Gaynor Reid Andrew Long Rosie Kneafsey Claire Hulme

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Gaynor ReidAndrew Long Rosie Kneafsey Claire
Hulme
EVALUATION OF AN ASSESSMENT AND
REHABILITATION SERVICE FOR OLDER PEOPLE IN
SOUTH CHESHIRE
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Why evaluate?

• Evaluation is attributing value to an
  intervention by gathering reliable and valid
  information about it in a systematic way, and by
  making comparisons, for the purposes of making
  more informed decisions or understanding causal
  mechanisms (Ovretveit 1998, 9)

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Evaluation study

• Broad aims
• To explore the way in which the care management
  model has been interpreted and applied within the
  Joint Investment Plan for Older People.
• To explore the extent to which care management
  enables independent living for older people

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Methods - Phase One

• Exploratory while the programme is being
  developed
• General operation of the RLT work and care
  management approach
• Team development
• Inter-agency working
• Multiple methods and points of data collection
• Observation
• Interview
• Stakeholder survey

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Methods - Phase Two

• Shift in focus to
• Client Outcomes -
• 5 outcome measures , 3 data collection points
• Modified Barthel Index
• Hospital Anxiety and Depression Scale (HADS)
• Carer Assessment of Difficulties Index (CADI)
• EQ-5D
• Client and carer experience - semi structured
  interviews
• Referral and acceptance patterns ,
• Costing - (potential cost effectiveness) health
  economist

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Internal v External

• Internal
• Political pressures
• Cost saving
• Time saving
• Biased

• External
• They just dont understand
• Better position to give unpleasant or unpopular
  information
• Vulnerable to response bias
• Honest broker

In some situations, a team composed of internal
and external assessors will confer the most
credibility Steiner et al (1998) Intermediate
Care - Approaches to Evaluation, Kings Fund,
London
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Key features of the service

• Comprehensive assessment and care management by a
  three inter-disciplinary teams
• Purchasing capabilities
• Targeted client group - older people with complex
  needs
• Time limited intensive rehabilitation services
• Rehabilitation beds in community support centres
• Home care services using an enabling approach to
  rehabilitation teams

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Care management approach

• Referral
• Screen
• Allocate
• Assess
• Rehab/care
• Discharge
• Review

Process of care management experienced by users
in this study
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Client group

• Volatile circumstances
• Vulnerable people
• Fragile homeostasis
• Not anticipated client group
• Incompatible client groups

• Complex
• Longer term intervention
• Last resort - depleted physical/ emotional
  stamina
• Dont always fit criteria

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Care managers experience

• Difference between traditional new role
• Role beyond initial expectations and
  understanding
• Lack of preparation
• Prior experience as SW helpful

• Complexity of case load
• Dealing with of risk
• Vulnerable exposed
• Adapting to new working patterns
• Concerns regarding safe practice

it's a very difficult job to do, to walk into it
from not having care managed before .to try and
take on that responsibility
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Team members roles

• Attention to detail
• Taking responsibility
• Crisis management
• Managing risks
• Avoids duplication of assessment

• Accountable
• Filling service gaps
• Carrying a case load
• Enhanced S.W role

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Team working

• Greater awareness in client assessments
• More holistic assessments
• Avoids duplication
• Less risk of manipulation
• Whole team to fall back on
• Integrated team

• Increased efficiency
• Learning from colleagues
• Learning to accept risk
• Learning new skills to basic level
• Concerns with legalities of skill mix

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Desired working issues

• Dedicated home care
• Better communication with home care
• No panel work
• Co-working
• Cover for leave
• See people sooner
• More individualised care packages

• Issues
• Case closed???
• Learning needs

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Whole System Implementation survey

• A range of staff groups targeted
• 223 completed questionnaires received
• A response rate of 84 for the directly mailed
  groups
• Much lower overall response rate when non-
  direct mailed groups included, at 28

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Results

• 78 had heard of the RLT
• 69 of respondents had had at least one client
  contact
• Contact more likely if had a hospital (80)
  rather than community base (63)
• Positive perceptions
• 43 view service as very useful
• 33 view service as being useful or
  moderately useful

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Anticipated Benefits of the RLTs - 84 commented
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Concerns with the RLTs - 64 commented
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Inter-agency working

• Conflict hostility -They feel that were
  taking their work away from them and the money
  from their service they should have got,
  Theyve been obstructive by not involving us
  (in new service developments)
• Home care - shortfalls, enablement vs do for,
  consistency, availability, co-ordination
• Acute - Disillusioned, pressure, focus on
  discharge, Just another scheme
• Awareness- Knowing whats available using it
• Cultures - Differing cultures and models can
  undermine rehab

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Inter-agency working

• Joint working and commitment at higher management
  levels
• Clarity of Purpose
• Awareness of rehabilitation opportunities in your
  locality
• Awareness of challenging aspects of the
  inter-agency service
• Willingness to problem solve

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Client and carer interviews

• Structured format focusing on
• Client perceptions of the level of support
  provided by the RLT
• Degree of client centredness
• Achievement of goals
• Experience of care management.

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Method of contact

• Clients receiving full rehab/care package
• During first contact, permission for interview
  sought
• Clients then sent information sheets and consent
  forms by post, along with a time and date of
  interview
• At interview, researcher read through and
  explained the information sheet and consent form
  
• Written consent was then gained

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Sample

• Reasons for Refusal
• Unaware of RLT
• Withdrawn from RLT
• Family felt client too confused
• Too ill (n 11)
• Other appointments
• Confused on the phone
• Spouse deceased or ill
• In a CSC

• Thirteen potential clients not contacted - too
  ill or deceased.
• Twenty-nine clients refused to be interviewed.

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Completed interviews

• 30 client/carer interviews completed to date.
• Of these, 20 completed with clients alone.
• For 8 interviews, both the client and carer were
  present.
• For 2, only the carer was present.

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Client centredness

• Being given information
• Hes answered everything Ive wanted to know.
  He keeps nothing back. He tells me it all
• Making choices
• She put all sorts of suggestions forward, some
  of which I accepted and some I didnt. The
  choice was therethe offer was completely
  free.you knowthe choice was given to you in
  such a nice way that you followed them

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Independence

• Impact of services - coping, adaptation,
  confidence
• Achieving own goals
• 'Im okay at home and thats the thing I
  wanted to do and that was the thing I achieved.
  My son didnt want me home because he was afraid
  I wouldnt be able to manage. I have managed. I
  mean I have falls. I have falls anytime. I mean
  I had falls in the residential home, falls in the
  hospital... you can't stop it

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Service implementation

• Development of care management role and
  inter-disciplinary team working
• Commitment to inter-agency co-operation - second
  stakeholder survey
• Positive client evaluations - access carer
  viewpoint
• Emerging findings on clinical effectiveness and
  client outcomes

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Implications of service evaluation

• Regular feedback - fosters reflection and
  provides opportunity to refine services
• Action research and empowerment
• Impact on care managers -
• very thorough yet succinct feedback. It was
  good to see that there has been some progress and
  we have moved on