Community Treatment Orders for People with Serious Mental Illness: A New Zealand Study

New Zealand legislation allows for the involuntary outpatienttreatment of people with serious mental illness. This studyexamines the views of service users, family members and mentalhealth professionals (MHPs) about the impact of this regime.Semi-structured interviews were completed with forty-two serviceusers, twenty-seven family members and ninety MHPs, with recentexperience of the regime. Participants were asked to commenton the functions of community treatment (or non-resident) orders,their benefits and restrictions, decisions about their terminationand any impact on relationships. Most service users believedthe main purpose of the order was to ensure they took medication.They also believed the order provided better access to othertreatments, supported accommodation and care from MHPs. Familiesconsidered the orders provided relief for them and a supportivestructure for their relative’s care. MHPs found the ordersuseful for engaging service users in a continuing therapeuticrelationship, and for promoting treatment adherence. In eachgroup, a majority of those interviewed viewed involuntary communitytreatment in a generally positive light, while acknowledgingthe restrictions imposed on service users’ freedom.     

Long Term Care for the Elderly: the Community Care Scheme

Summary The article describes the full evaluation of the Community CareScheme for the elderly in Kent. The evaluation compared therelative cost-effectiveness of the scheme for clients and carerswith the range of services which would otherwise have been received.It is argued that effective case-management by a key workeris an essential feature of more effective home care for thevery frail elderly and that the case-management role is an appropriatemodel of social work for other long term care groups. The newscheme appeared particularly appropriate for the extremely mentallyand physically frail who were living with others and for theless frail, socially isolated elderly person prone to minorpsychiatric disorder.     

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.     

Charging and Quasi-Markets in Community Care: Implications for Elderly People with Dementia

Social services authorities in the UK are increasingly involved in charging and fee collection activities with clients in receipt of community care services. This article explores the implications of these developments for elderly people with dementia. The starting point of the article is a critique of existing legal and administrative options for handling other people's money, including the difficulties and dilemmas raised for both paid and unpaid carers by the existing arrangements. This is then related to the failure of charging and fee collection systems which have developed as a result of the community care reforms to address the particular needs of elderly people with dementia. A case study of policies in one local authority is outlined and this is followed by the presentation of the view of 37 fieldlevel professionals who were interviewed in focus groups. The concerns of these respondents included the complexity of the assessment task, conflicts between care managers and finance/revenue staff, the difficulty of defining and responding to financial abuse, and dilemmas over the extent to which relatives and carers should be trusted. The final section of the article considers the implications of a move to quasi-markets in social care for elderly people with dementia, particularly in terms of their vulnerability to financial exploitation.     

Integration and Targeting of Community Care for People with Severe and Enduring Mental Health Problems: Users' Experiences of the Care Programme Approach and Care Management

Correspondence to Professor John Carpenter, Director, Centre for Applied Social Studies, University of Durham, Elvet Riverside II, Durham DH1 3JT, UK. E-mail: J.S.W.Carpenter{at}dur.ac.ukJ.S.W.Carpenter@dur.ac.uk Summary We report the experiences of different models of community careof random samples of 262 people with severe and enduring mentalhealth problems living in four districts in the north of England.The districts were characterized in terms of the extent of (1)integration between the health service-led Care Programme Approach(CPA) and social services Care Management, and (2) targetingof services on people with severe mental health problems. Themajority of service users felt involved in planning their owncare and considered that they had choice in their care and treatmentwhen in the community, but not in hospital. Although all theseusers were formally subject to the CPA, the proportions of usersin the districts believing they had a written care programmeranged between 37 per cent and 60 per cent. Of these, the greatmajority were very positive about their care programmes andfelt that they were being helped to become independent. Theseresults were replicated when 87 per cent of the original samplewas re-interviewed six months later. There were significantdifferences between the four districts and evidence that userspreferred an integrated health and social care service. In addition,a higher proportion of users in inclusive districts were satisfiedcompared to those in targeted districts. Notwithstanding thesepositive findings, there is still considerable room for improvementin relation to the involvement of family carers and the provisionof adequate information about prescribed medication and makingformal complaints.     

Family Placements for People with a Learning Difficulty: A Study using Time Budgets

Correspondence to Dr R. F. Drewett, Department of Psychology, University of Durham, Science Building, South Road, Durham DH1 3LE. Summary The Durham County Council Family Placement Scheme offers long-termcare in families for adults with learning difficulties. Theactivities of the twenty-four clients in family placements werestudied using interviews and diaries kept by carers. Althoughmost of the clients were only mildly handicapped three wereseverely disabled. Most of the carers have either professionalor voluntary experience of work with people with learning difficulties.Although four of the placements have broken down, the levelsof activity of the clients still in their families were similarto those found in other types of community-based care, and werejust as extensive in the more disabled. The previous experienceof the carer had no clear relationship with the activity levelsof the client.     

