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Biomedical subjects

David Challis

Publications and source records attributed to David Challis.

18 recordsLinked to original sources
PubMed2007

Old age mental health services in England: implementing the National Service Framework for Older People.

BACKGROUND: There is much variation in the services provided for older people with mental health problems. In England, the National Service Framework for Older People (NSFOP) sought to address these inconsistencies and improve care. This study describes the situation three years after its publication. METHODS: A postal survey of old age psychiatrists collected data on the NSFOP mental health model: the range of specialist mental health provision, the nature of the specialist:generic service interface and the degree of interdisciplinary/interagency working. RESULTS: Three hundred and eighteen (72%) consultants responded. Considerable differences existed in the deployment of key professionals within community teams, with more than a third lacking ring-fenced social work time. Few services had dedicated rehabilitation beds and nearly a third lacked separate facilities for people with organic and functional illnesses. Increasing numbers of consultants had access to a memory clinic and there was some suggestion that liaison services were developing, but little indication of increased support for care homes. Several services had yet to agree protocols with primary care, or to implement measures promoting effective information-sharing and integrated care, and there was little evidence that the introduction of the Single Assessment Process (SAP) had significantly changed practice. Although just over half of consultants reported that mental health services were improving, less than a quarter considered community provision adequate. CONCLUSIONS: Three years after the publication of the NSFOP there remained significant gaps in services for older people with mental health problems and substantial variation in provision between districts.

Aged↗
PubMed2006

Integrated specialist assessment of older people and predictors of care-home admission.

BACKGROUND: Effective community-based care for older people requires the integration of assessment approaches by old age psychiatry, geriatric medicine and social services care management. This study examines the value of such collaboration in the assessment of older people at risk of entering care homes. METHOD: A randomized controlled trial of integrated assessment (care management with additional clinical assessment by old age psychiatrist or geriatrician) versus care management assessment only, for older people at risk of care-home admission. Older people's characteristics, physical and cognitive functioning, depression, behaviour and quality of care measures were recorded at assessment and 6 months. Differences in clinicians' and care managers' recommendations and placement rates between experimental and control groups were analysed. Logistic regression, examining associations between different needs-related characteristics and the likelihood of care-home admission, was used to characterize placement decisions. RESULTS: Clinicians recommended fewer older people for placement than did care managers in their usual assessments (a reduction of 85%). This did not, however, translate into a reduction in actual numbers of placements, although placements were delayed in those receiving the integrated assessment. Placements of those receiving the integrated assessment were influenced more by clinical factors, most notably cognitive impairment, which clinicians detected more readily than care managers. CONCLUSIONS: In this at-risk group, integrated assessment offers a means of potentially both delaying care-home admissions and taking account of a wider range of factors in placement decisions. Such an approach is viewed as an important policy goal both in the UK and internationally.

Affect↗
PubMed2006

The needs of older people with dementia in residential care.

BACKGROUND: People with dementia often move into care homes as their needs become too complex or expensive for them to remain in their own homes. Little is known about how well their needs are met within care homes. METHOD: The aim of this study was to identify the unmet needs of people with dementia in care and the characteristics associated with high levels of needs. Two hundred and thirty-eight people with dementia were recruited from residential care homes nationally. Needs were identified using the Camberwell Assessment of Needs for the Elderly (CANE). RESULTS: Residents with dementia had a mean of 4.4 (SD 2.6) unmet and 12.1 (SD 2.6) met needs. Environmental and physical health needs were usually met. However, sensory or physical disability (including mobility problems and incontinence) needs, mental health needs, and social needs, such as company and daytime activities, were often unmet. Unmet needs were associated with psychological problems, such as anxiety and depression, but not with severity of dementia or level of dependency. CONCLUSION: Mental health services and residential home staff need to be aware that many needs remain unmet and much can be done to improve the quality of life of the residents with dementia.

Aged↗
PubMed2006

Levels of integration and specialisation within professional community teams for people with dementia.

