INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, VOL. 11: 29-39 (1996)

THE WORK OF A COMMUNITY MENTAL HEALTH TEAM FOR THE ELDERLY: REFERRALS, CASELOADS, CONTACT

HISTORY AND OUTCOMES PAMELA BROWN.* DAVID CHALLISt and RICHARD VON ABENDORFFI

*Research OfJlcer, TProjessor of Social Work and Community Care, $Research Fellow, Personul Social Services Research Unit. University of Kent at Canterbury, Canterbury, U K

SUMMARY A random sample of 120 open cases on the caseloads of two community mental health teams for elderly people, operating an open access policy, were followed up over 18 months. In comparison with referrals, caseloads had a higher proportion of patients with affective disorders and fewer with organic syndromes. Elderly patients with diagnoses of organic disorders tended to receive shorter episodes of intervention, more associated with assessment and diagnosis than continuing support, compared with those with affective disorders. A follow-up of those patients who were living at home at the point of sampling indicated that a higher proportion of those with affective disorders remained in their own homes compared with those with organic disorders.

KEY woms--community care; community teams; referrals; caseloads; elderly

Since the 1960s the need for locally based services to meet the requirements of elderly people in the community suffering from mental disorders has been recognized (Arie and Jolley, 1982) and one response has been the emergence of community teams with a variety of styles and patterns of response (Dening, 1992). The development of community-based mental health services has led to a range of questions about services, their structure and process (Onyett et a/., 1994a). Among these are issues of targeting and the coverage of the people the services are designed to reach, how effective they are in providing community-based support and how teams engaged in these services distribute their time (von Abendorff et al., 1994). The variations in the types of services received by different client groups are also important. One question is the extent to which some cases receive a service focused predominantly upon assessment while others receive more long- term support. This in turn raises the issue of how the pattern of their work dovetails with develop-

*Address for correspondence: Professor David Challis, Per- sonal Social Services Research Unit, University of Kent at Canterbury, Canterbury CT2 7NF, UK.

CCC OSSS--6230/96/010029-11 0 1996 by John Wiley & Sons, Ltd

ments in community care, particularly assessment and care management. Given the range of models of community mental health services for the elderly (Dening, 1992), in addition to providing descrip- tions of the operation of a service (Coles et al., 1991) there is a need to both tease out and evaluate specific aspects of the new ways of working. Among these are the role of multidisciplinary teams in diagnosis (Collighan er at., 1993), the effects of an open access referral system (Mac- donald et al., 1994) and developing approaches which systematically describe services for pur- chasers so as to permit comparison of services (Wimo et al., 1993).

This study focuses on one particular form of community team for the mental health of elderly people, in which there is more sharing of responsibility across the disciplines than in the more traditional doctor-led model of service. It covers two community-based multidisciplinary teams, with members who are psychiatrists, psychologists, nurses, occupational therapists, social workers and administrative staff. Although the service is based at a hospital where the consultants have their own inpatient provision, the work of the teams is with patients living in the

Received I0 October 1994 Accepted 7 March 1995

30 P. BROWN. D. CHALLIS AND R. VON ABENDORFF

community. The service aims to enhance its case- finding ability and increase uptake by providing open access for referrals. Assessments are home- based and new cases are initially seen at home by one or more members of the team. Following a case conference, interventions are planned within a key worker system involving all disciplines (Murphy and Macdonald, 1993).

To unravel some of the questions about teams, the present study attempts to identify which patients pass through the selection process from referral to caseload and thereby constitute the longer-term elements of the team’s workload and how the pattern of contact with the team varies by diagnostic group. I t then seeks to give a descrip- tion of a point prevalent caseload of a community- based mental health service, to differentiate this from its referral population, to delineate and examine the history of the teams’ patterns of contact and to describe the survival and destina- tional outcomes of those cases who were living in their own homes at the point of sampling for a follow-up period of 18 months.

