Who will care for older people? A case study of working with destructiveness and despair in long-stay care

Abstract

The reduction of services for older people is illustrated in a case study of a long-stay NHS service which has been transferred to a private, profit-making company. The effects of cuts in this service are most keenly felt in the very poor conditions of employment now offered by the company to new carers. Other illustrations of cuts are described in attempts to make savings on food or incontinence pads. The difficulties for staff, patients, their relatives, or indeed society at large, in challenging such destructiveness, may be understood in terms of the particular vulnerability of older people to projections of a dreaded infantile dependency and helplessness, in a society in the grip of a destructive narcissism which views ordinary human needs as a weakness.     

Sense of Need for Financial Support and Respite Services among Informal Caregivers of Older Americans

ABSTRACT

Financial support and respite services are two of the most frequently reported types of help that caregivers of older adults need. Using an expanded health behavioral model, this study examined the effects of predisposing, enabling, and needs factors on caregivers' sense of need for these two types help. Data were drawn from the 1999 National Long-Term Care Survey and included 1,058 caregiving dyads in the community. The results indicated that caregiver-related factors more than care recipient–related factors affected caregivers' sense of need to seek both types of help. The findings direct to two important implications for long-term care policy for and practice with older adults: improvement of service for caregivers and service delivery systems.     

Managing Risk in Community Care of Older People: Perspectives from the Frontline

Abstract

Since the mid-1980s, Australian governments have focused on expanding community and home-based services for older people. This has led to increased levels of dependency, vulnerability, and complexity to be managed in the community. Consequently, aged care services have had to develop mechanisms for regulating and managing these increased risks, and risk management has become more central to the practices of professional workers in this field. This paper reports on some findings from a large-scale study that explores the way risk management policies have been translated into practice by community-based services in Victoria, Australia. Drawing on interviews with 18 frontline and management professionals employed in community aged care, we found that these workers were wrestling with a diverse and new range of institutional risks beyond those encountered in the actual delivery of frontline care. We found that these workers experienced “risk” in four different contexts, which often created demands for contradictory or conflicting responses. Here we examine these “contexts of risk practice”: professional workers' relationships with their clients, relationships with other service providers, the unregulated nature of the home as a work environment, and community expectations about the management of risk. Despite tensions that frequently arose, workers expressed strong professional commitments to their clients and were motivated to find positive resolutions amid competing interests. We conclude that tensions experienced by workers were embedded in the structural dimensions of institutional relationships and the systematic absence of shared understandings of “acceptable” risks in the community care of older people, rather than in the failure of professional agency.     

Local Housing and Service Decisions

Abstract

The purpose of this research was to identify factors associated with local housing and service decisions that support aging adults in rural communities. These decisions represent de factostrategies that affect the quality of life of older residents and their ability to age in place. Data were collected from 951 informants in 134 Midwest rural communities. Analyses were undertaken to identify the role of community characteristics in predicting the availability of a group of housing options and support services. Findings support the notion that the community context is important to the delivery of key housing and service needs. Population size, proportion of community residents 65 years and older, and housing planning processes promoted gains in housing and services.     

Organization and Delivery of Long-Term Care in Singapore

Summary

This paper focuses on the Singaporean model of long-term care for older people. With only about 2% of the older population living in institutions, the mainstay of long-term care is community care. The reader is provided an overview of the Singaporean services, including case management, followed by a discussion of the current issues and future challenges. In keeping with the prospect of a rapidly aging population profile, the Singapore government plays a leading role in framing policy and planning for future needs of this sector of the population.     

Targeting Services to Those Most at Risk

Abstract

The budget crises facing many state Medicaid programs have increased interest in the goal of linking services and housing as a way to provide more options to people with disabilities at less cost than institutional care. This article examines some of the premises underlying this interest, especially with respect to linking supportive services and federally subsidized housing for older persons. The first section provides a brief history of the activity in this area. The second section examines the risk factors associated with nursing home admission and how those factors match the characteristics of renters receiving subsidies. The third section focuses specifically on the likelihood that subsidized renters will also become eligible for Medicaid. The fourth section explores the capacity of housing programs to meet the challenges associated with service delivery. Finally, the conclusion examines the implications for public policy decision-makers interested in linking services and housing in order to address the long-term care (LTC) needs of older persons with modest incomes.     

