Challis, D, Darton, R, Johnson, L, Stone, M and Traske, K,

1991,

Reviewed by Ailsa Cameron,
School for Policy Studies,
University of Bristol

Methodology

This series of 2 articles describes the introduction of a particular model of care and its impact on the lives of older people. The study evaluated the introduction of case managers, with devolved budgets, employed by SSD and located in a geriatric multidisciplinary team to provide an alternative for patients requiring long-stay hospital care. Case managers were responsible for co-ordinating care packages as well as deploying the time of home care assistants, a multi-purpose support worker trained to assist health care workers and provide traditional home help duties.

This 'quasi-experimental' study compared 101 elderly patients discharged to the project against 113 patients identified from a long stay ward of an adjacent health district. The long stay ward was thought to be providing a reasonably similar style of care. Both groups of people were assessed in hospital and followed up 6 months later. Interviews were also conducted with informal carers to explore their experiences, this data was compared with 2 other groups of carers: a sample selected from those attending traditional day hospital care and a sample of carers of elderly people in long-stay hospital. Cost data was collected during the 6 month evaluation to enable a cost benefit analysis being undertaken.

Quality of care information was measured by examining the differences between interview data collected whilst in hospital and 6 months post discharge. Equivalent measures were derived for the control group. Comparisons of data were based on an analysis of variance.

Critical appraisal

• The authors note the limitations of the evaluation and the process of sampling. They report that 'although the unit of analysis was the individual patient, to allocate patients randomly within the single service would neither have been acceptable nor practicable and would have risked contamination effects.'
• The authors identified that the control group appeared to have a higher degree of impairment which may suggest a selection effect.
• Some standardised measures were used, for example the Clifton Assessment Procedures for the Elderly Behaviour Rating Scale.  

Key findings

Placement findings:

• Almost two thirds of the experimental group were still in their own homes after 6 months and only 3 were in institutional care. After 12 months over 50% were still at home.
• Only 38 of the experimental group experienced any form of institutional care during the 6 month evaluation period.

Quality of life and quality of care outcomes:

• The experimental group were statistically more likely to have experienced improvements in morale and in satisfaction with their current life.
• No marked differences were observable using the Clifton Assessment Procedure.
• The experimental group experienced a significantly reduced need for additional care.

Effects upon carers:

• Carers for those in the experimental group carried out significantly fewer care tasks than day hospital carers and were less likely to be subject to distress associated with carrying out these tasks.
• Psychological stress was significantly lower for carers of those in the experimental group.
• The results suggest that the improvements in well-being experienced by the experimental group post discharge were not at the expense of higher stress for their carers.

Costs:

• The data suggests that the greater benefits achieved for both elderly people and their carers were no more expensive than traditional care.

The authors note several factors which they believe significantly improved co-ordination and collaboration between health and social services. These included:

• devolved budgets
• co-ordination of care package
• home care assistants who combined the functions of a home help, auxiliary nurse and aide.

Social work practice implications