BACKGROUND: Delivering integrated and specialist mental health services for the growing population of older people with dementia in Britain is a key concern of the present government. AIMS: To consider the nature of current practice among multi-disciplinary and single discipline health and social care teams providing a service to people with dementia and compare the quality of service offered. METHODS: A postal survey of professional community teams in North West England, providing services to people with dementia. Responses were analysed according to a number of standards measuring service quality, developed from research and policy documents. A response rate of 59% yielded a final sample of 52 teams. RESULTS: Multi-disciplinary teams scored more highly than single discipline teams on many of the measures used. Single discipline teams achieved a higher score on just one measure, culturally sensitive services. Generally teams were found to provide a more integrated, targeted and person-centred service, as measured in this study, compared with earlier findings. Teams performed less well on measures of flexibility and culturally sensitive provision. CONCLUSIONS: These findings indicate some potential gains from integration, and highlight the level of work still needed to achieve it. Further research is needed to build on the structural and process measures used in this research in order that the costs and outcomes consequent upon these practices can be measured.

Aged↗
PubMed2006

Standards of care in day hospitals and day centres: a comparison of services for older people with dementia.

BACKGROUND: Current policy in England emphasises the importance of caring for highly dependent older people for as long as possible at home. It is therefore crucial that day care services are effective and widely available. AIM: To compare the type and standard of care provided for older people with dementia in day centre and day hospital settings. METHODS: A cross-sectional postal survey design was employed. Representatives from three-quarters of identified specialist day care services for older people with dementia in the North West of England provided information on a range of indicators including: basic structural features; delivery of care; service content; and quality measures. RESULTS: Day hospitals tended to have more day care places and a greater number of attendees, but lower occupancy rates than day centres. Day hospitals reported higher standards of care in relation to systematic assessment and care planning, promotion of rehabilitation, carer involvement and individualised provision of care. They were also more likely to employ building design features to encourage independence and choice for people with dementia. A higher proportion of day centres provided services exclusively to older people with dementia and a greater proportion of staff in day centres had undergone specific training in caring for people with dementia. Day centres were also more likely to have effective transport arrangements in place. CONCLUSION: The standards developed for the study were sufficiently reliable to allow for an acceptable estimate of quality. Day centres and day hospitals appeared to perform two distinct, but complementary functions. These results provide key material for shaping the provision of day care for older people with dementia, especially given the absence of national standards in this area.

Aged↗
PubMed2006

Care management for older people: does integration make a difference?

England and Northern Ireland provide examples of different degrees of integration of health and social care within broadly similar administrative and funding frameworks. This paper examines whether integrated structures appear to impact upon the operation of care management, a key approach to providing coordinated care for vulnerable older people. There appeared to be more evidence of integrated practice between health and social care in Northern Ireland than England, although some key features, such as intensive care management, were no more evident. It is concluded that further investigation is required as to the extent to which integrated structures have impacted upon patterns of professional working and underlying beliefs about roles.

Aged↗
PubMed2006

Care managers' time use: differences between community mental health and older people's services in the United Kingdom.

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.

Adolescent↗
PubMed2005

Variations in care management arrangements for people with mental health problems in England.

Since 1989, government policy in the United Kingdom has advocated that social services providers develop care management systems in order to deliver coordinated and individually tailored packages of care to all user groups. This cross-sectional postal survey describes national variations in care management arrangements for people with mental health problems in England on 14 key indicators developed from previous research. One hundred and one social services providers (response rate: 77%) completed two questionnaires: The first related to care management arrangements for all user groups, and the second related specifically to arrangements for people with mental health problems. Significant national variation was found. Furthermore, there was little evidence of integration between health and social care, of care management being delivered through specialist multidisciplinary mental health teams, and of selective arrangements targeted at those most in need. The results are discussed in the context of apparently widespread disparity between existing care management arrangements and government policy guidance.

Case Management↗
PubMed2004

Perceived mental health needs and adequacy of service provision to older people in care homes in the UK: a national survey.

