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Despite apparent need, many older people with cognitive impairment and/or mental health needs do not fully engage with social care. This can manifest in different ways, including passive or aggressive attempts to avoid or repel care workers. However, little is known about how to support such individuals in their own homes and deliver effective care. Against this background, we undertook a scoping review with a view to developing a preliminary theory of change suggesting how care might be modified to engage this client group. The most recent search was conducted on 21/04/21. Papers were included if they (i) focused on older people (65+) living at home with social care needs and (ii) described difficulties/problems with the provision/receipt of social care associated with individuals' mental health needs. Twenty-six citations were identified through electronic database searches and reference screening, and the results were charted according to key theory of change concepts (long-term outcomes, preconditions, interventions, rationale and assumptions). All the included papers were related to people with dementia. Four subgroups of papers were identified. The first highlights those external conditions that make it more likely an intervention will be successful; the second describes specific interventions to engage older people who by virtue of their mental health needs have not engaged with social care; the third explores what services can be done to increase service uptake by older people with mental health needs and their caregivers more generally; and the fourth details theoretical approaches to explaining the behaviour of people with dementia. Each provides information that could be used to inform care delivery and the development of interventions to improve engagement with health and social care for these individuals. The study concludes that different framing of engagement difficulties, such as that offered through positioning theory, may assist in future service design.

Although prisoners have significant care needs and are particularly vulnerable following release, there have been longstanding concerns about their social care. Among its provisions, the 2014 Care Act defined the responsibilities of local authorities for identifying and meeting the social care needs of prisoners. Here, we report the findings of a national survey of local authorities undertaken in 2016, which explored the early arrangements put in place following the Care Act for prisoners on release. Eighty-eight of 158 local authorities responded, including 81 per cent of those with prisons in their catchment area. Key themes included difficulties with case finding, with a reliance on referrals from other agencies, although provision for those already known to local authorities generally worked well. Other themes were difficulties in sharing assessments and information between local authorities, and problems with care planning and co-ordination with other agencies. We discuss some of the tensions and challenges inherent in implementing the Act and highlight areas requiring attention, including the need for more robust case finding and systems for information transfer. We also suggest measures to strengthen arrangements.

Older people with mental health needs and dementia often face difficulties with daily living and community participation, requiring the intervention of social care services. However, cognitive and emotional needs often mean that mainstream support is not appropriate. In England, mental health support workers may attempt to address these concerns, to prevent mounting care needs and the potential for institutional care. Yet, their work has not been researched to identify good practices and to understand the mechanisms through which they engage older people. A new qualitative study used semi-structured interviews and focus groups with specialist support workers (n = 22), managers (n = 7), homecare staff (n = 4) and service users and carers (n = 6). The latter group were interviewed by co-authors with lived experiences of dementia and care. Participants were recruited from mental health services, home care organisations and third-sector agencies across the North of England in 2020-2021. The study identified three themes that described support worker activities. First, 'building trusting relationships' identified steps to establish the foundations of later interventions. Paradoxically, these may involve misleading clients if this was necessary to overcome initial reluctance, such as by feigning a previous meeting. Second, 're-framing care' referred to how the provision of care was positioned within a narrative that made support easier to engage with. Care framed as reciprocal, as led by clients, and having a positive, non-threatening description would more likely be accepted. Third, 'building supportive networks' described how older people were enabled to draw upon other community resources and services. This required careful staging of support, joint visits alongside workers in other services, and recognition of social stigma. The study was limited by constrained samples and covid context requiring online data collection. The study recommends that support workers have more opportunity for sharing good practice across team boundaries, and improved access to specialist training.

Background Emerging evidence suggests that the COVID-19 pandemic has been accompanied by increased rates of depression and social isolation. However, we do not yet understand how the COVID-19 pandemic has affected the psychosocial health of people with spinal cord injury (PwSCI), a population that is already at risk of experiencing mental health conditions. Objectives The aims of the study were to (1) examine the impact of the pandemic on the psychosocial health of PwSCI and (2) investigate the experiences of PwSCI and resources they reported needing during the peak of the pandemic. Methods A cross-sectional survey with closed- and open-ended questions was administered to 51 PwSCI. Participants were included if they had an SCI, were 18 years or older, lived in St. Louis, Missouri, and surrounding areas, and understood English. Results Canonical correlation showed a significant association between financial security, food insecurity, and personal assistance service use and adverse psychosocial health outcomes (p < .001). Participants reported interest in resources related to COVID-19 precautions for wheelchair users as well as home exercise programming and financial assistance with utilities. Finally, qualitative analysis revealed four major themes: (1) mental health during the pandemic, (2) financial concerns and reduced access to personal assistance services, (3) feelings of social isolation prior to the pandemic, and (4) local and national authorities’ handling of the pandemic. Conclusion PwSCI are impacted by the COVID-19 pandemic and reported a variety of resource needs. These findings may inform service providers, support systems, and organizations to better support PwSCI during times of crisis.

