The Care Path - Mainstream Care
Most support for older people with low to moderate levels of mental health need is provided by mainstream services. These are services that older people without mental health problems can access.
Mental health problems often present for the first time in mainstream service settings such as in a day centre or under the auspices of home care. Although these services are ‘the mainstay’ of community care, provision remains patchy and staff working in these settings are not always aware of mental health issues.
The mainstream services displayed on this screen are available in most areas. They are illustrative not prescriptive. One or more of the services may be offered to an older person assessed as eligible for them. Relatively few users receive a wide range, or significant quantity, of care.
If you click on each you can explore case studies or specific examples of each service.
Home Care
In England, considerably fewer households receive homecare now than was the case a few years ago but those who do are receiving a much more intensive package of support. Generally these are people with higher levels of need; a significant number have dementia either on its own or alongside a physical health problem.
(Home care: aims to enable people to remain at home and maintain independence. Home care workers visit service users in their own home to help with activities of daily living such as getting up, going to bed, dressing, toileting, personal hygiene, some household tasks, meal preparation and supervision of medication.)
Home care services are of mixed quality. Underlying problems include staff recruitment and retention difficulties, a poorly trained workforce, and a push by local authorities to keep prices low. Whilst home care is a key element of care packages for older people, many home carers have no training in mental health (Audit Commission, 2002).
What older users of home care want is a reliable caring worker who delivers hands-on care in an unhurried, respectful and sensitive manner.
Service Example
A number of social services departments have commissioned specialist home care services specifically to work with people with dementia. It provides especially trained home care workers to provide support to people with dementia. They tend to be given longer visits, build up a trust relationship with the user and are aware of the symptoms and behaviours that often accompany dementia.
Assistive Technology and telecare
Telecare offers the promise of enabling thousands of older people to live independently, in control and with dignity for longer. It can be as simple as a basic community alarm service, able to respond in an emergency and provide regular contact by phone. Equipment is provided to support an older person in their home and tailored to meet their needs. It can also include detectors or monitors such as motion or falls and fire and gas that trigger a warning to a ‘response centre’. The centre can call a nominated family member, neighbour or friend and arrange for them to come round, or if necessary, alert the emergency services. At present some 1.5 million people in the UK currently benefit from telecare services. They are particularly useful for supporting people with dementia.
Telecare is widely viewed as the ‘future’ for supporting older people with dependency needs. The Department of Health’s recent Preventive Technology Grant provided specific funding for telecare developments (Department of Health, 2005b).
Telecare services are known by a variety of names, including social or community alarm, lifeline or careline services.
Service example
The ‘Just Checking’ system allows older people who are becoming forgetful, to continue to live independently. It monitors the daily activity of the person in their home. Small, wireless sensors are installed at key locations around the dwelling. Typically, movement sensors would be placed in the kitchen, living room, bedroom and bathroom. A door sensor would be fitted to the front and back doors. The sensors are lightweight, small and similar to the movement sensors in a security (burglar alarm) system. Data from the sensors are gathered by the controller, a small box, and sent via a mobile phone connection to the Just Checking web-server. The carer or relative can log on to the Just Checking website, at any time and using a unique password to protect confidentiality, can view a simple chart of the activity of the person with dementia. For those on the move, the website can be accessed via a ‘smart’ mobile phone. The information provides family carers with reassurance that someone is following their usual pattern of life, without intruding on them or undermining their independence. It helps relatives to plan their visits and care input to best effect.
Respite Care
Respite care is designed to give carers temporary ‘respite’ from caring. It aims to provide a break, reduce stress and relieve the carer of their responsibilities. There are broadly three types of respite: short-term placements in a care home, daycare and sitting services (Faculty of old Age Psychiatry (2006). Respite care may be planned, offered in a crisis or at the request of the carer. Sitting services - which are a more recent service development - refer to a situation whereby a paid carer stays either on a day or overnight basis in the user’s home. This is often preferred by carers as it does not require the user to leave familiar surroundings or be transported (Lingard and Milne, 2004).