OBJECTIVE: To assess perceived need and adequacy of service provision by old age psychiatrists (OAPs) to older people living in care homes in the UK. METHODS: A postal survey of managers of a stratified random sample of 2638 (14% of 18,698) care homes in the UK caring for older residents. Reminders were sent to those not returning the questionnaires. RESULTS: The response rate was 64% (n = 1689). Forty-one percent of care home managers felt that at least 50% of their residents needed psychiatric evaluation. Cognitive impairment, depressive symptoms and challenging behaviour was thought to be present in at least a quarter of residents by 78%, 29% and 17% respectively. Thirty-eight percent of managers reported that their homes 'never' received any visits from OAPs and only a half described the current frequency of visits as adequate. Pharmacological advice was perceived to be adequate by about three-quarters but less than a half perceived non-pharmacological advice as adequate. Eighty percent wanted more input for staff education and training. Perceived need ( p < 0.001), frequency of visits by OAPs ( p = 0.001), availability of geriatrician ( p = 0.001), amount of non-pharmacological advice ( p = 0.014) and direct referral access to OAPs for known patients ( p = 0.036) were found to be independent predictors of perceived inadequacy of service provision by OAPs. CONCLUSION: The survey highlights the perception of unmet need and inadequacy of service provision by OAPs amongst managers of care homes in the UK. The study findings, if confirmed by direct observational studies, may have a considerable impact on already sparse resources with a need to explore efficacy of different models of care in meeting this need.

Aged↗
PubMed2004

The value of specialist clinical assessment of older people prior to entry to care homes.

OBJECTIVE: to ascertain the value of employing a specialist clinician's contribution to the assessment of older people prior to care home entry. DESIGN: randomised controlled trial. METHOD: 256 older people at risk of care home entry were randomly allocated to either a control group, who received the usual care management assessment, or to an experimental group who, in addition, received a clinical assessment by a geriatrician or old age psychiatrist. The value of the additional assessment was evaluated by an analysis of clinical recommendations, questionnaires eliciting the views of stakeholders and research interviews with older people and their carers at initial assessment and 6 months. Data on service use and costs over 6 months and on destination at 6 and 12 months were also collected. RESULTS: the clinical assessment uncovered covert morbidity previously unknown to care managers particularly in respect of cognitive impairment and was adjudged acceptable to the different stakeholders involved. Those receiving the clinical assessment experienced less deterioration in their physical functioning, had less contact with nursing homes and emergency services and their carers experienced reduced levels of distress. Overall, the costs of care for those receiving the assessment were no greater with NHS costs actually lower. CONCLUSIONS: the potential benefits in involving specialist clinicians in the assessment process include identifying previously undiagnosed conditions and enhancing care managers' decision making. Such an assessment could be provided at a modest marginal cost. The approach is fully compatible with proposals for the role of the community geriatrician and commensurate with current good clinical practice in old age psychiatry.

Aged↗
PubMed2003

Public funding for residential and nursing home care: projection of the potential impact of proposals to change the residential allowance in services for older people.

BACKGROUND: This paper investigates the potential effects of a policy change in the funding of UK residential care. The White Paper Modernising Social Services (Cm 4169, 1998) outlined plans to change the distribution of the Residential Allowance (RA), payable in support of residents in independent residential or nursing home care, from a component of income support paid direct to establishments to a grant to local authorities. This change was intended to remove the perverse incentive in accessing independent residential care more favourably than local authority care. A further objective was to encourage local authorities to use the grant to support home-based alternatives to residential care. The policy rests on a model in which price signals dictate the choice of care for an older person. By, in effect, raising the price of independent residential and nursing home care, the policy provides an incentive for authorities to seek alternatives to institutional care. METHODS: Managers from 16 UK social services departments attended a focus group discussion, completed questionnaires and provided information to assist in calculating the potential diversionary effect of the policy. RESULTS: Managerial estimates indicated a small diversionary effect of the policy; A potential effect of 0.26 and 0.19 per 1000 older people diverted from residential and nursing care respectively. CONCLUSIONS: The study indicated that wider organisational factors other than price are likely to play a greater role in deciding whether an older person is admitted to care. Changes in public funding alone do not reflect the complexities involved in decision-making concerning the residential placement of older people.