AIM To synthesize evidence on the ability of specialist care home support services to prevent hospital admission of older care home residents, including at end of life. DESIGN Systematic review, without meta-analysis, with vote counting based on direction of effect. DATA SOURCES Fourteen electronic databases were searched from January 2010 to January 2019. Reference lists of identified reviews, study protocols and included documents were scrutinized for further studies. REVIEW METHODS Papers on the provision of specialist care home support that addressed older, long-term care home residents' physical health needs and provided comparative data on hospital admissions were included. Two reviewers undertook study selection and quality appraisal independently. Vote counting by direction of effect and binomial tests determined service effectiveness. RESULTS Electronic searches identified 79 relevant references. Combined with 19 citations from an earlier review, this gave 98 individual references relating to 92 studies. Most were from the UK (22), USA (22) and Australia (19). Twenty studies were randomized controlled trials and six clinical controlled trials. The review suggested interventions addressing residents' general health needs (p

Summary In light of longstanding concern about the lack of social care in prisons, the 2014 Care Act made local authorities in England responsible for identifying, assessing and meeting prisoners’ social care needs. However, service planning is difficult, for little is known about the level of demand or the extent to which the needs of older and younger prisoners differ. Against this background, face-to-face interviews (including screens for social care needs, substance misuse and mental health problems) were undertaken with a sample of male prisoners in North-West England. Findings Three hundred and ninety-nine participants were aged 18–49 and 80 aged 50 plus. Overall, more than a 10th of participants had problems maintaining personal hygiene, dressing and/or getting around the prison safely; a significant minority lacked meaningful occupation; and approaching a sixth acknowledged problems forming/maintaining relationships. Older prisoners were significantly more likely than younger prisoners to need help with personal hygiene, dressing and moving around safely and to identify problems with their physical health and memory. Applications The findings highlight the substantial number of older prisoners who could potentially benefit from some form of social care and support if they are to maintain their safety and dignity and make best use of their time in prison. They also underline the need to develop suitable screening and assessment tools for older prisoners, and for further research on the best service models for prisoners requiring intimate personal care.

Talking about death and end-of-life care (EoLC) can be a sensitive topic for people affected by dementia and their families. However, recent research [1] has identified the need for people living with dementia (PLwD) to start planning timely discussions about their future care to help their family and professional carers to confidently make decisions on their behalf when they are no longer able to do so themselves [2]. This paper describes a five-stage iterative co-design approach aimed at understanding the type and nature of these sensitive discussions and developing a resource to support PLwD, their families and carers. The resource took the form of a Care Plan Guide app, as a tool to help initiate early discussions about anticipatory care planning [3] in dementia for PLwD to ensure good personalized care and that important wishes were honoured. The paper highlights the importance of the involvement and active collaboration of families living with the illness. It discusses lessons learned, reflections and recommendations for approaching co-designing healthcare digital resources for sensitive EoLC issues that may have wider applications than for PLwD alone.

BackgroundIn the UK, most people with dementia die in the community and they often receive poorer end-of-life care than people with cancer.ObjectiveThe overall aim of this programme was to support professionals to deliver good-quality, community-based care towards, and at, the end of life for people living with dementia and their families.DesignThe Supporting Excellence in End-of-life care in Dementia (SEED) programme comprised six interlinked workstreams. Workstream 1 examined existing guidance and outcome measures using systematic reviews, identified good practice through a national e-survey and explored outcomes of end-of-life care valued by people with dementia and family carers (n = 57) using a Q-sort study. Workstream 2 explored good-quality end-of-life care in dementia from the perspectives of a range of stakeholders using qualitative methods (119 interviews, 12 focus groups and 256 observation hours). Using data from workstreams 1 and 2, workstream 3 used co-design methods with key stakeholders to develop the SEED intervention. Worksteam 4 was a pilot study of the SEED intervention with an embedded process evaluation. Using a cluster design, we assessed the feasibility and acceptability of recruitment and retention, outcome measures and our intervention. Four general practices were recruited in North East England: two were allocated to the intervention and two provided usual care. Patient recruitment was via general practitioner dementia registers. Outcome data were collected at baseline, 4, 8 and 12 months. Workstream 5 involved economic modelling studies that assessed the potential value of the SEED intervention using a contingent valuation survey of the general public (n = 1002). These data informed an economic decision model to explore how the SEED intervention might influence care. Results of the model were presented in terms of the costs and consequences (e.g. hospitalisations) and, using the contingent valuation data, a cost–benefit analysis. Workstream 6 examined commissioning of end-of-life care in dementia through a narrative review of policy and practice literature, combined with indepth interviews with a national sample of service commissioners (n = 20).SettingThe workstream 1 survey and workstream 2 included services throughout England. The workstream 1 Q-sort study and workstream 4 pilot trial took place in North East England. For workstream 4, four general practices were recruited; two received the intervention and two provided usual care.ResultsCurrently, dementia care and end-of-life care are commissioned separately, with commissioners receiving little formal guidance and training. Examples of good practice rely on non-recurrent funding and leadership from an interested clinician. Seven key components are required for good end-of-life care in dementia: timely planning discussions, recognising end of life and providing supportive care, co-ordinating care, effective working with primary care, managing hospitalisation, continuing care after death, and valuing staff and ongoing learning. Using co-design methods and the theory of change, the seven components were operationalised as a primary care-based, dementia nurse specialist intervention, with a care resource kit to help the dementia nurse specialist improve the knowledge of family and professional carers. The SEED intervention proved feasible and acceptable to all stakeholders, and being located in the general practice was considered beneficial. None of the outcome measures was suitable as the primary outcome for a future trial. The contingent valuation showed that the SEED intervention was valued, with a wider package of care valued more than selected features in isolation. The SEED intervention is unlikely to reduce costs, but this may be offset by the value placed on the SEED intervention by the general public.LimitationsThe biggest challenge to the successful delivery and completion of this research programme was translating the ‘theoretical’ complex intervention into practice in an ever-changing policy and service landscape at national and local levels. A major limitation for a future trial is the lack of a valid and relevant primary outcome measure to evaluate the effectiveness of a complex intervention that influences outcomes for both individuals and systems.ConclusionsAlthough the dementia nurse specialist intervention was acceptable, feasible and integrated well with existing care, it is unlikely to reduce costs of care; however, it was highly valued by all stakeholders (professionals, people with dementia and their families) and has the potential to influence outcomes at both an individual and a systems level.Future workThere is no plan to progress to a full randomised controlled trial of the SEED intervention in its current form. In view of new National Institute for Health and Care Excellence dementia guidance, which now recommends a care co-ordinator for all people with dementia, the feasibility of providing the SEED intervention throughout the illness trajectory should be explored. Appropriate outcome measures to evaluate the effectiveness of such a complex intervention are needed urgently.Trial registrationCurrent Controlled Trials ISRCTN21390601.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. 8, No. 8. See the NIHR Journals Library website for further project information.

