents findings from the first nationally representative analysis of assessment documents used by social services agencies in the UK. Method In this paper analysis is made of 50 assessment documents used for the ‘comprehensive’ assessment of older people. The documents were examined in the extent to which they covered 33 assessment domains, grouped into four areas: functional domains; cognitive, mood and psychosocial domains; social environment domains; and clinico‐medical domains. The documents were analysed on three dimensions: whether the domains were covered at all; whether the domain was covered in sufficient detail; and whether it would elicit a structured response. Results Activities of daily living were covered to some extent on the majority of documents, as were the instrumental activities of daily living. Very few documents were designed to elicit information on the potential for rehabilitation. Whilst the majority of forms were designed to collect some information on cognitive patterns, mood state and social activity, very few were designed to collect this in any detail. Although functional activities of daily living were covered in greater detail than the other domains overall, there was enormous variability between the documents, thus hampering their ability to generate any standardized information. Copyright © 1999 John Wiley & Sons, Ltd.
There was little evidence of intensive care-management at home in older peoples' services. This is of concern, given the move towards community-based provision for frail older people. Closer links between secondary health-care services (such as geriatric medicine) and intensive care-management at home may promote more effective care at home for those who are most vulnerable.
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