Membership and management: structures of inter-professional working in community mental health teams for older people in England

Wilberforce, Mark; Tucker, Sue; Abendstern, Michele; Brand, Christian; Giebel, Clarissa; Challis, David

doi:10.1017/s104161021300077x

Cited by 24 publications

(29 citation statements)

References 23 publications

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“…At the same time, the mean number and length of support worker contacts per month increased, in accordance with reports of an increased reliance on practitioners without professional registration working in CMHTsOP in England. 272 Overall (Table 52), the average contact time with mental health services across the 6 months was just over 9 hours (mean 559.71 minutes, range 0-5490 minutes), and the total number of contacts was nine (mean 8.78 contacts, range 0-57 contacts).…”

Section: Main Outcomes Over Timementioning

confidence: 99%

“…An obstacle to delivery of interventions for dementia with CB may have therefore been the absence of particular professional expertise. It is hard to see why some prescribing practices were suboptimal, as old age psychiatrists were always available in these services; it may be that some practitioners may have been working 'in silos' 272 and that the timing of access of available professional expertise by the practitioner may have been an obstacle to the evaluation for, and delivery of, some interventions for CB. The sometimes hidden 'scaffolding' 185,186 that practitioners require for the delivery of these types of interventions is implicit in most successful applications of case-specific dementia care interventions, 289 including those for CB.…”

Section: Management Of Dementia and Challenging Behaviour In Family Smentioning

confidence: 99%

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Challenge Demcare: management of challenging behaviour in dementia at home and in care homes – development, evaluation and implementation of an online individualised intervention for care homes; and a cohort study of specialist community mental health care for families

Moniz–Cook

Hart

Woods

et al. 2017

Programme Grants Appl Res

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BackgroundDementia with challenging behaviour (CB) causes significant distress for caregivers and the person with dementia. It is associated with breakdown of care at home and disruption in care homes. Challenge Demcare aimed to assist care home staff and mental health practitioners who support families at home to respond effectively to CB.ObjectivesTo study the management of CB in care homes (ResCare) and in family care (FamCare). Following a conceptual overview, two systematic reviews and scrutiny of clinical guidelines, we (1) developed and tested a computerised intervention; (2) conducted a cluster randomised trial (CRT) of the intervention for dementia with CB in care homes; (3) conducted a process evaluation of implementation of the intervention; and (4) conducted a longitudinal observational cohort study of the management of people with dementia with CB living at home, and their carers.Review methodsCochrane review of randomised controlled trials; systematic meta-ethnographic review of quantitative and qualitative studies.DesignResCare – survey, CRT, process evaluation and stakeholder consultations. FamCare – survey, longitudinal cohort study, participatory development design process and stakeholder consultations. Comparative examination of baseline levels of CB in the ResCare trial and the FamCare study participants.SettingsResCare – 63 care homes in Yorkshire. FamCare – 33 community mental health teams for older people (CMHTsOP) in seven NHS organisations across England.ParticipantsResCare – 2386 residents and 861 staff screened for eligibility; 555 residents with dementia and CB; 277 ‘other’ residents; 632 care staff; and 92 staff champions. FamCare – every new referral (n = 5360) reviewed for eligibility; 157 patients with dementia and CB, with their carer; and 26 mental health practitioners. Stakeholder consultations – initial workshops with 83 practitioners and managers from participating organisations; and 70 additional stakeholders using eight group discussions and nine individual interviews.InterventionAn online application for case-specific action plans to reduce CB in dementia, consisting of e-learning and bespoke decision support care home and family care e-tools.Main outcome measuresResCare – survey with the Challenging Behaviour Scale; measurement of CB with the Neuropsychiatric Inventory (NPI) and medications taken from prescriptions; implementation with thematic views from participants and stakeholders. FamCare – case identification from all referrals to CMHTsOP; measurement of CB with the Revised Memory and Behaviour Problems Checklist and NPI; medications taken from prescriptions; and thematic views from stakeholders. Costs of care calculated for both settings. Comparison of the ResCare trial and FamCare study participants used the NPI, Clinical Dementia Rating and prescribed medications.ResultsResCare – training with group discussion and decision support for individualised interventions did not change practice enough to have an impact on CB in dementia. Worksite e-learning opportunities were not readily taken up by care home staff. Smaller homes with a less hierarchical management appear more ready than others to engage in innovation. FamCare – home-dwelling people with dementia and CB are referred to specialist NHS services, but treatment over 6 months, averaging nine contacts per family, had no overall impact on CB. Over 60% of people with CB had mild dementia. Families bear the majority of the care costs of dementia with CB. A care gap in the delivery of post-diagnostic help for families supporting relatives with dementia and significant CB at home has emerged. Higher levels of CB were recorded in family settings; and prescribing practices were suboptimal in both care home and family settings.LimitationsFunctionality of the software was unreliable, resulting in delays. This compromised the feasibility studies and undermined delivery of the intervention in care homes. A planned FamCare CRT could not proceed because of insufficient referrals.ConclusionsA Cochrane review of individualised functional analysis-based interventions suggests that these show promise, although delivery requires a trained dementia care workforce. Like many staff training interventions, our interactive e-learning course was well received by staff when delivered in groups with facilitated discussion. Our e-learning and decision support e-tool intervention in care homes, in its current form, without ongoing review of implementation of recommended action plans, is not effective at reducing CB when compared with usual care. This may also be true for staff training in general. A shift in priorities from early diagnosis to early recognition of dementia with clinically significant CB could bridge the emerging gap and inequities of care to families. Formalised service improvements in the NHS, to co-ordinate such interventions, may stimulate better opportunities for practice models and pathways. Separate services for care homes and family care may enhance the efficiency of delivery and the quality of research on implementation into routine care.Future workThere is scope for extending functional analysis-based interventions with communication and interaction training for carers. Our clinical workbooks, video material of real-life episodes of CB and process evaluation tool resources require further testing. There is an urgent need for evaluation of interventions for home-dwelling people with dementia with clinically significant CB, delivered by trained dementia practitioners. Realist evaluation designs may illuminate how the intervention might work, and for whom, within varying service contexts.Trial registrationCurrent Controlled Trials ISRCTN02553381 (the ResCare trial) and ISRCTN58876649 (the FamCare study).FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 15. See the NIHR Journals Library website for further project information.