OBJECTIVE: Integrated community mental health teams (CMHTs) are a key component of specialist old age psychiatry services internationally. However, in England, significant shifts in policy, including a focus on dementia and age inclusive services, have influenced provision. This study portrays teams in 2009 against which subsequent service provision may be compared.METHODS: A bespoke national postal survey of CMHT managers collected data on teams' structure, composition, organisation, working practices, case management, and liaison activities.RESULTS: A total of 376 CMHTs (88%) responded. Teams comprised a widespread of disciplines. However, just 28% contained the full complement of professionals recommended by government policy. Over 93% of teams had a single point of access, but some GPs bypassed this, and 40% of teams did not accept direct referrals from care homes. Initial assessments were undertaken by multiple disciplines, and 71% of teams used common assessment documentation. Nevertheless, many social workers maintained both NHS and local authority records. In 92% of teams, nominated care coordinators oversaw the support provided by other team members. However, inter-agency care coordination was less prevalent. Few teams offered the range of outreach/liaison activities anticipated in the national dementia strategy.CONCLUSIONS: Compared with previous studies, teams had grown and changed, with a clear increase in non-medical practitioners, particularly support workers. Measures to facilitate integrated care within CMHTs (eg, common access and documentation) were widespread, but integration across health and social care/primary and secondary services was less developed. Consideration of barriers to further integration, and the impact of current reforms is potentially fruitful.

Objective This study examined the nature, extent and perceived quality of the support provided by community mental health teams for older people (CMHTsOP) to care home residents. Methods A postal survey was sent to all CMHTsOP in England. Information was collected about teams' staffing and their involvement in case finding, assessment, medication reviews, care planning and training as well as team managers' rating of the perceived quality of the service they provided for care home residents. Data were analysed using chi-squared tests of association and ordinal regression. Results Responses were received from 225 (54%) CMHTsOP. Only 18 per cent of these teams contained staff with allocated time for care home work. Services for care home residents varied considerably between teams. Two-fifths of teams provided formal training to care home staff. Team managers were more likely to perceive the quality of their service to care homes as good if they had a systematic process in place for reviewing antipsychotic drugs or routine mental health reviews, including contact with a GP. Conclusion The findings suggested that more evidence is needed on the best approach for supporting care home residents with mental health needs. Areas to consider are the potential benefits of training to care home staff and regular mental health reviews, utilising links between GPs and CMHTsOP. Copyright © 2017 John Wiley & Sons, Ltd.

Context: Support workers play an essential role in multidisciplinary community mental health teams for older people (CMHTsOP) in England. However, little is known about how they perceive their role or the impact this has on their levels of stress, wellbeing and job satisfaction.Objectives: To compare CMHTsOP support workers’ perceptions of the psychosocial characteristics of their work with those of registered CMHTsOP practitioners.Methods: A postal survey of CMHTsOP staff in nine mental health trusts. Information was collected about job demands, controls and support using the Job Content Questionnaire. Additional data was collected on other psychosocial features of CMHTsOP working using job satisfaction and intention-to-quit measures and a set of bespoke statements which were supplemented by a subset from the Occupational Stress Indicator.Findings: Responses were received from 43 support workers and 166 registered practitioners. Support workers reported significantly lower job demands and better co-worker support than registered practitioners. They were also significantly more satisfied with their jobs and more likely to believe that their skills and strengths were used appropriately. The majority of both groups were positive about their team’s climate and their value and identity within it.Limitations: Although the study explored the psychosocial characteristics of work that contribute to wellbeing, it did not directly measure stress.Implications: Given the growing number of CMHTsOP support workers and their diverse roles, future research might usefully explore the specific tasks which contribute most to individual satisfaction and wellbeing.