Aged↗
PubMed2003

Understanding the roles of registered general nurses and care assistants in UK nursing homes.

BACKGROUND: The recent government decision to fund the costs of Registered nursing time in long-term care facilities in England through the Registered Nurse Contribution to Care renders the need to distinguish the role of Registered General Nurses (RGNs) from that of Care Assistants (CAs) in nursing homes increasingly important. AIM: The objective of this qualitative study was to obtain an in-depth understanding of the main differences between the roles and functions of RGNs and CAs working in nursing homes in the United Kingdom (UK). DESIGN: Data were collected through interviews with nine RGNs and 12 CAs employed in four different nursing homes across England. FINDINGS: Our findings suggest that RGNs have difficulty defining and limiting their roles because they have all-embracing roles, doing everything and anything within the home. By contrast, CAs define their role in terms of what they are not allowed to do. This difficulty in limiting their role, in addition to their sense of professional accountability for residents' care, leads RGNs to experience difficulty in delegating tasks to CAs. Both RGNs and CAs agreed that an increase in the number of assistive staff is needed to provide residents with good quality care and suggested that a measure of resident dependency would be a good method by which to determine staffing levels. CONCLUSIONS: We recommend that job descriptions that clearly define the roles and responsibilities of both RGNs and CAs are developed so that caregivers at all levels understand each others' roles and work together to co-ordinate, plan and provide residents' care.

Caregivers↗
PubMed2003

Identification of registered nursing care of residents in English nursing homes using the Minimum Data Set Resident Assessment Instrument (MDS/RAI) and Resource Utilisation Groups version III (RUG-III).

AIM: to determine if a combination of Minimum Data Set/Resident Assessment Instrument (MDS/RAI) assessment variables and the Resource Utilisation Groups version III (RUG-III) case-mix system could be used as a method of identifying and reimbursing registered nursing care needs in long-term care. METHOD: the sample included 193 nursing home residents from four nursing homes from three different locations and care providers in England. The study included assessments of residents' care needs using either the MDS/RAI assessments or RUG stand-alone questionnaires and a time study that recorded the amount of nursing time received by residents over a 24-h period. Validity of RUG-III for explaining the distribution of care time between residents in different RUG-III groups was tested. The difference in direct and indirect care provided by registered general nurses (RGN) and care assistants (CA) to residents in RUG-III clinical groups was compared. RESULTS: the RUG-III system explained 56% of the variance in care time (Eta2, P=0.0001). Residents in RUG-III groups associated with particular medical and nursing needs (enhanced RGN care) received more than twice as much indirect RGN care time (t-test, P<0.001) and 1.4 times as much direct RGN and direct CA time (t-test, P<0.01) than residents with primarily cognitive impairment or physical problems only (standard RGN care). Residents with enhanced RGN care received an average of 48.1 min of RGN care in 24 h (95% CI 4.1-55.2) compared with an average of 31.1 min (95% CI 26.8-35.5) for residents in the standard RGN care group. A third low RGN care group was created following publication of the Department of Health guidance on NHS Funded Nursing Care. With three levels, the enhanced care group receives about 38% more than the standard group, and the low group receives about 50% of the standard group. CONCLUSIONS: the RUG-III system effectively differentiated between nursing home residents who are receiving 'low', 'standard' and 'enhanced' RGN care time. The findings could provide the basis of a reimbursement system for registered nursing time in long-term care facilities in the UK.

Aged↗
PubMed2003

Quality assurance practices in care management: a perspective from the United Kingdom.

