A model of care coordination for patients with complex health and social
                        care needs – what is best?

Purpose The purpose of this paper is to stimulate a wider debate around the coordination of workforce planning in non-statutory services (in this case, specialist housing for older people or those with long-term health and social care needs, such as learning disabilities). The authors argue that current NHS reforms do not go far enough in that they fail to include specialist housing and its workforce in integration, and by doing so, will be unable to optimise the potential efficiencies and streamlining of service delivery to this group. Design/methodology/approach The paper used exploratory study using existing research and data, enhanced by documentary analysis from industry bodies, regulators and policy think tanks. Findings That to achieve the greatest operational and fiscal impact upon the health care services, priority must be given to improving the efficiency and coordination of services to older people and those requiring nursing homes or registered care across the public and third sectors through the integration of service delivery and workforce planning. Research limitations/implications Whilst generalisable and achievable, the model proposed within the paper cannot be fully tested theoretically and requires further testing the in real health and social care market to evidence its practicality, improved quality of care and financial benefits. Originality/value The paper highlights some potential limitations to the current NHS reforms: by integrating non-statutory services, planned efficiency savings may be optimised and service delivery improved.

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Informing patterns of health and social care utilisation in Irish older people according to the Clinical Frailty Scale

HRB Open Research ◽

10.12688/hrbopenres.13301.1 ◽

2021 ◽

Vol 4 ◽

pp. 54

Author(s):

Aisling M. O'Halloran ◽

Peter Hartley ◽

David Moloney ◽

Christine McGarrigle ◽

Rose Anne Kenny ◽

...

Keyword(s):

Older People ◽

Social Care ◽

Markov Models ◽

Classification Tree ◽

Community Health Services ◽

Health Services Use ◽

Care Needs ◽

Clinical Frailty Scale ◽

Care Utilisation ◽

Health And Social Care

Background: There is increasing policy interest in the consideration of frailty measures (rather than chronological age alone) to inform more equitable allocation of health and social care resources. In this study the Clinical Frailty Scale (CFS) classification tree was applied to data from The Irish Longitudinal Study on Ageing (TILDA) and correlated with health and social care utilisation. CFS transitions over time were also explored. Methods: Applying the CFS classification tree algorithm, secondary analyses of TILDA data were performed to examine distributions of health and social care by CFS categories using descriptive statistics weighted to the population of Ireland aged ≥65 years at Wave 5 (n=3,441; mean age 74.5 (SD ±7.0) years, 54.7% female). CFS transitions over 8 years and (Waves 1-5) were investigated using multi-state Markov models and alluvial charts. Results: The prevalence of CFS categories at Wave 5 were: 6% ‘very fit’, 36% ‘fit’, 31% ‘managing well’, 16% ‘vulnerable’, 6% ‘mildly frail’, 4% ‘moderately frail’ and 1% ‘severely frail’. No participants were ‘very severely frail’ or ‘terminally ill’. Increasing CFS categories were associated with increasing hospital and community health services use and increasing hours of formal and informal social care provision. The transitions analyses suggested CFS transitions are dynamic, with 2-year probability of transitioning from ‘fit’ (CFS1-3) to ‘vulnerable’ (CFS4), and ‘fit’ to ‘frail’ (CFS5+) at 34% and 6%, respectively. ‘Vulnerable’ and ‘frail’ had a 22% and 17% probability of reversal to ‘fit’ and ‘vulnerable’, respectively. Conclusions: Our results suggest that the CFS classification tree stratified the TILDA population aged ≥65 years into subgroups with increasing health and social care needs. The CFS could be used to aid the allocation of health and social care resources in older people in Ireland. We recommend that CFS status in individuals is reviewed at least every 2 years.

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Needs of patients with dementia and their caregivers in primary care: lessons learned from the Alzheimer plan of Quebec

BMC Family Practice ◽

10.1186/s12875-021-01528-3 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Vladimir Khanassov ◽

Laura Rojas-Rozo ◽

Rosa Sourial ◽

Xin Qiang Yang ◽

Isabelle Vedel

Keyword(s):