The study sought to identify the variables associated with increased length of stay on old age psychiatry inpatient wards. It also explored the factors related to delayed discharge and the likelihood of patients admitted from home returning there. : Data were collected on the sociodemographic, clinical and service receipt characteristics of a 6-month series of admissions to seven wards in England in 2010/2011. The cohort was followed for a 9- to 11-month period. The relationship between patients' status on admission and the specified outcome variables was explored. : Information was collected on 216 admissions, of whom 165 were discharged in the study period. Mean length of stay was 64 days. Female gender, higher dependency, greater challenging behaviour and locality predicted extended stay. Forty per cent of cases experienced delayed discharge. Better physical health, more cognitive impairment, receipt of social care and locality were associated with delayed discharge. The vast majority of patients admitted from home returned there. Younger patients and patients with less dependency, cognitive impairment and challenging behaviour had a higher likelihood of returning home. Patients receiving social care or admitted because of carer stress, a risk of self-neglect, accidental self-harm or abuse/exploitation were less likely to return home. : The study provides a useful starting point for identifying cases on which future efforts to improve inpatient outcomes might centre and suggests local rather than national responses may be needed. It also highlights an urgent need for a national focus on the scope, purpose and effectiveness of acute inpatient care. Copyright © 2016 John Wiley & Sons, Ltd.

To synthesize the evidence relating to the ability of specialist care home support services to prevent the hospital admission of older care home residents, including hospital admission at the end-of-life. Design: Systematic review and narrative synthesis. Methods: Ten electronic databases will be searched from 2010 to 31st December, 2018 using pre-determined search terms. All studies of specialist healthcare services to meet care home residents’ physical healthcare needs which provide outcome data on hospital admission or place of death compared with usual care will be included. Two reviewers will independently assess studies’ eligibility and methodological quality using the Effective Public Health Practice Project Quality Assessment Tool. Data will be extracted by one reviewer and checked by a second according to pre-determined categories. Data will be synthesized in evidence tables and narrative. Funder: National Institute for Health Research School for Social Care Research, November 2016. Discussion: Care of older people within care home settings is a key aspect of nursing nationally and internationally. This review will increase understanding of the extent to which different models of specialist healthcare support for care homes are associated with key resident outcomes. Impact: Standard healthcare support for care home residents is often inadequate, resulting in avoidable hospital admissions and lack of resident choice as to place of death. Although a range of specialist healthcare services are emerging, little is known about their relative effectiveness. This paper marshalls evidence of relevance to commissioners investing in healthcare provision to care homes to meet NHS targets. Keywords: Long-term care facilities; nursing homes; care homes; older people; systematic review; specialist health services; place of death; hospital admissions; outcomes

Aim:To identify discrete approaches to specialist healthcare support for older care home residents in the UK and to estimate their prevalence.Background:Internationally, a range of new initiatives are emerging to meet the multiple and complex healthcare needs of care home residents. However, little is known about their relative effectiveness and, given their heterogeneity, a classification scheme is required to enable research staff to explore this.Method:A UK survey collected information on the funding, age, coverage, aims, staffing and activities of 64 specialist care home support services. Latent class analysis (LCA) was used to allocate the sample into subgroups with similar characteristics.Findings:Three classes were identified. Class 1 (55% of sample) contained services with a high probability of providing scheduled input (regular preplanned visits) and support for all residents and a moderate probability of undertaking medication management, but a low probability of training care home staff (‘predominantly direct care’). Class 2 (23% of sample) had a moderate/high probability of providing scheduled input, support for all residents, medication management and training (‘direct and indirect care’). Class 3 (22% of sample) had a low probability of providing scheduled input, support for all residents and medication management, but a high probability of providing training for care home staff (‘predominantly indirect care’). Consultants were more likely to be members of services in Class 1 than Class 2, and Class 2 than Class 3.Conclusions:LCA offers a promising approach to the creation of a taxonomy of specialist care home support services. The skills and knowledge required by healthcare staff vary between classes, raising important issues for service design. The proposed classification can be used to explore the extent to which different organisational forms are associated with better resident, process and service outcomes.

Despite an obvious and growing need, there has historically been scant provision of social care and social work in prisons. Thus although the 2014 Care Act gave local authorities in England responsibility for identifying, assessing and meeting adult prisoners’ social care needs, little was known about the number of prisoners eligible for support, the extent of their needs or how best to meet them. Against this background, this paper reports the findings of two national surveys of local authority managers undertaken in 2016 which found that upwards of 1,800 prisoners with social care needs were identified in the first year, of whom almost 1,600 received an assessment and approaching 800 were deemed eligible for the provision of care and support. Whilst specialist social care staff (primarily social workers) were widely engaged in prisoner assessments, many local authorities had delegated their responsibility for identifying prisoners with social care needs to prison healthcare staff, and there was considerable variation in the way that social care and support were delivered. A number of implications for social work practice and research were identified, including a need for greater active case finding and further evaluation of the impact of the emerging arrangements on prisoners’ outcomes.

