Facing Up to Underfunding: Equity and Retrenchment in Community Care

Local social services departments in the UK are expected to distribute their cash-limited budgets for community care in ways that achieve an equitable allocation of resources in situations where, with present levels of funding, they cannot meet all the needs with which they are presented. This paper discusses a case study of the introduction of a needs-based formula to allocate a local authority's budget for home care services and a follow-up survey to investigate whether services reached the people intended to benefit. The article argues that the gatekeeping role of community care assessments is important to safeguard equity without the inflexibility of highly standardized tests of eligibility. However, with the new Labour government seeking to reduce dependency on public expenditure, and a growing lobby for national standards of social care, it will be increasingly important that local authorities justifiy their different practices with evidence about how they relate to local needs.     

Healthcare Provision for Elderly People in Argentina: The Crisis of PAMI

This paper highlights the problems of administering health insurance programmes in Latin America and the difficulties of imposing effective reforms. It examines the development, financial collapse and subsequent restructuring of a health insurance programme specifically targeting elderly people in Argentina. By the 1990s the Integrated Healthcare Programme (PAMI) had become one of the largest components of the country's public welfare system, managing an annual budget of US $2.5 billion. It provided elderly people with a wide range of services, including free and discounted medical care and a national network of day centres. The Programme was widely praised as efficient and innovative both within Argentina and beyond and was considered a model which other developing countries might emulate.
However, in 1994 it was discovered that PAMI had accumulated a deficit of US $1.3 billion and was suffering from a large number of serious structural weaknesses. These included a complete absence of financial accountability (both internally and externally), the piecemeal expansion of services, employment featherbedding, political patronage and corruption. Also, the Programme had contributed to long-standing inequalities between different geographical regions and between insured and uninsured populations. Since then, numerous attempts have been made to reform the Programme, some of which have received funding from the World Bank, but these initiatives are only being very gradually implemented.     

探讨医务社会工作在社区养老中的作用

社区是老年人生活和活动的主要场所,在提供养老服务方面具有很大优势。由于政府投入社区养老的资源有限和人们观念认识等方面的问题,使得社区养老没有达到预期的效果,即没有满足老年人的有效需求,特别是老年人的医疗需求,使得老年养老问题再次陷入困境。医务社工的介入,是解决当前社区养老中追切需要解决的问题的有效元素,也是使得社区养老资源发挥更大效用的关键因素。     

Care for Elderly People in the European Community

All EEC countries are faced with an ageing population, which means an increase of people in some way handicapped in everyday activities. A comparison of the solutions adopted by several EEC countries in the sectors of housing, home care services, residential and nursing homes shows that a real medico-social policy has been worked out only in Denmark and the Netherlands. In France and the United Kingdom, public authorities have certainly defined policies which lay claim to providing overall coverage but they have not provided corresponding resources. In Germany and in Italy there is no clearly defined policy. Here we discuss the various factors which may account for these differences.     

老年人社区服务需求与社区工作专业化

本文以南京市鼓楼区某街道为例,探索了老年人不同层次的社区服务需求及其满足状况。本文认为,当前老年居民低层次的社区服务需求已经基本得到满足,但高层次的社区服务需求难以满足。必需加快社区工作者的职业化和专业化,提升社区服务的质量才能更好地满足老年人的社区服务需求,实现社区和谐发展。     

Promoting Personalization in Social Care Services for Older People

This article presents findings on 4 themes associated with the personalization of social care for older people: integration of health and social care services; initiatives that prevent the need for more costly interventions; services to maintain people at home; and systems that promote choice, control, and flexibility. The quantitative study utilized data from a national postal survey conducted in England. Findings suggest variable progress regarding the range and style of support available to older people. These are discussed in the context of service integration, community-based services, and consumer-directed care. Implications for service development and future research are highlighted.     

Sharing Meals With Institutionalized People With Dementia: A Natural Experiment

Nutritional deficiency can have dramatic effects on the physical and psychological status of older adults. Although food supplements can enhance nutritional status, several authors suggest that more ecological means could also have beneficial impacts. Therefore, a natural experiment was conducted to study the impact of changed mealtime experiences for people with Alzheimer-type dementia. Two special care units (in separate facilities) in France were included in this study: one implemented shared mealtimes between residents and caregivers and the other served as a comparison group. Weight was measured and staff observations were collected. Positive outcomes were observed for the experimental group. Implications for practice are discussed.     

