Sue Tucker

The balance of care: Reconfiguring services for older people with mental health problems

The belief that most older people, including those with complex needs, can, and would prefer to be, cared for in their own homes underpins community care policy in many developed nations. There is thus a common desire to avoid the unnecessary or inappropriate placement of older people in care homes or in hospital by shifting the balance of provision. This paper demonstrates the utility of a ‘balance of care’ approach to address these issues in the context of commissioners’ intention to reconfigure services for older people with mental health problems in a defined geographical area of the North West of England. The findings suggest that, if enhanced community services were available, a number of people currently admitted to residential or hospital beds could be more appropriately supported in their own homes at a cost that is no greater than local agencies currently incur.

Towards integrated community mental health teams for older people in England: progress and new insights

To investigate progress in joint working within community mental health teams for older people (CMHTsOP) against a range of national standards, and to consider team characteristics that may hinder or facilitate integrated practice.

Integrating mental health services for older people in England - From rhetoric to reality

The provision of integrated, person-centred care is particularly important for older people with mental health problems. Nevertheless, a series of reports at the end of the last century highlighted unacceptable differences in collaborative working practices in England, variations that a national service framework specifically aimed to address. This study utilized a cross-sectional survey of old age psychiatrists to explore the extent to which, some three years after the publication of this guidance, structures to deliver integrated care across the interfaces between specialist old age mental health and primary, acute and social care services were in place. Three hundred and eighteen (72%) consultants responded. Measures to facilitate integrated practice were generally poorly developed: many areas missed targets to agree protocols for the management of older people with mental health problems with primary care; more than 45% of respondents reported the presence of fewer than two of four indicators of integration with the acute sector; and approaching 30% of respondents reported the presence of fewer than four of 13 markers of integration with social care. The implications of these findings and the challenges inherent in providing integrated care for this client group are discussed.

The balance of care approach to health and social care planning: Lessons from a systematic literature review

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 models 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.

All things to all people? The provision of outreach by Community Mental Health Teams for Older People in England: Findings from a national survey

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.

Variations in structures, processes and outcomes of community mental health teams for older people: a systematic review of the literature.

Objectives: In the UK and elsewhere, specialist community mental health teams (CMHTs) are central to the provision of comprehensive services for older people with mental ill health. Recent guidance documents suggest a core set of attributes that such teams should encompass. This article reports on a systematic literature review undertaken to collate existing evidence regarding the structures and processes of CMHTs for older people and to evaluate evidence linking approaches to effectiveness. Method: Relevant publications were identified via systematic searches, both electronic and manual. Searches were limited to the UK for descriptions of organisation and practice but included international literature where comparisons between different CMHT arrangements were evaluated. Empirical, peer-reviewed studies from 1989 onward were included, extended to non peer-reviewed nationally or regionally representative reports, published after 1998, for the descriptive element. Results: Forty-five studies met inclusion criteria of which seven provided comparative outcome data. All but one were UK based. The most robust evidence related to research conducted in exemplar teams. Limited evidence was found regarding the effectiveness of many of the core attributes recommended in policy directives although their presence was reported in much of the literature. Conclusions: The contrast between presentation and evaluation of attributes is stark. Whilst some gaps can be filled from related fields, further research is required that moves beyond description to evaluation of the impact of team design on service user outcomes in order to inform future policy directives and practice guidance. A framework for an evidence-based model of CMHTs for older people is provided.

An evaluation of the use of self-assessment for the provision of community equipment and adaptations in English local authorities.

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.

Is integrated care associated with service costs and admission rates to institutional settings? An observational study of community mental health teams for older people in England

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.

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

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.

Self-assessment processes within care management: Learning from pilot projects

• 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.