Purpose A growing ageing population with complex healthcare needs is a challenge to the organisation of healthcare support for older people residing in care homes. The lack of specialised healthcare support for care home residents has resulted in poorer outcomes, compared with community-dwelling older people. However, little is known about the forms, staff mix, organisation and delivery of such services for residents’ physical healthcare needs. The paper aims to discuss these issues. Design/methodology/approach This systematic review, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, aimed to provide an overview of the range of healthcare services delivered to care homes and to identify core features of variation in their organisation, activities and responsibilities. The eligibility criteria for studies were services designed to address the physical healthcare needs of older people, permanently residing in care homes, with or without nursing. To search the literature, terms relating to care homes, healthcare and older people, across ten electronic databases were used. The quality of service descriptions was appraised using a rating tool designed for the study. The evidence was synthesised, by means of a narrative summary, according to key areas of variation, into models of healthcare support with examples of their relative effectiveness. Findings In total, 84 studies, covering 74 interventions, identified a diverse range of specialist healthcare support services, suggesting a wide variety of ways of delivering healthcare support to care homes. These fell within five models: assessment – no consultant; assessment with consultant; assessment/management – no consultant; assessment/management with consultant; and training and support. The predominant model offered a combination of assessment and management. Overall, there was a lack of detail in the data, making judgements of relative effectiveness difficult. Recommendations for future research include the need for clearer descriptions of interventions and particularly of data on resident-level costs and effectiveness, as well as better explanations of how services are implemented (review registration: PROSPERO CRD42017081161). Originality/value There is considerable debate about the best means of providing healthcare to older people in care homes. A number of specialist initiatives have developed and this review seeks to bring these together in a comparative approach deriving models of care of value to policy makers and commissioners.

© The Author(s) 2017. Extra care housing facilities in the UK are intended to offer a community-based alternative to care home placement. However, little is known about staff’s views of the appropriateness of extra care housing for people with dementia. This paper describes a mixed-methods study which explored this issue using statistical modelling of frontline staff’s recommendations of the best care setting for care home entrants; thematic analysis of transcripts from a simulated Resource Allocation Management Panel meeting; and content analysis of care coordinators’ reasons for not considering extra care housing in actual care home applications. Frontline practitioners saw extra care housing as a valuable alternative for a significant minority of care home entrants. However, extra care housing was not recommended if people needed care at night. Social care managers expressed general support for the idea of extra care housing, but appeared overwhelmingly focused on maintaining people at home and unsure where in the care pathway extra care housing sat. More evidence is needed on whether extra care housing can be an alternative to care homes and how services should be arranged to meet the needs of people living in extra care housing.

Aims To investigate the extent of variability in individuals' and multidisciplinary groups' decisions about the most appropriate setting in which to support people with dementia in different European countries. BackgroundProfessionals' views of appropriate care depend on care systems, cultural background and professional discipline. It is not known to what extent decisions made by individual experts and multidisciplinary groups coincide. DesignA modified nominal group approach was employed in eight countries (Estonia, Finland, France, Germany, the Netherlands, Spain, Sweden and the UK) as part of the RightTimePlaceCare Project. MethodsDetailed vignettes about 14 typical case types of people with dementia were presented to experts in dementia care (n=161) during November and December 2012. First, experts recorded their personal judgements about the most appropriate settings (home care, assisted living, care home, nursing home) in which to support each of the depicted individuals. Second, participants worked in small groups to reach joint decisions for the same vignettes. ResultsConsiderable variation was seen in individuals' recommendations for more than half the case types. Cognitive impairment, functional dependency, living situation and caregiver burden did not differentiate between case types generating high and low degrees of consensus. Group-based decisions were more consistent, but country-specific patterns remained. ConclusionsA multidisciplinary approach would standardize the decisions made about the care needed by people with dementia on the cusp of care home admission. The results suggest that certain individuals could be appropriately diverted from care home entry if suitable community services were available.

Objectives: To explore associations between carer burden and characteristics of (1) the informal carer, (2) the person with dementia, and (3) the care support network in 8 European countries.Design: Cross-sectional study.Setting: People with dementia judged at risk of admission to long-term care (LTC) facilities in 8 European countries (Estonia, Finland, France, Germany, Netherlands, Spain, Sweden, United Kingdom).Participants: A total of 1223 people with dementia supported by community services at home or receiving day care or respite care and their informal carers.Measurements: Variables regarding the informal carer included familial relationship and living situation. Variables relating to the person with dementia included cognitive functioning (S-MMSE), neuropsychiatric symptoms (NPI-Q), depressive symptoms (Cornell depression scale), comorbidity (Charlson Comorbidity Index), and physical functioning (Katz Activity of Daily Living [ADL] Index). The care support network was measured using hours of caregiving (ADLs, instrumental ADLs [IADLs], supervision), additional informal care support, and service receipt (home care, day care). Experience of carer burden was recorded using the Zarit Burden Interview. Logistic regression analysis was used to determine factors associated with high carer burden.Results: Carer burden was highest in Estonia (mean 39.7/88) and lowest in the Netherlands (mean 26.5/88). High burden was significantly associated with characteristics of the informal carer (family relationship, specifically wives or daughters), of the person with dementia (physical dependency in ADLs; neuropsychiatric symptoms, in particular night time behaviors and irritability), the care support network (hours of caregiving supervision; receipt of other informal care support) and country of residence.Conclusion: A range of factors are associated with burden in informal carers of people with dementia judged to be on the margins of LTC. Support for informal carers needs to take account of gender differences. The dual challenges of distressed behaviors and difficulties in ADLs by the person with dementia may be addressed by specific nonpharmacological interventions focusing on both elements. The potential protective effect of additional informal support to carers highlights the importance of peer support or better targeted home support services. The implementation of appropriate and tailored interventions to reduce burden by supporting informal carers may enable people with dementia to remain at home for longer. (C) 2017 AMDA - The Society for Post-Acute and Long-Term Care Medicine.