Respite care is popular with carers; they often describe high levels of satisfaction with it. They also tend to express a wish either for more respite care or for more flexible arrangements. Although it has been evidenced as delaying, or even preventing, admission to a care home, for some, it can function as a stepping stone on the way to long term care (Alzheimer's Society, 2007).
Service Example
Bill is 83 years old and has advanced dementia. His wife Cath has been looking after him for over 10 years and increasingly finds caring full time very tiring. She recently fell and although she ‘carried on caring’ she is becoming frail herself at 82 and is more and more worried about how she will cope in the future. Although Bill used to wander he was put on medication which stopped it. He has begun to do this again and Cath recently told her daughter, tearfully, that she may have to consider putting Bill in a home. She does not want to do this but can see no other way. The daughter contacts Social Services; they conduct an assessment of need and offer the couple respite care in a care home for a weekend once a month. Cath feels so much better since he went that she now also has a sitting service for a day a week to allow her to do domestic chores and meet a friend for lunch. She may even let Bill stay in the home when she goes on holiday for a week in the summer.
Housing with extra care
A significant addition to the service portfolio for older people in recent years has been the development of ‘extra care housing’. This is badged as an alternative to long term care in a residential or nursing home. Earlier versions of this model were called ‘very sheltered housing’; retirement villages also share some of its features. Extra care housing provides housing alongside support services. It enables an older person to remain in one place when they become dependent. Although evidence of its efficacy is limited, these schemes are popular, are what older people want and have the ability to be flexible, promote independence and offer a home for life.
Housing with extra care is an increasingly popular option for older people with a range of dependency needs, including people with dementia (Vallelly et al, 2006). Most extra care housing is provided by the social rented sector. Many local initiatives in England are linked to the Supporting People programme (Communities and Local Government website, accessed 2007).
(Extra care housing) Housing that can easily accommodate aids and adaptations and is linked to care servcies that are close by. Often they are part of larger 'community' which offers shared facilities and a care home.
(Retirement villages) offer purposefully designed barrier-free housing, facilities and activities that are not care related which generate opportunities for informal and formal social activity and engagement, alongside a range of care and support services that can respond quickly and flexibly to a range of care needs over time.
Service example
Housing 21, a housing association providing extra care sheltered housing, appointed a Dementia Services Advisor in 2004 to provide professional advice and support to their scheme managers in identifying and supporting tenants with dementia and promoting good practice in dementia care.
Westbury Fields is home to more than 200 older people who occupy 150 retirement/sheltered apartments and a 60-bed care home on a large landscaped site in a Bristol suburb. The aim of ‘the village’ is to encourage a lively, balanced community ranging from active independent residents to those requiring a high degree of support.
The development includes housing with extra care. The residents who in these facilities may otherwise need residential care. They receive help from the site based ‘Care and Support team’ who provide personal care and support with activities of daily living. They also have access to the villages wide range of recreational and leisure facilities.
Daycare
There are a number of types of day centres for older people. Some perform a largely social function and tend to be run by the voluntary sector for those who are lonely or who simply want a square meal twice a week! Often they run classes e.g. Art, and offer activities such as Bingo or outings.
Social services departments also run and/or fund a number of day services for older people with mental health problems including dementia. Their function is partly social and partly therapeutic. Many provide structured activities such as occupational therapy groups and exercise classes.
Day care also provides a break for the carer. Transport is often a problem; it is expensive and unreliable and can shorten a user’s day at the centre by several hours (Lingard and Milne, 2004).
(Occupational therapists (OT’s) facilitate rehabilitation enabling individuals to retain or recover independent living skills and build confidence. OTs assess a patient’s abilities to perform activities and design treatment programmes to increase their capability to tackle difficulties.)
Service Example
In Glasgow day care services are available for people with dementia who enjoy and can benefit from support offered in a group setting. These are either provided in mainstream day centres or day centres specifically for people with dementia. Activities include: group activities such as exercise classes; individual support such as skills training (training to help users do a task(s); and information and advice. There is also the opportunity to access more individual support through a ‘day opportunities programme’. This provides a flexible response to needs and can be offered within a user’s home, and/or via local social and recreational activities. The services consist of a range of opportunities designed to promote ordinary living through developing and maintaining links with existing community services.