Coordinating Health,Extended Care,and Community Support Services

Abstract

Under pressure to maximize the cost-effectiveness of programs, efforts to improve coordination have become increasingly central to the development of the broader health and welfare service delivery system in Australia in the past few years. This article reviews recent experience in two related fields: (1) the coordination of different community care services for older people and people with disabilities, funded by the Home and Community Care program; and (2) the attempt to enhance links between community and residential care services, hospitals, and other health care providers. Why coordination has emerged as such an important issue in the field of community care and, increasingly, across the entire system of what the Australian government now terms health and family services is discussed. A number of measures that have been introduced or are proposed to improve a coordination of services are briefly reviewed. These range from individualistic approaches based on information and referral, through schemes involving gatekeeping, case management and brokerage of services, to models involving the reconfiguration of organizational structures, linkages, and finances. These measures are not mutually exclusive and are increasingly likely to be applied in more complex mixed models of service coordination. It is argued that coordination at the level of direct-service provision is difficult if government policies that direct services lack coordination.     

The accommodation and support needs of people with a mental illness: A process and framework for action

Abstract

This paper reports the results of a consumer-focused assessment of the accommodation and support needs of people with a mental illness living in a regional city. The study utilises a 'pathway to stability' approach to assess the phase-contingent accommodation and support needs of mental health consumers through interviews and focus groups with consumers, carers and service providers. The study identifies five broad phases of the life course impacted by mental illness—beginnings, long-term needs become clearer, instability as needs evolve, finding stability and ongoing. Five key issues—information, self-competence, comorbidity, coordination and flexibility were expanded upon in focus groups. Principles for planning future service delivery are identified. The implications of the findings and research methodology for social work practice and research are discussed.     

Austerity and the lives of people with learning disabilities. A thematic synthesis of current literature

Abstract

The Financial Crisis of 2008 resulted in many western economies implementing cuts in health and social care. This systematic review provides a holistic picture of the impact of austerity policy on the lives of people with learning disabilities (LD) and the collateral effects on the people who support them. Our review suggests that in the current climate of economic austerity, available funding to support people with LD is no longer aligned to their care needs. Cuts in disability services have adversely affected the well-being both of people with LD and their informal carers. Individuals with LD have lost social support and are experiencing increased social isolation. Heightened demands on family carers’ time have negatively influenced their wider roles, including parental functioning, and labour market participation. Our review provides the foundations for further discourse and research on the effects of austerity on people with LD and their family carers.     

Failed individualism in community care: An example from elder abuse

Summary

Community care has been associated with a particular vision of interpersonal relations reflecting the demands of a market economy of welfare. It is argued that individualised notions of citizenship significantly effect how social actors respond to issues such as dependence, independence and interdependence, with consequences that locate unacceptable attributes within failed individuals'. This gives rise to a number of possibilities for collusion between workers, carers and older people who require services, and forms the basic triangle for interpersonal relations within community care policy. The parallel rise of elder abuse as a recognised social problem is considered in this light and three forms of collusive alliance, based on life-task, family solidarity and heroic defence are explored in greater detail. The paper concludes by examining the possibility of interdependence as a guiding principle which can be used to contain each actor's perspective, whilst contributing to the development of non-abusive relationships.     

The Fount of All Knowledge: Training Required to Involve Service Users and Carers in Health and Social Care Education and Training

A modified Delphi study was carried out in order to obtain consensus regarding the content of a university training course to involve service users and carers at all stages of the health and social care educational process within a higher education environment. Telephone interviews were carried out with service users and carers, educationalists and leaders in the field of service user and carer involvement to generate curriculum ideas. A questionnaire was developed from their responses and sent to a purposive sample of 65 people (24 service users and carers, 28 health and social care educationalists and 13 leaders in the field of service user and carer involvement). Fifty‐five statements were generated with consensus being reached on 46 (84%) statements. Mismatches between service users and carers, educationalists and leaders in the field were explored. Key themes to be included in the curriculum were identified. This paper demonstrates that the best training is not imposed upon service users and carers by academics or others who think they know best; rather, that service users and carers themselves can play a leading role in identifying their training needs and devising strategies to ensure these needs are effectively met.     