Sheltered Housing and Community

This paper considers the role of sheltered housing following the introduction of new community care arrangements in 1993 and examines the continuing uncertainty about its exact role as community care continues to develop. It reports on a study conducted in Shropshire, using a postal survey and interviews with older people and service professionals. The study highlights the importance of sheltered housing for older people, particularly in relieving them of concerns about maintenance and repairs, social isolation and security. These factors were crucial for their overall peace of mind and quality of life. While only a small proportion of tenants received help under social services' community care arrangements, the additional support, monitoring and service coordination provided by wardens helped some of them to remain in sheltered housing when residential or nursing home care might otherwise have been necessary. Sheltered housing was overwhelmingly popular with older people — but their satisfaction was closely associated with the availability and quality of the warden service. Although sheltered housing is not currently in vogue in housing policy, the paper argues that it plays a vital role in local provision for older people and needs to be more closely integrated into community care policy, while at the same time preserving the characteristics that make it popular with its residents.     

The Right to Take Risks: Alcohol and Older People

This paper examines policy and practice regarding the purchase of alcohol for older clients of home carers in three local authorities in the Greater London area. Data were gathered from interviews with home carers and their managers, focus group discussions, and a postal survey. None of the local authorities had a written policy or written guidance on alcohol purchase or on appropriate responses to the identification of problematic drinking in older clients. The findings illustrate the problem of balancing "rights" and "risks" within a philosophy of community care which emphasizes client choice and autonomy, and show how policy and practice are "tailored" by local contexts. It is suggested that both home carers and other domiciliary workers, as well as their older clients, could benefit from a clear code of practice regarding responses to alcohol consumption and problematic drinking by older people.     

Older People and Permanent Care: Whose Decision?

This paper looks at decision making when older people enterpermanent care, and focuses on power issues. The recent pastis reviewed and related to aspects of the current picture. Dementiaand capacity are a specific focus. The complexities of the workfor practitioners, together with their sometimes difficult workingenvironments, engender a climate which can be counter productiveto protecting the self-determination of older people.     

农村留守老人需要社会关怀

本文分析了我国农村留守老人的形成原因,并对农村留守老人的社会关怀展开具体论述。对农村留守老人施以社会关怀,既是农村留守老人的主观愿望,又是农村经济发展的客观需要。对这一问题的探讨,具有很强的现实意义。     

Recognizing But Not Acknowledging: On Using Research Information in Social Work with Elderly People Suffering from Dementia

The gap between theory and practice in social work continuesto be great, and research results seem to live a life of theirown, far from the field they were intended to improve. Thisarticle considers research information as a useful contributionto the practice of social work with elderly demented peopleand to qualitative methods used in the area of social scientificresearch. Arising out of a project aimed at studying the usefulnessof research information through an interactive exercise withinfocus groups, the author discusses how the results of researchcan be used to improve practice. When the researchers’theoretical- oriented perspectives meet with the practitioners’action-oriented perspectives, two different models enrich eachother in the process of developing integrated knowledge.     

Helping Older People in Residential Care Remain Full Citizens

New Labour’s project of modernization has involved thepromotion of interlocking ideas about active citizenship andnew modes of democratic engagement combining to produce whathas described as ‘participative governance’. Concernsabout legitimacy, a ‘democratic deficit’ and theneed to shift power and responsibility to the ‘citizen’have led to the emergence of a range of new deliberative foraand democratic processes. This has led to debates about howto ensure that social diversity can be represented in the decision-makingprocess. A challenge has been how to engage with the issuesof an ageing population and represent older people in all theirdiversity. In recent years, there have been growing calls toextend advocacy rights to older people living in residentialcare. Mostly, this has been to ensure that as consumers, theyhave a fuller say in how their service is run. Older care homeresidents are service users but, as persons, should not be reducedto this role only; they are also citizens in the broadest senseand should not be cut adrift from debates at the national, localand community levels on issues that concern them. This paperexamines how the moves to bring older people into deliberativedemocratic processes have tended to focus on those in their‘Third Age’. Those in institutional settings, beingin the ‘Fourth Age’, occupy a much more marginalposition. This effective disenfranchisement is yet another reasonwhy, for many, the move into residential care—a difficulttransition for a variety of reasons—becomes regarded asthe ‘last refuge’. It contributes to the sense ofloss of identity, lowering of self-esteem and a reduced senseof personhood. This article accepts that there should be moreeffective involvement of care home residents in decision makingabout their personal care. However, there are dangers in adoptinga too narrowly consumerist approach. This can reinforce a reductionistview of care home residents simply as ‘service users’—aform of ‘othering’ in itself. As citizens and membersof a wider community, they should be included in consultationsabout any community and wider political debates that affectthem. Such a proposal implies a widening and deepening of advocacyservices available to this group. As most older people in residentialcare are there following the intervention of a social care professional,then ensuring that they have access to advocacy must surelybe a key task. This paper argues that this is frustrated bythe lack of suitable services. Without a significant investmentby the Government in independent advocacy services, not onlyis the social work task with one of social care’s coreclient groups rendered impossible, but the Government cannotdeliver on its own agenda of empowerment, active citizenshipand inclusion.     