Purpose – The purpose of this paper is to identify features of community mental health teams (CMHTs) for older people valued by their managers, and those they would most like to change. Design/methodology/approach – Content analysis was used to analyse “free text” responses to open questions from a national survey about CMHTs’ organisational structures and processes. Responses were sorted into statements which were categorised into content areas and higher level dimensions. Findings – Free text information was provided by 376 teams (an 88 per cent response rate). Eight higher level dimensions were identified. One related specifically to integration with social care services, whilst several more included material about other aspects of intra-team integration (e.g. documentation and location). The largest proportion of statements related to staffing and teamwork. Statements about inter-personal and inter-professional issues were largely positive, whilst statements about resources, bureaucracy and integration with social care services typically detailed desired changes. Practical implications – Four key issues emerged comprising a high level of support from managers to develop integrated practices; a need to define the focus of CMHTs for older people and to be fully resourced; and the importance of a nurturing and supportive team environment. Originality/value – The methodology provides a bridge between qualitative and quantitative research, exploring the volume of statements on particular topics and their meaning.

Social workers have worked with older people with mental ill health in multidisciplinary teams for many years. Research regarding their contribution is nevertheless sparse. This article addresses this gap. Qualitative data from semi-structured staff interviews were drawn from a multiple case study of community mental health teams (CMHTs) for older people, some with and others without social worker members. Interviews included questions about team roles and the impact of the presence or absence of social workers on team functioning. A grounded theory approach was adopted to analyse the data, enabling issues of importance to interviewees to emerge. Non-social work CMHT staff were found to place a high value on social worker team membership due to their specific skills, knowledge and values, and with regard to communication pathways. Social workers and other team members' views were found to differ regarding whether social workers within CMHTs should operate as generalists or specialists. The findings suggest the need for formal structures extending beyond the co-location of multidisciplinary staff; appropriate and sufficient supervision for social work team members; and the development of more workable and direct referral systems between CMHTs and social services adult social work teams.

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. Copyright © 2014 John Wiley & Sons, Ltd. Language: en

Objective The objective of this study is to identify the extent of outreach activity community mental health teams (CMHTs) for older people provide to mainstream services in light of the recommendations of the National Dementia Strategy. In particular, to determine the range of settings in receipt of support; to specify the form of this activity; to identify the professionals involved; and to explore the factors associated with the provision of such support. Methods A self-administered postal questionnaire was sent to all CMHTs in England. The reported arrangements were categorised and reviewed according to a taxonomy of outreach developed from the literature. Results Three hundred and seventy six (88%) of the CMHTs responded. Although nearly all teams undertook some outreach work, much of this was informal in nature. Nevertheless, the vast majority of teams had some formal outreach arrangements in at least one mainstream setting. Just less than three-quarters provided support (most typically education) to care homes, approaching half centres to day centres, and over a third to primary care practices, social services teams, home care providers and general hospitals, respectively. Link workers were the favoured means of supporting general hospital staff. Community mental health nurses were most commonly involved in providing outreach, and larger teams were more likely than smaller teams to have formalised arrangements. A significant minority of teams expressed concerns about their capacity to provide effective services. Conclusions The findings suggest that both more resources and more evidence will be needed to meet the National Dementia Strategy's aim of improving care for older people with mental health problems in mainstream settings. Copyright © 2013 John Wiley & Sons, Ltd.

This study examined the nature, extent and perceived quality of the support provided by community mental health teams for older people (CMHTsOP) to care home residents.A postal survey was sent to all CMHTsOP in England. Information was collected about teams' staffing and their involvement in case finding, assessment, medication reviews, care planning and training as well as team managers' rating of the perceived quality of the service they provided for care home residents. Data were analysed using chi-squared tests of association and ordinal regression.Responses were received from 225 (54%) CMHTsOP. Only 18 per cent of these teams contained staff with allocated time for care home work. Services for care home residents varied considerably between teams. Two-fifths of teams provided formal training to care home staff. Team managers were more likely to perceive the quality of their service to care homes as good if they had a systematic process in place for reviewing antipsychotic drugs or routine mental health reviews, including contact with a GP.The findings suggested that more evidence is needed on the best approach for supporting care home residents with mental health needs. Areas to consider are the potential benefits of training to care home staff and regular mental health reviews, utilising links between GPs and CMHTsOP. Copyright © 2017 John WileySons, Ltd.

Introduction: This English study is the first to focus on the contribution of occupational therapists to the work of community mental health teams for older people. Method: A mixed methods study comprising: a national survey of community mental health team managers, caseload audit, qualitative interviews, and a practitioner survey; provided information on team membership and functions, user characteristics, accounts of occupational therapists’ roles and experiences, and work characteristics. Findings: Occupational therapists worked mainly with people with dementia and were involved in both generic and specialist tasks, with the latter focusing largely on maintaining functionality. They had found ways to balance their roles for the benefit of the team without loss of professional identity. Some differences of opinion between clinical leads and occupational therapists were reported. Stress levels among occupational therapists were similar to those of professional colleagues.Conclusion: Some findings contrast with earlier studies of community mental health teams for working age adults, offering new insights into the nature of the occupational therapists’ experience. To ensure that occupational therapists in these settings are able to contribute effectively, a shared understanding of their role is required between them and their clinical leads.