The Needs of Older Lesbians and Gay Men in Chicago

Abstract

The authors report results from a study assessing the social service needs of gay menand lesbians over 45 years of age in Chicago. Results suggest that this population is diverse and presents a wide range of needs. The authors advocate the use of a community organizing approach that involves older gay men and lesbians in the provision of services. The authors also highlight the need to consider the social context in which services will be provided.     

Time to ask and tell: Voices of older gay and bisexual male veterans regarding community services

ABSTRACT

This participatory action study involved lesbian, gay, bisexual, transgender, and queer (LGBTQ) veterans in determining community-based service needs for health and wellness, illuminating perspectives of older LGBTQ veterans regarding community services. This study explored veterans' perceptions of being LGBTQ later in life. The study included data from interviews with gay and bisexual male veterans ages 51 to 87. Participants valued engagement as part of community. Their recommendations for action included communal meals, transportation, housing, and the coming-out process. Community services facilitated community engagement to support health and wellness for LGBTQ older veterans. The authors used participatory action research (PAR), a method of systematic inquiry integrating the perspective of persons living the experience, to organize the study. Further PAR is recommended to implement community services to meeting health and wellness needs of participants.     

Mind the Gap: Built Infrastructures,Sustainable Caring Relations,and Resilient Communities in Extreme Weather Events

Abstract

Climate change debates seldom link the insights derived from the physical sciences to the concerns of social scientists. Understanding how failures in built infrastructures increase the caring burden on women is one of these instances. This article draws on a pilot study on climate change and older people to demonstrate that women who provide informal care services are called upon to fill the gap between declining levels of formal care provisions and care needs when the infrastructures serving a community fail. This research challenges policymakers, emergency planners, and practitioners to think about the increased care burdens that women are expected to undertake during disasters involving extreme weather events like heat waves, cold snaps, and flooding, and reconsider policies that pass this responsibility down to the level of community without the necessary support services and built infrastructures being in place. This issue acquires additional urgency in the context of declining levels of care being publicly funded through the age of austerity as public expenditure cuts begin to bite.     

WORKING CARERS OF OLDER ADULTS

Juggling work and care presents particular challenges to carers and employers. Employers are increasingly under pressure, both from within organizations and from recent government legislation and policy, to develop family-friendly policies to support informal carers in the workplace. Yet existing ‘family-friendly’ schemes and services are still primarily designed for working parents of young children and rarely address the needs of employees who care for older or disabled adults. This paper reports on a study which investigated how working carers and managers in two public sector organizations — a Social Services Department (SSD) and a National Health Service (NHS) Trust — combined their work and caring responsibilities. A multi-method approach was adopted consisting of five phases. First, a profile of the two organizations was established, followed by a short screening questionnaire to all employees to identify who was caring for an older adult over the age of 60. Third, a lengthier postal survey was sent to the 365 carers who had indicated a willingness to participate further. In the fourth and fifth phases, carers and managers were interviewed in depth about their experiences. This paper reports briefly on the survey, but then concentrates in particular on what was said in the interviews about what helps and hinders working carers of older adults. Despite the existence of policies to support carers, our findings suggest that these were far less important than informal support from colleagues and a sympathetic manager in the workplace. Commuting distance between work, home and the older person also posed difficulties for carers, along with inflexible schedules and work overload. Employers are urged to explore these issues further if they are serious about recruiting and retaining employees, and developing the work – life balance agenda to meet the needs of those caring for older and disabled adults.     