METHOD

A sample of the two teams’ current caseload in 1991, on the closest feasible dates (March 12 for one team and March 25 for the other-referred to as the index date), was obtained from their computer-based caseload information system. This lists cases accepted by the teams since their forma- tion in 1984 and 1988 respectively in chronological order and provides accurate and comprehensive basic information on clients referred to the teams. The two different dates were as close together as was possible. The listing provided 370 cases; in order to achieve a sample of over 100, a number between 1 and 3 was randomly selected and starting from the earliest cases every third case was sampled. Eleven cases were eliminated and substituted because they were incorrectly recorded as open to the teams on the index date; these errors had been caused in the most part by a time-lag in information being entered on the computer. Four cases were excluded because they were either receiving at the time or were to receive within the next 12 months a specialist case management service. This was atypical of the mainstream team service in that it offered an additional team worker role focusing on the long-term support of people with dementia and was subject to a separate

evaluation. This left a sample of 120 cases to be studied.

Information on the characteristics of each case and the process of contact with teams was obtained from the teams’ records. From these the characteristics of the caseload at the time of first referral for assessment could be described in terms of age, sex, living situation and diagnosis. Although detailed information about diagnosis was available, for the purpose of classification it was decided to follow the teams’ adoption of the ICDlO Clussificution of Mental and Behuvioural Disorders (WHO, 1992), which made it possible to categorize the cases in one of four major diagnostic groups:

1 . ‘Organic mental disorder’ including all types of dementia, dementia with depression and acute confusional states

2. ‘Affective disorders’ including depression and hypomania

3 . ‘Schizophrenias’ including paranoid states in the elderly

4. ‘Other’ including other psychiatric diagnoses (such as hypochondriasis, anxiety and alcohol dependence), non-psychiatric diagnoses (in- cluding bereavement) and missing diagnoses (unclear or impossible to diagnose)

A staged approach was adopted to discover the destinational outcomes for those cases who were living in the community at the index date, that is, whether they had survived for the 18-month period from the index date and whether their place of residence had remained the same. First, the teams’ records were consulted, and then if these did not provide the necessary information, other sources of formal care such as the social services depart- ment, residential homes and hospitals were contacted. Only as a last resort were next-of-kin or other informal carers contacted for infonna- tion. By this method outcomes after 18 months were established for all but two of the sample.

The focus of the study was upon the service model as a whole and interteam variance was deliberately subsumed by aggregating the data from the two teams, which maximized numbers for the analysis. Where differences could be perceived between the two teams these appeared to be as likely to be attributable to features of the catch- ment areas as to elements of team style.

Comparison of categorical variables such as diagnosis were made using chi-squared tests. Continuous variables were examined by means of

THE WORK OF A COMMUNITY TEAM 31

Table 1. Characteristics of the caseload sample on first referral by diagnotic groups compared with referral population by diagnostic groups

Organic Affective Schizophrenias Other All diagnoses Referral syndrome disorders caseload sample population

No. % NO. % NO. % NO. Yo NO. Yo NO. % ( N = 120) ( N = 576) (N = 48) ( N = S O ) ( N = 14) ( N = 8)

Sex Male Female

Age, mean

Age profile Under 65

75-84 85-t Missing

65-74

Living situation Lives alone Lives with spouse Lives with other In residential care

Diagnostic group Organic Affective Schizophrenia Other

16 33.3 32 66.7

78

4 8.3 13 27.1 20 41.7 10 20.8

1 2.1

23 47.9 14 29.2

5 10.4 6 12.5

11 22.0 39 88.0

76

I 2.0 22 44.0 25 50.0

1 2.0 1 2.0

23 46.0 19 38.0 4 8.0 4 8.0

4 28.6 4 50.0 10 71.4 4 50.0

78 76

- - ~ ~

4 28.6 4 50.0 9 64.3 3 37.5 1 7.1 1 12.5 - ~ ~ ~

5 35.7 2 25.0 5 35.7 3 37.5

- 1 12.5 4 28.6 2 25.0

.-

35 29.2 180 31.2 85 70.8 396 68.8

77 N /A

5 4.2 18 3.1 43 35.8 197 34.2 57 47.5 273 47.4 13 10.8 88 15.3

- 2 1.7 ~

53 44.2 41 34.2 N/A 10 8.3 16 13.3

48 40.0 271 47.0 50 41.7 152 26.4 14 11.7 35 6.1 8 6.6 118 20.5

N/A, no data available.

analysis of variance with individual group differ- ences tested where appropriate using the New- man-Keuls test (Snedecor and Cochran, 1980).

