The Situation on the Ground- Challenges and Opportunities

Ageing Well NetworkResidential Meeting 25th March

Mary Higgins Independent Consultant

Purpose and Approach • To critically look at the implementation of the

approach of supporting older people to stay in their own homes - housing, health and social care services

• To identify enablers and barriers to successful implementation and future opportunities and challenges

• Based on consultation with key informants and review of research and other reports

Key Issues – Housing • Preference to stay in own home (87%) followed by granny flat

(40%), care of relative, sheltered housing (25%). Boarded out unacceptable to 77%

• Housing conditions generally improved but for older more likely to be poor (heat, insulation, bathroom, accessibility) or inappropriate (too big, isolated)

• Sheltered housing growing in size and importance but weaknesses in funding and other arrangements and increased competition threaten continued development. One third catering for high support needs

• Private sector provision of ILU retirement villages beginning – 352 units nationally- with nursing homes

• Information on needs crude - waiting lists don’t equate with need, housing strategies general

• Severe weaknesses in information for consumers and promotion of proactive planning

Key Issues – Adaptations and Improvements

• Three separate improvement/adaptation schemes with different means tests

• Increase in applications for new scheme of improvement grants. No transfer of funds from HSE and some concerns about the scope of the scheme

• Adaptations usually considered at point of crisis• Requirements for assessments, quotes, contracting

information on tax liability onerous on applicants • Schemes funding led • No joint assessments between health and local

authorities and no consideration of alternatives at that stage

Key Issues – Assistive Technology

• Technology under utilised by professionals as a means of supporting independence

• Limited or no training for medical professionals in technology

• Concern that range of aids available driven by commercial interests

• Must be based on the capacity and attitude of person • Not enough to provide the technology – have to ensure

older person is comfortable with it and uses it on ongoing basis

• Concern that costs can be prohibitive

Key Issues- Home Care Services

• Investment (€120m) in Home Care Packages has contributed to improving range and quality of care available to people at home

• Home Help hours 2007 12. 4 million; 11,565 receiving HCP 6,279 new

• Attention has been on meeting needs of those at risk of admission to hospital and has not been used for prevention or early intervention

• HCP not always been ideal because of multiplicity of visitors to home

• Question about whether everyone is entitled to HCP or if it is/should be means tested or depend on tenure

• Definitions of care can be rigid and militate against providing what is needed (bathing versus a walk on the beach)

• HCP and HH need support of Day Centres, PHN, family carers to be effective

• Community care under resourced compared to hospitals -budgets have not followed care in the community

• No real assessment of level of need or performance management system means there are unanswered questions about the value for money and effectiveness of HCP and Home Helps, although evaluation currently being undertaken

Key Issues- Day Centres

• No comprehensive data on centres – undersupply generally – 21,300 places in 2008 (HSE)

• Centres in most voluntary and local authority sheltered schemes – some open to wider community

• Scope of services and quality varied (food, activities, medical, hairdressing)- some with waiting lists some under used – no agreed definition of

• Fragmented funding – Section 39 and HCP have been used

• Have potential for greater involvement in health care delivery

• Lack of transport major obstacle to accessing

Key Issues- Assessments

• A standard assessment for HCP but not applied consistently

• PHN key person in some areas, social workers in others

• Summary Assessment Record for Fair Deal – medical assessment of need for residential care. Controversial – some wanted assessment tool and this is a record

• Support for single assessment and single assessment point and care management

Key Issues -Nursing Homes

• 24,253 beds 2006 78% private 48% of income from HSE. 13,000 in receipt of subvention monthly

• Concerns that no incentives to move people home, although examples of good rehab in places

• Concerns about windfall profits for private providers

• Concerns about location of private provision

Key Issues- Hospitals

• PA Bed Review found 13% admissions and 39% of hospital days inappropriate based on AEP criteria; 75% admitted early than necessary for surgery; discharge planning in place for only 40%

• Average stay for over 65s 11.3 days compared to average of 5 days (HIPE)

• Some tension between hospital and community care services in terms of discharge and assessments - not related to living circumstances and create unrealistic expectations of community services

Key Issues- Costs and Expenditure

• Limitations in comparing costs – information not directly comparable. Information on expenditure no accessible

• HCP average €600 per week (accommodation costs not included)

• Day Care – no charges -• Nursing homes €800- €1200 per week • Sheltered housing rents €65-70 per week subsidised by

SWA -€18 – generally no charge for additional services • ILU – rent and charges €271 per week• No evaluation of reasonable costs, VFM, cost

effectiveness – unit costs good starting point

Enablers• Individuals (PHN, Directors of Nursing, Social Worker,

Home Help) and individual relationships • Additional Resources • Improvements in housing quality and supply• Primary Care approach and Teams – beginning to bring

multi disciplinary focus

• Stronger cross department activity – although

communication poor • Health and wider government policy focus on outcomes,

evidence base, person centred services, integration of services, local responses

Barriers• Absence of overarching strategy to drive, direct and evaluate

activity• No one in charge • HSE new organisation; centralised control; weaknesses in

management infrastructure • Lack of adequate information systems to plan and review

service provision and quality • Hospital and community services not integrated• Community health, social and housing services not integrated • Budgets not integrated • Multiple assessments and means tests • Services provider or funding led • People, vested interests

Opportunities• Network • Building on existing information and research• Learning from others – sectors in Ireland and older

people internationally - • Cut backs in funding – driver to

Make services more accountable and effective Use existing resources better, get better value for money Make earlier and preventative interventionsShift resources to social for better effectivenessProvide more low level interventions Streamline assessment and other processesShare information and resources better Develop information systems not just focused on inputs and

activities - Healthstat Use voluntary bodies better – go/do what public cannot Reward effectiveness and innovation

Challenges

• Cut backs and a return to default position of policy and people

• Weaknesses in management personnel and systems • Making changes within existing services and structures • Understanding what works and why

• Putting policy into practice

• People stepping outside discipline/profession to combine resources

• Addressing centralisation, devolving budgets and decision making