Primary Care ◽

Unmet Needs ◽

Social Care ◽

Phase 1 ◽

Lessons Learned ◽

Community Dwelling ◽

Care Plan ◽

Phase 2 ◽

Care Needs ◽

Health And Social Care

Abstract Background Persons living with dementia have various health and social care needs and expectations, some which are not fully met by health providers, including primary care clinicians. The Quebec Alzheimer plan, implemented in 2014, aimed to cover these needs, but there is no research on the effect this plan had on the needs and expectations of persons living with dementia. The objective of this study is to identify persons living with dementia and caregivers’ met and unmet needs and to describe their experience. Methods This is a sequential mixed methods explanatory design: Phase 1: cross-sectional study to describe the met and unmet health and social care needs of community-dwelling persons living with dementia using Camberwell Assessment of Need of the Elderly and Carers’ Assessment for Dementia tools. Phase 2: qualitative descriptive study to explore and understand the experiences of persons living with dementia and caregivers with the use of social and healthcare services, using semi-structured interviews. Data from phase 1 was analyzed with descriptive statistics, and from phase 2, with inductive thematic analysis. Results from phases 1 and 2 were compared, contrasted and interpreted together. Results The mean total number of needs reported by the patients was 5.03 (4.48 and 0.55 met and unmet needs, respectively). Caregivers had 0.52 met needs (3.16 unmet needs). The main needs for both were memory, physical health, eyesight/hearing/communication, medication, looking after home, money/budgeting. Three categories were mentioned by the participants: Persons living with dementia and caregiver’s attitude towards memory decline, their perception of community health services and of the family medicine practice. Conclusions Our study confirms the findings of other studies on the most common unmet needs of the patients and caregivers that are met partially or not at all. In addition, the participants were satisfied with access to care, and medical services in primary practices, being confident in their family. Our results indicate persons living with dementia and their caregivers need a contact person, a clear explanation of their dementia diagnosis, a care plan, written information on available services, and support for the caregivers.

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Refugee-like migrants have similar health needs to refugees: a New Zealand post-settlement cohort study

BJGP Open ◽

10.3399/bjgpopen20x101013 ◽

2020 ◽

Vol 4 (1) ◽

pp. bjgpopen20X101013

Author(s):

Jonathan Donald Kennedy ◽

Serena Moran ◽

Sue Garrett ◽

James Stanley ◽

Jenny Visser ◽

...

Keyword(s):

Primary Care ◽

Cohort Study ◽

New Zealand ◽

Primary Care Practice ◽

Social Care ◽

Hospital Admissions ◽

Outpatient Service ◽

Care Practice ◽

Care Needs ◽

Health And Social Care

BackgroundRefugees and asylum seekers have specific health and social care needs on arrival in a resettlement country. A third group — migrants with a refugee-like background (refugee-like migrants) — are less well defined or understood.AimUsing routinely collected data, this study compared demographics, interpreter need, and healthcare utilisation for cohorts of refugee-like migrants and refugees.Design & settingA retrospective cohort study was undertaken in Wellington, New Zealand.MethodData were obtained for refugee-like migrants and refugees accepted under the national quota system (quota refugees), who enrolled in a New Zealand primary care practice between 2011 and 2015. Data from the primary care practice and nationally held hospital and outpatient service databases, were analysed. Age and sex standardisation adjusted for possible differences in cohort demographic profiles.ResultsThe cohorts were similar in age, sex, deprivation, and interpreter need. Refugee-like migrants were found to have similar, but not identical, health and social care utilisation to quota refugees. Primary care nurse utilisation was higher for refugee-like migrants. Clinical entries in the primary care patient record were similar in rate for the cohorts. Emergency department utilisation and hospital admissions were similar. Hospital outpatient utilisation was lower for refugee-like migrants.ConclusionThis research suggests that health, social care, and other resettlement services should be aligned for refugee-like migrants and quota refugees. This would mean that countries accepting quota refugees should plan for health and social care needs of subsequent refugee-like migrant family migration. Further research should investigate matched larger-scale national health and immigration datasets, and qualitatively explore factors influencing health-seeking behaviour of refugee-like migrants.

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Health and social care services for older male adults in prison: the identification of current service provision and piloting of an assessment and care planning model

Health Services and Delivery Research ◽

10.3310/hsdr01050 ◽

2013 ◽

Vol 1 (5) ◽

pp. 1-138 ◽

Cited By ~ 16

Author(s):

J Senior ◽

K Forsyth ◽

E Walsh ◽

K O'Hara ◽

C Stevenson ◽

...