Correlates of Treatment Retention Among Persons with Serious Mental Illness Receiving Integrated Care in a Community Mental Health Setting

ABSTRACT

Knowledge about methods to retain community mental health (CMH) clients in integrated primary and behavioral health care (PBHC) programs is needed to address longstanding health disparities. A preexisting data set that contained the clinical records of 446 PBHC program participants was used to examine whether baseline sociodemographic, health, and psychosocial characteristics predicted retention in care at 6 months post-enrollment. Results indicated that less than half of PBHC participants (43.7%) were retained in care, and approximately 17% of the variance in retention was explained by the inclusion of seven predictors in the model (overall health, medications, laboratory data, primary care provider, disorder type, transportation, and living arrangement). Clients with thought disorders were almost twice as likely as those with mood disorders to be retained in care, and greater frequency of prescribed medications also increased the likelihood of treatment continuation (ORs = 1.99 and 1.20, respectively). Future research should identify factors that improve retention in integrated PBHC programs overall, and among persons with mood disorders, in particular.     

Care Management and Professional Autonomy: The Impact of Community Care Legislation on Social Work with Older People

Correspondene to Mark Lymbery, Centre for Social Work, School of Sociology and Social Policy, University of Nottingham, University Park, Nottingham NG7 2RD, UK. e-mail: Mark_Lymbery{at}nottingham.ac.uk Summary The 1990 National Health Service and Community Care Act appearedto herald a new dawn for social work with older people, whichhad previously been a relatively neglected and undervalued areaof social work practice. The legislation proposed a new rolefor social workers as ‘case managers’, with considerableautonomy and flexibility about the way in which the ‘casemanager’ responded to need. By the time community carepolicy was implemented, the role of ‘case manager’had been transformed into that of ‘care manager’,with a focus which emphasized procedural and managerial requirementsrather than a more flexible professional practice. This paper explores the extent to which this shift has substantivelyaltered the nature of social work practice with older people.It outlines key theories of professions and their applicabilityto social work, and critically analyses the impact of the ‘newmanagerialism’ within social services departments. Thepaper also examines the nature of social workers' practice witholder people following the impact of community care legislation,and concludes that the impact on the social work professionhas been to locate an increasing control of practice with socialwork managers, with potentially serious consequences for thecontinuation of a distinctive social work role in relation toservices for older people.     

Prevention Programmes in Community Mental Health: A Review

Allocation of resources to community mental health care in Australia has escalated rapidly in recent years. The major conceptual advance has been the balancing of traditional therapeutic or remedial intervention with the goal of preventing psychological distress. The authors argue that the implementation of preventive programmes has fallen short of expectation. Two reasons are advanced: the differing status accorded the two activities, and the lack of goal definition in prevention programme development. Recommendations are made for the successful implementation of prevention programmes in community mental health care.     

The Geriatric Worker in a Community Mental Health Clinic:

Special geriatrics services are now a reality in many community mental health clinics, thus making it timely for clinicians and administrators to look at the problems faced by geriatric workers in that setting. This article addresses the problems in the worker's role by first comparing it to those of other special population mental health workers. Systemic difficulties and structural problems of the job are examined with emphasis on the worker's experiences and feelings. The author contends that the worker's issues parallel those of elderly clients. Solutions for changing negative aspects of the separate service role are discussed and their impact on service delivery described.     

Working in Multidisciplinary Community Mental Health Teams: The Impact on Social Workers and Health Professionals of Integrated Mental Health Care

Correspondence to Professor John Carpenter, Centre for Applied Social Studies, University of Durham, Elvet Riverside II, Durham DH1 3JT, UK. E-mail: J.S.W.Carpenter{at}dur.ac.uk Summary This study investigated the relationships between the organizationof community mental health services and professional and teamidentification, team functioning and the psychological well-beingand job satisfaction of staff working in multidisciplinary communitymental health teams (CMHTs). Staff in four districts in theNorth of England completed anonymous questionnaires on two occasions,twelve months apart. There were systematic differences in teamfunctioning, favouring teams in districts where mental healthand social care services were integrated. However, service organizationhad no evident impact on professional or team identificationor on outcomes for staff in terms of stress or job satisfaction.There were differences between social workers (n = 31) and healthservice professionals (n = 82) indicating that social workershad poorer perceptions of team functioning and experienced higherlevels of role conflict. Controlling for other factors includingthe study districts, role conflict was a significant predictorof stress and of job dissatisfaction, while role clarity promotedjob satisfaction. We conclude that support and supervision aimedat ensuring a social work contribution to multidisciplinaryworking should be provided in the course of establishing CMHTsand integrated health and social care services.     

Aging and Elder Care in Japan: A Call for Empowerment-Oriented Community Development

This article provides a brief overview of the situation of the elderly and their caregivers in Japan, including demographic changes in Japan, development and changes in long-term care policy that have targeted the poorly integrated community care system, and other challenges that the elderly and family caregivers face. Policy direction designed to address these issues is increasingly targeting care by the community versus support care by society (which was initially the main strategy). The potential of empowerment-oriented community development intervention strategies to decrease the gap between available institutional and formal community-based services and the needs of the elderly and their families in their efforts to meet late life challenges is described. The need for an increased role of social workers in community development interventions is explored and strategies are suggested.     

Building Care Management Competence in Services for People with Learning Disabilities

Correspondence to Paul Cambridge, Tizard Centre, The University of Kent at Canterbury, Canterbury, Kent CT2 7LZ, UK. Summary This paper examines care management arrangements in servicesfor people with learning disabilities. Its perspective is informedby research on the long-term outcomes and costs of care in thecommunity for people with learning disabilities (Cambridge etal., 1994) and by earlier experimental approaches to care managementin Britain. Building on arguments developed by the author ina position paper in 1992 (Cambridge, 1992), the focus here shiftsto the performance of mainstream care management in servicesfor people with learning disabilities, with an identificationand review of critical dimensions for reviewing competence.Lessons from earlier experimental and demonstration approachesare used to inform the analysis and to construct pointers forcommissioners or providers who are looking to assess the effectivenessof care management arrangements in learning disability withintheir own service systems.     

Hostel Care for Elderly People: The Association with Hospital and Nursing Home

In order to achieve its purpose a hostel should have a clearly defined association with both acute hospital and nursing home. This report is a study of the reasons for separation of residents from a hostel over a period of four years; it included temporary admissions to an acute hospital situation and permanent transfer to a nursing home. It is estimated that one nursing home place is needed for every three residents in this kind of hostel. Thirty-six of the 79 residents in a hostel with 32 places had a total of 58 temporary admissions to an acute hospital situation during the four year period. Thirty-three (42 per cent) of the 79 residents needed transfer to a nursing home during the study period. Analysis was made of the time spent (person years) in each institution. Although 42 per cent of the residents needed transfer from hostel to nursing home they spent approximately 75 per cent of their time in the hostel.     

Vital Conversations with Family in the Nursing Home: Preparation for End-Stage Dementia Care

Family members of persons with advanced dementia may be asked to make complex treatment decisions without having adequate knowledge regarding the risks and benefits. This 6-month, prospective, randomized trial tested the effect of an intervention consisting of a face-to-face, structured conversation about end-of-life care options with family members of nursing home residents with advanced dementia. A comparison group received only social contact via telephone. Structured conversations between a palliative care team and intervention group family members included goals of care and how best to achieve those goals, and provision of psychosocial support. Psychosocial support was also provided via telephone at three 2-month intervals. Family members participated in three telephone interviews: baseline, 3, and 6 months. Specific advance directives for persons with dementia were extracted from medical records. Results showed that intervention families had higher satisfaction with care than comparison families at the 6-month time point, and they were more likely to have decided on medical options listed in residents' advance directives (Do Not Resuscitate, Intubate, Hospitalize) over time. Study findings reinforce the need for increased education and support for families around issues of end-of-life care decisions for advanced dementia.     

Evaluation of a Carer Support Scheme for Elderly People: the Importance of 'Coping'

Correspondence to Dr Derek Milne, District Psychology Service, St George's Hospital, Morpeth, Northumberland NE61 2NU. Summary One year's consecutive referrals to an Age Concern carer supportscheme entered an evaluation of the carers' stress, coping andstrain. Unlike a comparison group who did not use the scheme,these carers of elderly dependants had significantly poorerpersonal coping strategies, which were bolstered by the scheme.Stress and strain were high for both groups of carers, indicatingthat the critical variable in their continued role as carerswas coping. Implications for the formal services are discussed.     

Family Caregiving and the Site of Care: Four Narratives About End-of-Life Care for Individuals with Dementia

Little is known about end-of-life care for individuals with Alzheimer’s disease and other dementias. Four case studies are presented, using data collected by qualitative interviews conducted with family caregivers who were closely involved with end-of-life care for relatives with dementia. The case studies are formatted in two pairs, with one reflecting two deaths occurring at home and the other pair representing two deaths in the nursing home. The cases reveal a range of end-of-life experiences, suggesting that there is not just one “good” path. The extent of care needed, the responsiveness of the individual, the health of the caregiver(s), and the residence and support situations, can all intersect in a variety of ways that make no one scenario the answer for all. Although most people say they would prefer to die at home, in some situations the nursing home can be a satisfactory choice, particularly if hospice is involved. These narrative case studies give the reader insight into the variety of the end-of-life experiences and suggest the environment should be considered as part of the care provision.