RESULTS

Caseload characteristics

The first aim of this study was to provide a description of the caseload carried by the community teams for the elderly at a specific moment in time, as distinct from a description of the cases referred to these teams. There were no significant differences between the teams, which for the purposes of analysis were treated as one unit. The caseload sample reflected the balance of numbers between the two teams and it was distributed between the four social service districts in Lewisham comprising the teams’ catchment area. In common with other studies of the work of psychogeriatric teams (Ratna, 1982; Buckwalter et al., 1991; Doyle and Varian, 1994), it was found

that a higher proportion of the sample was female than is found in the population at large of retirement age: 71% were women, 29% men, as can be seen from Table 1. The mean age at first referral was 77 years and the distribution ranged from the late fifties to 90. Just over 5% were under retirement age, these being largely accounted by cases of dementia of early onset. However, although the distribution for those with organic syndromes was flatter, there were no significant differences employing the usual statistical criteria in the age profiles of the different diagnostic groups on first referral (chi-square exact = 15.7; p = 0.07). In most cases the ethnic origin of cases was not recorded.

Depression was the most frequently attributed single diagnosis (38 %). However, when multiple diagnoses, such as dementia with physical condi- tions like epilepsy and Parkinson’s disease, were taken into account, and the diagnoses grouped according to the ICD10 criteria, it was found that organic syndromes accounted for almost as much of the teams’ caseload as the affective disorders

32 P. BROWN, D. CHALLIS AND R. VON ABENDORFF

(40 and 42% respectively). Schizophrenia and related paranoid conditions accounted for 11 % of the cases, while a miscellaneous group of neurotic, non-psychiatric and unclassifiable dis- orders made up the remaining 7 % of the caseload. With regard to living situation, it was found that 44% of all cases had been living alone at the time of first referral. Overall, 34% were living with their spouse, 8% with someone else (relative or other carer) and 13% were in residential care. Only 5% were in any kind of supported housing, with the remaining 82% living in independent accommoda- tion.

By the time of the index dates in March 1991, the proportion of cases living in residential care had risen to 21% of the caseload from the 13% at the time of referral. Three-quarters of these people who had subsequently moved into institutional care were suffering from dementia. Although the residential care group appeared to differ from those remaining in the community in that they were slightly older (mean age 79 against 77 for the community group), were even more likely to be women (80% against 68% for the community group) and more were diagnosed as suffering from dementia (48% of those in homes, 38% of those in the community), none of these differences were found to be significant. However, it was notable that those cases who were attributed a multiple diagnosis such as dementia together with anxiety or paranoia, or physical complications such as epilepsy, Parkinson’s disease or syphilis, were almost exclusively found in the residential care group. Those living in residential care were equally divided between local authority homes for the elderly, private and voluntary homes (residential or nursing) and the small specialist nursing homes for severe dementia sufferers known as ‘domus’ which are run on the housing model of care, managed by a housing association but with support from the community teams and local CPs (Lindesay et al., 1991).

Caseload and referral group characteristics

Most studies of services have been carried out on consecutive cases referred. The Lewisham service carries out its own annual review and comparison between these referral data and the caseload sample yields interesting differences. Whereas descriptions of referral populations capture the assessment and open access functions of the service, the snapshot of the caseload can

give indications of the main ongoing workload and aspects of longer-term care and support. When referrals for the 6 months before and after the index date, for the year October 1990- September 1991 (MHES, 1991), were compared with the caseload at March 1991, there were no significant differences in gender balance or age profile between the referral and caseload groups. However, as shown in Table 1, there was found to be a striking difference in the composition of the two groups when analysed by diagnosis; whereas a far higher proportion of the referred population carried a diagnosis of an organic syndrome (47%) than of an affective disorder (26%), in the caseload sample slightly more were diagnosed as having an affective disorder (42%) than an organic syndrome (40%) (chi-squared = 21.89; p = <0.001). As might be expected, there were also proportionately more with a diagnosis of schizophrenia and fewer in the ‘other’ category in the caseload sample than in the referral popula- tion.

This would seem to indicate a greater tendency for cases with a diagnosis of depression or schizophrenia to be taken on to the caseload for longer-term intervention and for those with a diagnosis of dementia to be seen for assessment and more short-term work. The pattern of contacts provides more detailed information on the extent to which the diagnostic groups are assessed, selected and managed by the teams in different ways.

