National trends and local delivery in old age mental health services: towards an evidence base. A mixed-methodology study of the balance of care approach, community mental health teams and specialist mental health outreach to care homes

Abstract

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.

Predicting admission to long‐term care and mortality among community‐based, dependent older people in Ireland

“…3,4 Not only is this what people want, but enabling older people to remain at home for longer reduces the potential cost of care for government. [7][8][9] A large UK BoC study found that up to half of new care home entrants could be cared for in alternative settings. 2 The "Balance of Care" (BoC) approach, a systematic framework for exploring the potential costs and consequences of changing the mix of community and long-stay residential services in a defined geographical area 6 can be used to identify the types of dependent older people who could equally be cared for at home or in residential care.…”

“…5 However, shifting the focus from LTC requires better information on older people in receipt of home care, which is in line with the World Health Organization (WHO)'s recommendation for improved measurement, monitoring, and understanding of health and ageing, including in relation to older people in need of LTC. 9 For each of these case-types, nursing home care could be delayed by 3 to 12 months with sufficient community supports. [7][8][9] A large UK BoC study found that up to half of new care home entrants could be cared for in alternative settings.…”

“…Formal home support is allocated based on a care needs assessment by a health care professional and is currently not subject to a financial means assessment, although this may change as the Department of Health in Ireland is currently in the process of undertaking work to develop a new statutory formal home care scheme for older people. 4,9 Case types that are more likely to be viable for home support are those without a combination of high levels of physical dependency, cognitive impairment (CI), or challenging behaviours. [15][16][17] The types of cases that could be cared for in the community rather than in residential care tend, not surprisingly, to be those that are less complex.…”

What makes extra care housing an appropriate setting for people with dementia? An exploration of staff decision-making

“…The local authority was interested in exploring the use of ECH as an alternative to care home placement and had recently upgraded several sheltered housing complexes into ECH for older people; however none of these were specifically dedicated to the care of people with dementia. The data were collected as part of a Balance of Care (BoC) study, which sought to identify the most appropriate mix of community and institutional services to provide for older people with mental health problems in North-West England (Challis et al, 2014;Tucker, Brand, Wilberforce, Abenstern, & Challis, 2015). Balance of care is a longstanding strategic planning framework, identifying people whose needs can be met in more than one setting (e.g.…”

“…Approximately two-thirds had at least medium ADL dependency; more than four-fifths had medium or high levels of cognitive impairment; and a still higher proportion presented with medium or high levels of challenging behaviour. Full details of the study sample are available elsewhere (Challis et al, 2014).…”