Aims The aim of this study was to explore the support worker functions in community mental health teams for older adults in relation to roles, boundaries, supervision and training. Background Support workers in community mental health teams provide important help to older people with complex mental and physical health needs in their own homes. Their numbers have grown substantially in recent years, but without professional registration there is concern that boundaries with qualified practitioners are insufficiently clear and that they do not receive the support they require. Design Qualitative research using interview data and thematic framework analysis investigated support workers’ and registered practitioners’ perspectives on roles, boundaries, supervision and training. Methods Semi-structured face-to-face interviews were undertaken in 2011, with 42 members of nine teams spread across England, including support workers and community mental health nurses. Coding of transcribed audio-recordings and subsequent analysis was undertaken by four researchers. Results Support workers undertook diverse roles and had considerable autonomy over their duties. Participants agreed about what tasks support workers should not undertake, yet there was evidence of ‘negotiated’ boundaries and examples of these being breached. Lines of authority were complex, yet support workers were supported through open communication with the wider team. Training was problematic, with few courses tailored for support workers and efforts towards formal qualification hindered by low pay and time pressures. Conclusion Local and national attention is needed to prevent ‘drift’ into activities that both support workers and registered practitioners consider outside their remit. Barriers to training and further qualification need to be addressed.

The strategic allocation of resources is one the most difficult tasks facing health and social care decision makers, with multiple organisations delivering complex services to heterogeneous populations. The enduring appeal of the balance of care approach, a systematic framework for exploring the potential costs and consequences of changing the mix of community and institutional services in a defined geographical area, is thus unsurprising. However, no attempt has previously been made to synthesise or appraise the methodological approaches employed and lessons to inform future applications may go unheard. This paper seeks to address those concerns by reporting the findings of a systematic literature review that identified 33 examples of the model's use spanning 40 years. The majority of studies were undertaken in the UK and explored the services needed by frail older people. There is, however, nothing in the model to restrict it to this context. The paper also details the different ways key elements of the model (information about clients, resources, the appraisal of settings, costs and outcomes) have been operationalised, and considers their strengths and weaknesses. Whilst several studies identified a potential to reduce costs via the use of less institutional care, not all applications predicted cost savings.

Managing the physical healthcare needs of care home residents presents a considerable challenge to national healthcare systems. A range of local, specialist support initiatives are emerging to address this. A study is being conducted to identify what services are being provided, how they are organised and delivered, and the relative worth of each care model. Preliminary findings indicate that forms of specialist healthcare support for care homes range from enhanced primary care services to multidisciplinary support teams. These initiatives present challenges and opportunities for staff. The roles of nurses in care homes and specialist services will change as they establish new ways of working, extend their responsibilities and enhance their skills. These services can help nurses provide high quality care to residents. Gaps in the evidence base for dedicated healthcare support services can be addressed through this study and further research planned.

Prevention, comprising services that seek to delay deterioration of existing conditions and circumstances or prevent their occurrence by early access to support, is recognised as having an important role in adult social care. The gateway to social care services has traditionally been via needs-led assessments undertaken with professionals. In England, self-assessment, promoted as a means of accessing services more independently, has come to the fore in recent years. This article explores the relationship between prevention and self-assessment in practice. Data are derived from interviews with social services managers of five self-assessment projects situated within the adult social care sector that were described as providing a preventative approach, as well as project developmentdocumentation. A number of issues are highlighted including for whom self-assessment might be most optimal, the potential of self-assessment to widen access and the role it can play in promoting self-determination. It is argued that a natural relationship exists between self-assessment and prevention and that both concepts are at the core of the personalisation agenda. However, in order to achieve its potential in practice, self-assessment must be offered in conjunction with support and as an additional rather than alternative means of accessing preventative services.

• Summary: Self-assessment is one of a range of new practices within adult social care, aimed at increasing the choices available to service users in relation to both the assessment process and the way services are delivered. By analysing the results of both project documentation and interviews with managers of pilot projects set up to test out this approach, this article examines issues relating to the introduction of a new initiative within a social care setting and considers whether the introduction of self-assessment poses particular challenges for care management. • Findings: The interviews revealed a mix of general as well as setting and process specific findings. The latter included the importance of the appropriate targeting of self-assessment and the need to reach a clear consensus within the service as to what self-assessment means and how it should be incorporated into an individualized model of practice. Other findings reflected issues highlighted in the literature on the management of change. • Applications: Together the results provide useful lessons for those interested in both the specific area of study and, more generally, the implementation of new initiatives in social care.