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Section: Main Outcomes Over Timementioning

confidence: 99%

Section: Management Of Dementia and Challenging Behaviour In Family Smentioning

confidence: 99%

Challenge Demcare: management of challenging behaviour in dementia at home and in care homes – development, evaluation and implementation of an online individualised intervention for care homes; and a cohort study of specialist community mental health care for families

Moniz–Cook

Hart

Woods

et al. 2017

Programme Grants Appl Res

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“…The rapid growth in the population aged 65 years and above is posing challenges for health care systems worldwide with the increases in psychiatric and physical ill-health typically associated with ageing, including dementia (Wilberforce et al, 2013). Based on estimates of the increase in mental disorder prevalence in later life, mental health services for older people will need to prepare for a near doubling of potential demand (Draper & Anderson, 2010).…”

Section: Introductionmentioning

confidence: 99%

“…While community health services continue to be the preferred tier of specialist support, integrated healthcare teams are believed to provide greater continuity of care (Wilberforce et al, 2013). Evidence of the growing use of such integrated teams is provided by Wilberforce et al (2013) who surveyed English community mental health teams for older people seeking information on team structure and management.…”

Section: Introductionmentioning

confidence: 99%

“…Evidence of the growing use of such integrated teams is provided by Wilberforce et al (2013) who surveyed English community mental health teams for older people seeking information on team structure and management. Responses from 376 (88%) teams showed broader multidisciplinary membership than found previously, especially in the number of community support workers (CSWs) and other unqualified practitioners.…”

Section: Introductionmentioning

confidence: 99%

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The Impact of a Participatory Care Model on Work Satisfaction of Care Workers and the Functionality, Connectedness, and Mental Health of Community-Dwelling Older People

Bernoth

Burmeister

Morrison

et al. 2016

Issues in Mental Health Nursing

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This study describes and evaluates an innovative program designed to reduce functional decline among seniors, using a participatory care approach and integrated health teams. The evaluation provides older people and community support workers (CSWs) with the opportunity to share their experiences of being involved with an innovative program to reduce functional decline (mobility, skin integrity, nutrition, mental health, continence) of older, community dwelling adults implemented by a Nursing Service in a major capital city in Australia. As part of the program, CSWs were trained to provide care that aimed to reduce functional decline, and improve the quality of life for the care recipients. Data were collected through in-depth interviews with older people receiving care and a focus group (FG) was conducted with CSWs. Seven themes emerged during data analysis: 1) functionality/independence; 2) prevention; 3) confidence; 4) connection; 5) the approach; 6) care plans; and 7) the role of the CSWs. The relationship built between care giver and receiver and the mutual respect facilitated through adopting a participatory care approach was crucial. This relationship-focused care contributed to improved functionality and consequently quality of life for the older person, and for the CSW professional it contributed to their development, improved satisfaction with their role, and increased pride in the difference they make in the lives of their clients. Opportunities for improvement of the program included ensuring that participants understood the rationale for all aspects of the program, including regular reminders, as well as the use of regular reviews of individual outcomes.

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Community mental health teams for older people: variations in case mix and service receipt (II)

Wilberforce

Tucker

Brand

et al. 2014

Int J Geriat Psychiatry

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Objectives: To determine the extent to which services provided to older people via community mental health teams (CMHTs) vary in duration, composition and intensity. In particular, to identify the degree to which differences between teams are due to casemix. Methods: Data were collected about the services provided to a random sample of patients from 15 CMHT caseloads, including contact with CMHT staff, other specialist mental health and social care services. The relationship between patients' needs and service receipt was explored. Results: Information was obtained for 1396 patients. Average time on CMHT caseloads was 11.6 months, but there were marked between-team differences. The proportion of re-referrals also varied from under a tenth to over half. People with functional mental health problems and complex needs were most likely to be long-term CMHT clients. The proportion of patients seen by a consultant in the previous 6 months ranged from approximately a fifth to almost all. Differences with respect to contact with other qualified practitioners were less marked. Older people with functional disorders, challenging behaviour and at least one medium risk had the most regular contact with CMHT staff. Risk of self-harm, delusions and paranoia increased the likelihood of consultant involvement. Support workers were more likely to see people at risk of self-neglect. The receipt of other services, including day hospitals and inpatient care varied greatly. Conclusions: Considerable diversity was found in the length, nature and frequency of services provided to patients with different needs. Differences between teams were not wholly explained by case mix.

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Membership and management: structures of inter-professional working in community mental health teams for older people in England

Cited by 24 publications

References 23 publications

Challenge Demcare: management of challenging behaviour in dementia at home and in care homes – development, evaluation and implementation of an online individualised intervention for care homes; and a cohort study of specialist community mental health care for families

Challenge Demcare: management of challenging behaviour in dementia at home and in care homes – development, evaluation and implementation of an online individualised intervention for care homes; and a cohort study of specialist community mental health care for families

The Impact of a Participatory Care Model on Work Satisfaction of Care Workers and the Functionality, Connectedness, and Mental Health of Community-Dwelling Older People

Community mental health teams for older people: variations in case mix and service receipt (II)

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