Keyword(s):

Social Care ◽

Qualitative Interviews ◽

Research Programme ◽

Older Men ◽

Care Needs ◽

Care Services ◽

Older Prisoners ◽

Care Assessment ◽

Health And Social Care ◽

The Impact

AbstractBackgroundOlder prisoners are the fastest growing subgroup in the English and Welsh prison estate. Existing research highlights that older prisoners have high health and social care needs and that, currently, these needs routinely remain unmet.Objectives(1) To explore the needs of men entering and leaving prison; (2) to describe current provision of services, including integration between health and social care services; and (3) to develop and pilot an intervention for identifying health and social care needs on reception into prison, ensuring that these are systematically addressed during custody.MethodsThe research programme was a mixed-methods study comprising four parts: (1) a study of all prisons in England and Wales housing older adult men, establishing current availability and degree of integration between health and social care services through a national survey and qualitative interviews; (2) establishing the health and social care needs of older men entering prison, including experiences of reception into custody, through structured (n = 100) and semistructured (n = 27) interviews; (3) the development and implementation of an intervention to identify and manage the health, social care and custodial needs of older men entering prison; and (4) exploration of the health and social care needs of older men released from prison into the community through qualitative interviews with older prisoners prior to and following discharge from prison. Descriptive statistics were produced for all quantitative data, and qualitative data were analysed using the constant comparison method.ResultsThe number of older prisoner leads has increased in recent years but they do not all appear always to be active in their roles, nor in receipt of specialist training. Nearly half (44%) of establishments do not have an older prisoner policy. There is a lack of integration between health and social care services because of ambiguity regarding responsibility for older prisoners' social care. The responsible social service may be located a considerable distance from where the prisoner is held; in such instances, local social services do not co-ordinate their care. The most frequent unmet need on prison entry was the provision of information about care and treatment. Release planning for older prisoners was frequently non-existent.LimitationsThe study used a cut-off age of 60 years as the lower limit for the definition of an older prisoner; evidence has emerged that supports a redefinition of that cut-off to 50 years. Our study examined the care provided for men and this should be considered if contemplating using the Older prisoner Health and Social Care Assessment and Plan (OHSCAP) with older women in prison.ConclusionThe OHSCAP, developed as part of this study, provided a feasible and acceptable means of identifying and systematically addressing older prisoners' health and social care needs. Future work will include the conduct of a randomised controlled trial to examine the impact of the OHSCAP in terms of improving a range of outcomes, including economic impact.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Role of the Single Assessment Process in the Care of Older People. How Will Primary Dental Care Practitioners be Involved?

Primary Dental Care ◽

10.1308/135576106778529080 ◽

2006 ◽

Vol os13 (4) ◽

pp. 130-134 ◽

Cited By ~ 1

Author(s):

Elizabeth A Lane ◽

Jennifer E Gallagher

Keyword(s):

Older People ◽

Dental Care ◽

Social Care ◽

Assessment Process ◽

Care Needs ◽

National Service Framework ◽

Health And Social Care ◽

Dental Practitioners ◽

One Stop

Following the publication of the National Service Framework for Older People, there have been developments across health and social care to facilitate holistic assessment of older people's needs, through what is called a ‘single assessment process’ or ‘SAP’. In this paper, readers are introduced to the SAP. The process can be seen as a ‘one-stop’ approach to the assessment of vulnerable older people that facilitates cross-referral between the agencies involved and triggers access to dental care. The paper explores the benefits of this new way of working in support of older people and how it will provide an opportunity for innovative dental practitioners to integrate oral healthcare for people with complex health and social care needs into the SAP. In concludes that as local commissioning evolves, opportunities for practitioners to develop targeted services for this important patient group should be expanded to improve the uptake of healthcare and oral healthcare.

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Introduction: Key sociopolitical changes affecting the health and wellbeing of people

Local Authorities and the Social Determinants of Health ◽

10.1332/policypress/9781447356233.003.0001 ◽

2020 ◽

pp. 1-12

Author(s):

Adrian Bonner

Keyword(s):

Health Care ◽

Social Care ◽

Care Needs ◽

Local Authorities ◽

Late 20Th Century ◽

Health And Wellbeing ◽

Health And Social Care ◽

Key Driver ◽

The Relationship

This introductory chapter provides an overview of the relationship between health and housing, regional disparities and responses across England, Wales, and Scotland in the provision of health and social care and local authority commissioning. It considers how the Municipal Corporations Act (1835) led to the establishment of elected town councils. In the mid- to late 20th century, municipalisation gave way to centralised government, which subverted the autonomy of local authorities. Currently, social care is provided and funded by local authorities and private funders. The main objective of social care is to help people to live well and happily, and live as long as they can. This person-centred approach is in contrast to the systems that have been developed to support the health care needs of people. In 2020, poverty still remains a key driver of poor health and wellbeing.

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A model of care coordination for patients with complex health and social care needs – what is best?