Leading Article: Community Care as an Alternative to State Welfare

This paper challenges prevailing notions of community and community care. It exposes some of the confusions associated with current thinking and offers a more realistic interpretation, drawing upon the roots of the idea of community. By this standard, genuine community care is to be regarded as an alternative to state welfare, which it might serve to replace or complement.     

社区照顾在残疾人社会保障中的运用

社区照顾最早产生于英国,自诞生以来,便以其新型的理念与模式日益受到各国学者和政府的重视。社区照顾作为一种专业化的照顾模式,在残疾人社会保障方面具有广阔的发展空间。本文试图将社区照顾的制度安排应用于我国残疾人社会保障事业,并探析我国残疾人社区照顾的模式,以推动我国残疾人社会保障事业向人性化、社会化、专业化方向发展。     

社会工作介入老年临终关怀探析

随着老龄化时代的到来和人们生活质量的提高,老年临终关怀受到越来越多的关注。社会工作是一项助人自助的专业工作,可以通过综合运用个案工作、小组工作、社区工作三大社会工作专业方法,对临终老人及其家属进行多层次、全方位的介入。     

Asian Pacific Islander Dementia Care Network: A Model of Care for Underserved Communities

This study presents the results of the work of the Asian Pacific Islander Dementia Care Network (APIDCN)—a collaborative model of care created to develop community capacity to deliver dementia capable services, build community awareness about Alzheimer’s disease and other dementias, and offer direct services to caregivers in the API community in Los Angeles. Through trainings, mentoring, and outreach campaigns, the APIDCN expanded the availability of culturally competent services in the API community. The knowledge that was embedded within partner organizations and in the community at large assures sustainability of the services after the project ended.     

Halfway There? Policy,Politics and Outcomes in Community Care

The community care reforms which followed the 1989 White Paper "Caring for People"were apparently focused on addressing the needs of people requiring long-term care, and on achieving improved outcomes and better quality of life.
The agenda set out by the White Paper was for community care in the next decade and beyond. Half way through this decade, we question the extent to which the objectives of promoting choice and independence for users and carers have been achieved. The paper draws particularly on a programme of monitoring conducted jointly by the Nuffield Institute for Health and the King's Fund, based on national and local focus groups meeting over a two-year period. It proposes a framework for evaluation which consists of four components: the definition of desired outcomes; specification of service systems necessary to deliver such outcomes; promotion of access to services; and the development of supporting operational policies and resource allocation mechanisms.
This framework offers a substantial step beyond much of the monitoring of the community care reforms which has taken place to date. This has assessed progress largely in terms of the establishment of new systems and processes. We conclude that such changes were essential building blocks for delivering better-quality community care services, and in the short term it may have been legitimate to view their establishment as proxies for progress towards delivering user-centred services. However, monitoring and evaluation should now be increasingly oriented towards ensuring that these changes are in fact producing the desired service outputs and urn outcomes. We propose that our framework offers one such way forward.     

Considerations in Care for Individuals with Intellectual Disability with Advanced Dementia

Abstract

A number of physical, psychosocial, or ethical issues related to the care of the individual with advanced dementia are reviewed and related to individuals with intellectual disabilities. The sources used include the published literature and illustrations drawn from personal observations. The author notes that through anticipation and early planning, advanced directives and service planning (which looks to adaptation of services and other care management interventions), can effectively impact care at the end. Areas that need to be addressed include technical information, including a review of and, as appropriate, adaptation of general advanced dementia resources, relief, rest, support, reassurance, receipt of on-going information, participation in planning, a sense of humor, and appreciation. Also noted, are the differences experienced because of the presence of paid staff as carers and residence outside of the family home. It is concluded that, although the goals of quality care is the same for all people with advanced dementia, the process by which to reach these goals often needs further consideration and adaptation for people with intellectual disabilities.