An exploration of older Hong Kong residents’ willingness to make copayments toward vouchers for community care

Because of its rapidly aging population, Hong Kong faces great challenges in the provision and financing of long-term care (LTC) and needs to explore sustainable funding mechanisms. However, there is a paucity of research on older people’s willingness to pay (WTP) for LTC services in Hong Kong. This study utilizes data collected in Hong Kong in 2011 (N = 536) to investigate older people’s receptivity to this financing mode by assessing their co-payments for a community care service voucher scheme and then testing how potential factors affect respondents’ amount of co-payment. Results show that respondents’ WTP was positively associated with family financial support, financial condition, and positive attitudes toward this novel policy and negatively associated with family caregiving support. Direct and moderating effects of family financial support on WTP were found. The policy-related implications of LTC financing to improve older people’s acceptance of co-payment mechanisms, financial condition, and shared responsibility of care are discussed.     

User and Carer Experiences of International Social Care Workers in England: Listening to their Accounts of Choice and Control

Abstract

This paper develops a typology of people using social care services’ preferences for care workers and satisfaction with social care services from a large multimethod study that explored international recruitment to the English social care sector (home and health care, including residential homes). We developed this typology with two questions in mind: (a) what led to satisfaction of care and (b) what led to preference and satisfaction with workers? Data were collected from face-to-face interviews with 35 people who were using social care services and carers (2007–2009) and these data were used to develop the typology. Using the theoretical concept of homophily, we explored contentions that people might prefer to receive care and support from individuals resembling themselves. We observed that preferences for care workers and satisfaction with social care services may be linked, but highlighted that the concept of meeting a preference is personal to the individual. The implications of users’ preferences for certain care workers at a time where policy is promoting greater consumer-led care or self-directed support are discussed.     

Community Care in Taiwan

SUMMARY

This article explores the policy definitions and the funder roles of central and local governments in community care in Taiwan. The notion of community care has been adopted in Taiwan following the model of Hong Kong but the main question of the article is whether this has resulted in actual service provisions at the community level, forming an alternative to institutional care. The data has been collected from several sources: policy documents, official statistics, surveys, general reports, funding provision reports, and empirical studies. The results show that neither central nor local authorities are seriously involved in caring for elderly people or persons with disabilities in Taiwan's communities. In Taiwan, community care for these groups of people still means, in practice, informal care provided by female family members without any support from public policies.     

Sources of Double Disadvantage for People with Disabilities Living in Remote and Rural Areas of New South Wales, Australia

This study demonstrates how people with disabilities living in remote and rural areas experience double disadvantage in regard to receipt of services. They tend to experience similar disadvantages to other remote and rural dwellers (as compared with their urban counterparts), but these disadvantages are compounded by those associated with living in an environment which does not cater for the needs of people with disabilities. Findings display how geographical, physical, cultural, social and psychological factors within the external environment create disadvantages for the individual. The project involved data collection from people with disabilities, disability groups, service providers, families and carers through consultations and field trips. Major issues emerging from consultations were concerned with: transport and distance, isolation, the need for more consumer involvement, the nature of service provision (appropriateness, flexibility, co-ordination and location), the need for community and professional disability awareness education, protection of rights, carers and respite care, accommodation and housing, education, employment, information dissemination and access to specialised equipment. Comparison with overseas studies indicates that findings from this Australian study have applicability in other countries which have large remote and rural areas.     

Heterogeneity Among Potential Foster Carers: An Investigation of Reasons for Not Foster Caring

Abstract

Although Australia is experiencing a shortage of foster carers, there is currently little understanding of why people do not become carers. This study explores the reasons given for not fostering though a survey of 897 non carers. Results indicate that, at the aggregate level, people do not become carers because they do not know anything about fostering, or because they are busy with their own children, work, or commitments to family and friends. However, if we account for heterogeneity, differences in these barriers are observed for subgroups within the sample. We investigate the structure of the market of potential foster carers by segmenting the market using cultural background as the segmentation base. Results indicate that the reasons for not fostering differ depending on the subgroup being examined. Theoretically, this suggests that heterogeneity exists within the foster care market, and that examining barriers to foster care only at the aggregate level neglects the importance of individual subsegment characteristics. Practically, results are important because they suggest that generic marketing campaigns aimed at the entire community have limited effect and that customised strategies are required to attract the particular types of carers most needed.