Alongside the development of care management in many countries has emerged a need to monitor the quality of both care management practices, as well as the quality of services provided as a consequence of care planning by care managers. Designing and implementing quality assurance practices in care management present special challenges. This article examines current practices from the perspective of the United Kingdom (UK). First, current performance initiatives at the central government level are described, including an indication of their limitations in judging quality in care management; second, existing work on assuring quality in care management is reviewed along with its relevance for the UK; and third, a local study, identifying measures within an analytical framework and using them to monitor care management against set dimensions, is described. Parallel developments are now occurring at both national and local levels in the UK, with local work both influencing and being informed by national developments. Future issues to address include the problems in collecting relevant data and in extending methods of analysis to monitor care management more comprehensively.

Health Care Reform↗
PubMed2002

Care management, dementia care and specialist mental health services: an evaluation.

OBJECTIVE: To evaluate a model of intensive case management for people with dementia based in a community-based mental health service for older people. METHOD: Quasi-experimental design. Individuals in one community team setting received case management and were compared with those in a similar team without such a service. Forty-three matched pairs were identified. Eligible older people and their carers were interviewed at uptake and again at 6 and 12 months. RESULTS: The impact of the scheme upon placement occurred in the second year at the end of which 51% of the experimental group remained at home compared with 33% of the comparison group. For the experimental group significant improvements in the social contacts of older people were noted; a decrease in the stress of their carers was observed, together with a reduction in their input to the care of the client; and there were significant improvements on ratings of overall need reduction, aspects of daily living and level of risk. Differences between the two groups based on service receipt showed higher costs for the experimental group. DISCUSSION: The benefits to older people and their carers confirms previous findings that the most effective case management interventions are those targeted on a highly specific client group. Issues which influence the cost-effectiveness of intensive case management are discussed. The benefits of locating this service within a specialist mental health team are explored in the context of current initiatives to promote greater service integration between health and social services.

Activities of Daily Living↗
PubMed2002

Policy, organisation and practice of specialist old age psychiatry in England.

OBJECTIVE: To describe and compare service arrangements in old age psychiatry across England according to three broad domains: (i) levels of professional autonomy; (ii) degree of community orientation (delivery of and links with community services) and (iii) degree of integration between health and social care provision. DESIGN: Cross sectional survey of consultants in old age psychiatry in England. Potential respondents were sourced from the Royal College of Psychiatrists and Regional Advisers in Old Age Psychiatry. MEASURES: A self-administered postal questionnaire was piloted and refined. The questionnaire domains listed above reflect core policy issues for older people's services, covering the domains above. RESULTS: There is marked variation in the deployment and use of professional staff in old age psychiatry, ranging from open access to multidisciplinary assessment to services only accessible by clinician referral. Patterns of linkage with primary care are likewise variable with only half of services providing the types of support recommended by the Audit Commission (2000). Community orientation was evident to a considerable extent in support to care homes and assessment practices. Links between health and social care appeared strongest in terms of liaison and training. There was less evidence of more formal integration through shared management of staff or for links with intensive home support for those with dementia. CONCLUSIONS: The data provide a unique picture and benchmark of the configuration of old age psychiatry, a core element of mental health care in old age, after some 25 years of development in the UK. There appears to be substantial variation on all three domains of comparison.

Aged↗
PubMed2002

Frail old people at the margins of care: some recent research findings.

BACKGROUND: Community-based care at the margin is a substitute for institutional care. Three factors are considered critical: definitions of eligibility, assessment procedures and balance of care. AIMS: To examine determinants of the margin between institutional and home-based care, review current practice, identify the implications and contribute to planning of integrated long-term care services. METHOD: A selective review was made of findings from research conducted after the community care reforms. RESULTS: Marked variability and inconsistency in eligibility and assessment processes may contribute to misplacement of frail older people. There remains capacity to shift the balance of care from institutional to home-based care within reasonable cost parameters, particularly with more integrated services. CONCLUSIONS: Greater standardisation of approaches to the determination of eligibility for social care and to assessment of need is required. Providing care at home for some of those currently entering care homes is feasible, but will require different service structures and staff roles, including specialist clinicians.

Activities of Daily Living↗