Purpose – The purpose of this paper is to raise issues around the involvement of clinicians relevant to current policies for integrated care by reviewing a previous policy to integrate assessments.Design/methodology/approach – This paper is a review of data from a survey of specialist clinicians' involvement in the single assessment process for older people.Findings – The paper finds that clinician involvement was limited, with assessments not changing to a discernable degree and little involvement of older people. Changes to assessment were predominantly related to paperwork. However, the use of standardised tools by clinicians did increase. The use of shared record systems with social services was significantly associated with involvement.Practical implications – Clinicians have previously not been engaged in policies around integrated assessments. Factors that can help engagement include development of a shared vision, drawing on the traditions of particular groups of clinicians in informing integrated...

Introduction: The Government plans to transform adult social care in England. Future services will place more emphasis on prevention and enablement, and promoting personalisation and choice. Self-assessment is one possible facilitator of this agenda. However, little is known about its utility in social care. This evaluation examined how eight local authorities employed self-assessment in the provision of community equipment and adaptations, and explored the implications for service delivery. Method: A multiple case study was employed, using a mixed methods approach. This drew on internal documents, management interviews, and service user and administrative records. Findings: Self-assessment was primarily used to facilitate service access. Although the authorities differed in the way in which they operationalised self-assessment, professional staff were almost always involved. The differences between people receiving self and traditional assessments were modest, but the people undertaking self-assessments in preventative services formed a particularly healthy subgroup. There was little consensus about the items suitable for provision through self-assessment. Conclusion: The concept of self-assessment was variously interpreted and not all its possible uses were explored. Nevertheless, the evaluation suggested that self-assessment can facilitate access to community equipment and adaptations and has the potential to extend the population traditionally served by social care services, thereby addressing the preventative agenda.

© 2016 The Authors. International Journal of Geriatric Psychiatry published by John Wiley & Sons, Ltd. Objectives: To evaluate the association between the degree of integration in community mental health teams (CMHTs) and: (i) the costs of service provision; (ii) rates of mental health inpatient and care home admission. Methods: An observational study of service use and admissions to institutional care was undertaken for a prospectively-sampled cohort of patients from eight CMHTs in England. Teams were chosen to represent ‘high’ or ‘low’ levels of integrated working practice and patients were followed-up for seven months. General linear models were used to estimate service costs and the likelihood of institutional admission. Results: Patients supported by high integration teams received services costing an estimated 44% more than comparable patients in low integration teams. However, after controlling for case mix, no significant differences were found in the likelihood of admission to mental health inpatient wards or care homes between team types. Conclusions: Integrated mental health and social care teams appeared to facilitate greater access to community care services, but no consequent association was found with community tenure. Further research is required to identify the necessary and sufficient components of integrated community mental health care, and its effect on a wider range of outcomes using patient-reported measures. © 2016 The Authors. International Journal of Geriatric Psychiatry published by John Wiley & Sons, Ltd.

Objectives: To examine whether the mix of community and institutional long-term care (ILTC) for people with dementia (PwD) in Europe could be improved; assess the economic consequences of providing alternative services for particular groups of ILTC entrants and explore the transnational application of the Balance of Care' (BoC) approach.Method: A BoC study was undertaken in Estonia, Finland, France, Germany, the Netherlands, Spain, Sweden, and the UK as part of the RightTimePlaceCare project. Drawing on information about 2014 PwD on the margins of ILTC admission, this strategic planning framework identified people whose needs could be met in more than one setting, and compared the relative costs of the possible alternatives.Results: The findings suggest a noteworthy minority of ILTC entrants could be more appropriately supported in the community if enhanced services were available. This would not necessarily require innovative services, but more standard care (including personal and day care), assuming quality was ensured. Potential cost savings were identified in all countries, but community care was not always cheaper than ILTC and the ability to release resources varied between nations.Conclusions: This is believed to be the first transnational application of the BoC approach, and demonstrates its potential to provide a consistent approach to planning across different health and social care systems. Better comparative information is needed on the number of ILTC entrants with dementia, unit costs and outcomes. Nevertheless, the findings offer important evidence on the appropriateness of current provision, and the opportunity to learn from different countries' experience.

Objective: to compare liaison psychiatric nursing with usual medical care in the management of older medical inpatients who screen positive for depression. Design: pragmatic randomised controlled trial. Setting: medical wards of UK district general hospital in rural East Anglia. Participants: one hundred and thirty-eight medical inpatients aged 65+ screened positive on the 15-item geriatric depression scale (GDS). One hundred and twenty-one out of 138 screen positives entered the trial (58/121 fulfilled criteria for depressive disorder at baseline). Interventions: (i) A liaison psychiatric nurse assessed participants, formulated a care plan for treatment of their depression, ensured its implementation through liaison with appropriate agencies, and monitored participants' mood and response to treatment for up to 12 weeks. (ii) Usual treatment by hospital and primary care staff. Main outcome measures: ICD-10 depressive disorder, change in GDS-15 score, quality-adjusted life weeks (QALWs) and patient satisfaction rating. Results: eighty-six out of 121 participants completed the 16-week trial. Participants in the intervention group were more satisfied with their care, but no significant differences in depressive disorder, depression rating or QALWs gained were found between groups. However, there was a trend towards improvement in the intervention group and effect sizes were higher in the subgroup with depressive disorder. Conclusions: this study is the first RCT to evaluate liaison psychiatric nursing specifically for depression in older medical inpatients; the findings suggest improvement in mental health and quality of life, but a larger trial is required to provide convincing evidence. © The Author 2007. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved.