Care Management in Social and Primary Health Care

The Gateshead Community Care Scheme

David Challis, John Chesterman, Rosemary Luckett, Karen Stewart

• Publisher: Routledge
• Year: 2018
• Print ISBN:
  9781138737716
• eBook ISBN:
  9781351733465
• Topic: Social Sciences
• Subtopic: Social Work
• Index: Social Sciences

This title was first published in 2003: This book provides an evaluation of the Gateshead Community Care Scheme which was devised as an alternative to residential and hospital care for frail elderly people. An important feature of the scheme was the decentralization of control of resources to individual social workers acting as care managers, with defined caseloads and expenditure limits to ensure accountability. The initial social social care scheme was subsequently extended to provide both health and social care to clients from a large general practice based in a health centre. The social care team was enlarged to include a nurse care manager and part-time doctor and physiotherapist. The study examines the operation of care management in both settings, the use of devolved budgets and services developed, the outcomes for clients and carers and the costs of care. Admissions to residential care were reduced and the elderly people who received the scheme's support experienced a better quality of care and greater well-being when compared with elderly people receiving the usual range of services. This was achieved at no greater cost. The characteristics of those for whom the scheme was most appropriate are described. In addition, the pattern of development of the scheme as it was incorporated into the mainstream of the Social Services and after the implementation of the NHS and Community Care Act are examined. Final, the implications for the development of care management are considered.

1
Care Management, Coordinated and Integrated Care

There has been a longstanding concern to provide integrated and coordinated care for vulnerable older people. This is evident in the long-term care policies of many countries (Kraan et al., 1991; Challis et al., 1994; Campbell and Ikegami, 1999). In the UK, this concern can been seen to have moved from approaches which address inter agency collaboration and joint planning through the 1970s (Webb and Wistow, 1986), towards an increasing emphasis upon integration at the practice level. This is evident in such initiatives as Care in the Community (DHSS, 1981) and most obviously the White Paper Caring for People (Cm 849, 1989). The latter marks the point at which policy focuses both on macro and on micro level initiatives to promote these goals at the same time. In that policy document assessment and care management were framed as the cornerstone of high quality care. In the recent White Paper Modernising Social Services (Cm 4169, 1998) the importance of coordination, clarity of role, flexibility of services and efficiency are again stressed. Key areas for action are the promotion of independence, improving consistency and providing convenient user-centred services. These activities are set in a context of more macro level integration reflected in the development of partnerships between health and social care (Department of Health, 1998b). This is particularly evident in proposals to create care trusts and the growing leadership importance of primary care exemplified in the current emergence of primary care trusts (Cm 4818-1, 2000). Care management can thus be seen as a field level mechanism for coordinating care, which links into the more macro issues of commissioning, service development and joint working.

This book examines intensive care management for frail older people, designed to provide a realistic community-based approach to long-term care for vulnerable people.

Current issues in care management

The contribution of care management to the long-term care of older people spans the policy agenda of the 1990s and that of the new millennium (Warburton and McCracken, 1999). However, following its introduction in mainstream social care in the UK, there appear to be a number of concerns regarding certain aspects of the approach that have been relatively poorly developed. In a review of care management implementation, as part of an evaluation of the impact of Caring for People, five key areas for development were identified

(Chains, 1999). These were assessment; definition of care management; differentiation of care management; service development; and integrating health and social care. Each is discussed briefly below.

Assessment

There appears to be wide variability in assessment systems both in terms of content (what information is sought about needs and how it is recorded) and also in form (the personnel and processes involved in conducting the assessment). This remains the case even where critical decisions are being made such as whether or not a person requires residential or nursing home care. Hence, the degree of variability in assessment approaches appears to be far greater than could be attributed to the variability of the needs and circumstances of those being assessed (Stewart et al., 1999).

Definition of care management

There appears to be little evidence of a shared and agreed definition of care management used by agencies. In the absence of such a definition, care management may be coming to have no more meaning than the process by which people are processed through a care agency. The definition of care management provided in the official guidance on assessment and care management described care management as ‘the process of tailoring services to individual needs. Assessment is an integral part of care management’ (SSI/SWSG, 1991a, p. 11). Such a definition is broad and permits a wide variety of interpretations. It is in contrast to the sorts of definition which relate care management more specifically to long-term care (Applebaum and Austin, 1990; Challis, 1994a; Challis et al, 1995). As a consequence, care management in the UK more frequently represents a description of the broad variety of processes by which people are assessed and gain access to services and less a specific form of activity — coordinating care for highly vulnerable individuals. Accordingly, it may be helpful to define care management in terms of six characteristics, which distinguish it from other community-based care activities. These are the specific functions of care management; the goals it aims to achieve; the core tasks of the activity itself; the attributes of the target population; specific differentiating features; and the multi-level focus of the activity, both at practice level and system level (Challis et al., 1995).

Differentiation of care management

In the UK in many local authorities care management is perceived as a process provided to all service users, irrespective of the intensity, severity or complexity of their needs. This is in contrast to much of the substantive research evidence on care management, which has targeted the most vulnerable older people and has been designed to shift the balance of care towards community-based support from a reliance on nursing and residential care, thereby enhancing user choice. The need to differentiate between, at the very least, care management approaches for very vulnerable people and the assessment and allocation of services to less vulnerable people has been a consistent theme in reports of the Social Services Inspectorate, following implementation of the community care reforms in 1993 (Department of Health, 1994; SSI, 1997).

Indeed, in the annual report of the Social Services Inspectorate in 1997 difficulties experienced by local authorities in coping with the volume of work were in part ascribed to a failure to differentiate between levels of intervention. It rightly concluded that no single model of care management will suit all levels of need or service user groups and identified three distinct types of care management activity, each of which was necessary for an integrated and comprehensive approach. In general terms these three approaches could be identified as screening — to provide information and advice; coordination — organising the care of a relatively large number of cases requiring relatively straightforward services; and intensive care management — where a designated care manager plans and coordinates care, undertaking a supportive role for a much smaller number of users with complex and frequently changing needs.

Service development

The main focus of care management activity appears to have been at the level of the individual service user. Although this is an entirely right and proper focus of activity, the associated activity of service development, designed to produce more user centred services, has been much less evident. Service development may be initiated either through the micro purchasing activities of care management teams, or indirectly through feedback to those with responsibility for commissioning services from providers. Reasons why this area of activity may have been neglected include the lack of devolved budgets (Audit Commission, 1997; Challis et al., 2001).

Integrating health and social care

Integrating health and social care is a key theme of recent policy initiatives (Department of Health, 1997, 1998b; Cm 4169, 1998; Cm 4818-1, 2000). There is a lack of evidence of the appropriate influence of health care professionals in the assessment of older people (Challis, 1999) and even more so, a lack of evidence of the inputs from secondary health care services such as geriatric medicine and old age psychiatry. Care management systems working on a single agency basis and lacking access to appropriate expertise in assessment are unlikely to be fully effective, particularly in the care of individuals with complex problems. Integration of health and social care on the basis of differentiated care management, perhaps linking intensive care management and secondary health care, offers possibilities in the world of new care trusts (Challis et al., 1998a).

The wider care management context

These issues are by no means confined to the UK, but in various ways are the concerns of care management and integrated care in many countries (Applebaum and Austin, 1990; Ozanne, 1990; Davies, 1992; Challis et al., 1995; Rothman and Sager, 1998). Assessment has been central to the matching of needs and resources for frail older people in many countries and the history of variation in the size and content of assessment tools would receive a ready response in many other jurisdictions. The relationship of health expertise, and particularly health care expertise, to the assessment process is also a subject of debate (Challis et al., 1998a). For example, in Australia, a concern for more appropriate targeting of cases in nursing homes is reflected in a precise focus upon the improvement of assessment processes at the point of entry to long-term care. The Aged Care Reforms of the 1980s made Aged Care Assessment Teams, which are frequently full multidisciplinary groupings, responsible for pre-placement assessment (Department of Community Services, 1986). This provided for greater consistency in the personnel undertaking assessment and, in addition, specific goals and guidelines were provided to shape the work of assessment teams (Brown and McCallum, 1991). These would be entirely within the spirit of UK current policy and were:

• To focus upon the needs and wishes of the assessed persons and their carers.
• To be able to refer to a range of services if institutional care is not deemed appropriate.
• To ensure that service users are involved in the development and management of assessment services.
• To ensure equity of access.

In terms of the integration agenda, the Australian reforms again suggest ways in which health and social care may link more effectively by providing examples of care management linked to assessment teams and based within the auspices of a health care service (Challis et al., 1995, 1998a). Finally, with regard to the issue of differentiation, there are concerns in other countries where the term care management has been employed to describe coordination of single agency activities, rather than the more circumscribed definition of long-term care case management employed by Applebaum and Austin (1990) in the USA. Thus, the nature of care management needs greater clarification (Rothman and Sager, 1998).

Care management and the Gateshead study

The Gateshead study assumes importance through being one of the studies of care management for highly vulnerable people which were influential in shaping certain aspects of the UK community care reforms. It was explicitly cited as an exemplar of care management in the White Paper Caring for People (Cm 849, 1989). As such it was one of a family of demonstration studies of intensive care management targeted upon vulnerable older people, whose needs ranged from the equivalent of those living in residential care settings through nursing home and hospital residents. These studies were undertaken both as single agency approaches to intensive care management (Challis and Davies, 1986; Challis et al., 1990a) and also as joint health and social care interventions in primary health care (Challis et al., 1990a), linked to geriatric medicine (Challis et al., 1995) and old age psychiatry (Challis et al., 1997). These were designed to provide an effective and realistic alternative to institutional care for vulnerable older people, increasing the range of choice available, and are summarised in Challis (1999).

The model of care management that was developed in these initiatives was designed to ensure that improved performance of the core tasks of care management could contribute towards more effective and efficient long-term care for highly vulnerable people. The devolution of control of resources to individual care managers, within an overall cost framework, was arranged to permit more flexible response to need and the integration of fragmented services into a coherently planned pattern of care. Care managers specialised in work with highly vulnerable older people and had defined caseload limits.

There were two distinct developments within the experimental phase of the Gateshead scheme. The first was the social care scheme, a social services department initiative designed to prevent unnecessary admissions to institutional care. As such it sought to test the validity of the Kent community care project (Challis and Davies, 1986) within an urban setting. Due to the operational success of the social care scheme, additional resources were provided some four years later by central government and the health authority for a pilot health and social care scheme. This built upon the existing social care scheme, by providing a multidisciplinary care management team, including rehabilitation inputs, covering the patients of one large group practice.

In reviewing models of long-term care in the US, Kane (1999) identifies seven features that are characteristic of effective systems. Interestingly, six of these characteristics were key elements in the Gateshead programme. These were:

• A programme shaped by clearly articulated goals and values, such as independence and choice.
• A single point of access for determining eligibility, assessment and care management.
• A continuum of services and the capacity to make flexible, innovative and unorthodox care arrangements.
• Ready availability of personal care services.
• Flexibility of providers of care, including the capacity for family members to be paid providers.
• A focus not only upon safety and basic care needs, but also upon broader care goals.

The Gateshead study and current policy developments

The Gateshead study is particularly valuable in the light of current policy for a number of reasons. First, it was cited as an exemplar of intensive care management, providing a realistic community alternative for vulnerable people, and thereby contributing to the policy goal of shifting the balance of care and increasing the range of choice (Cm 849, 1989, para. 3.3.3). In subsequent years the development of care management has provided few examples of an intensive approach to home support (Challis et al., 2001) and therefore, as policy makers and practitioners seek to develop such services the relevance of this study is increasingly evident. Second, it was one of the first approaches to care management that developed close links with primary health care. These linkages were more than an approach to case-finding and effective liaison, as has often been the case, but were more the kinds of developments that might be associated with primary care trusts today. The Gateshead initiative sought to engage medical assessment at home with joint nursing and social work care management and rehabilitative approaches in the community. Third, unlike many innovations, the scheme has in various forms been maintained over a long period of time as part of a social services organisation and continues to provide support to vulnerable older people who are more dependent than the average person entering residential and nursing home care. Its influence cannot therefore be seen as that of a short-term project. Finally, and as a consequence of the earlier three points, it provides a particularly relevant example of a number of the key concerns facing care management in the UK at the present time.

Structure of the book

Following this brief introductory chapter, Chapter 2 describes the service context and the research design for both the social care and the health and social care scheme. Chapters 3 to 8 provide a detailed evaluation of the social care scheme, examining in turn: care management in social care; the role of helpers commissioned by care managers; the variety of responses made to common areas of need of older people; the outcomes of the scheme for older people; the outcomes of the scheme for carers; and the costs of care and the factors that determined variation in costs. Chapter 9 examines integrated provision and the impact of the joint primary health and social care scheme. Chapter 10 reviews the lessons from the scheme for current policy and practice developments and considers how the scheme developed before, during and after the community care reforms of the 1990s.

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• List of Boxes, Figures and Tables
• Preface
• 1 Care Management, Coordinated and Integrated Care
• 2 Service Context and Research Design
• 3 Care Management in the Social Care Scheme
• 4 The Role of Helpers and their Experience of the Scheme
• 5 Responding to Particular Needs
• 6 Outcomes for Older People
• 7 Outcomes for Carers
• 8 Costs and Outcomes of Care
• 9 Integrated Provision: Bringing Together Social Care and Primary Health Care
• 10 Intensive Care Management and Community Care
• Reference
• Name Index
• Subject Index