History of contact prior to the index date

The history of the caseload sample was examined in terms of the length of contact with the team for each case; the period of time which had elapsed since first referral, whether there had been discharges and rereferrals and the duration of care episodes up to the index date.

Although some cases had been on the caseload for 7 years, over 60% had been known for 15 months or less. Seventy-one per cent were ‘first referrals’, meaning that they had been on the caseload continuously since first referred until the index date. Figure 1 shows the pattern of referrals by diagnosis. There were found to be no significant differences by diagnosis in the number of times cases were rereferred.

However, when the length of time that cases remained open to the teams was calculated, marked differences emerged. As shown in Table 2,

T H E WORK OF A COMMUNITY TEAM 33

Not discharged Relerred once

AneClN0 Schizophrenia 11.7 Schkophrenia 9.4 Other Other

Case. own at Index date [n= 120)

I

Schuophrenla 28.6 Other

per cent

Fig. 1. Client contact pathways-before index date

cases in the affective group had been known to the teams for more than twice as long overall (119 weeks) as the organic cases (52 weeks; p = < 0.05); their contact time since the last referral before the index date was twice as long (79 weeks as against 32 weeks; p = <0.05), as was the total amount of time the cases had been open to the teams since they were first referred (91 weeks compared with 38 weeks; p = <0.05). Contact with the schizo- phrenia group was similar in length to the affective group; the ‘other’ group had broadly the same pattern as the organic group except that cases were open in total to the team for a considerably longer period of time. Not only was the mean length of

contact with affective cases longer than that of organic cases but the distribution was much more dispersed, as indicated by the higher standard deviation,

Patterns of contact following the index date

The 18-month period following the index date was examined to obtain a picture of the process of care of those cases which had remained in the community and to derive similar indicators to those used in the analysis of care from referral to the index date. In order to focus on outcomes as well as the processes of care, the 25 cases living in

Table 2. Contact with the team before index data expressed in mean number of weeks

Organic Affective Schizophrenias Other All diagnoses Tests p Group ( N = 48) ( N = 50) ( N = 14) ( N = 8) ( N = 120) F* comparisons

Time since first referral 52 (77) 119 (105) 90 (77) 69 (1 12) 86 (96) 4.46 <0.01 a

referral 32 (53) 79 (84) 60 (60) 35 ( S O ) 55 (71) 4.12 t0.01 a

index date 38 (56) 91 (87) 77 (64) 72 (150) 67 (82) 3.67 t0.05 a

Time since last

Total time before

* Analysis of variance. Notes 1. Significant differences: a, organic disorders vs affective disorders p = <0.05. Newman-Keuls test. 2. Figures in brackets indicate standard deviation.

34 P. BROWN. D. CHALLIS A N D R. VON ABENDORFF

perceni

Paderred once

0 AHeclive Schizophrenia L

#t P

0 P Cnher Re-referred Wice Other

I -

Fig. 2. Client contact pathways--community sample follow-up

residential care at the index date were excluded from the follow-up analyses, and there were no significant differences in the characteristics of the community-based subset of 95 compared with the total sample of 120. Figure 2 shows the pattern of closure and rereferral for the 18-month period after the index date. Nearly a quarter of the com- munity sample was kept open for the whole 18- month period. Of these cases, 57% suffered from affective disorders and only 14% from an organic syndrome (chi-squared = 9.18; p = ~ 0 . 0 5 ) ; and of the latter, one-third suffered from depression as well as dementia. In other words, 27% of cases with an affective disorder and half of those with a schizophrenic illness were on the caseload con- tinuously through the period compared with only 8% of the organic cases. The organic and affective diagnostic groups were equally likely to have been simply discharged after the index date and not rereferred within 18 months. Of those discharged, over three-quarters were not rere- ferred but the majority of those who were rereferred suffered from organic disorder. In all, more than one-third of people with organic disorders who were discharged from the service were rereferred compared with less than one-fifth of those with affective disorders; indeed, the few cases which had been rereferred twice within the

18-month period all had a diagnosis of organic syndrome.

Length of contact following the index dute

A consistent and similar pattern can be found when the length of contact is compared. Table 3 indicates that those with affective disorders had consistently greater length of contact. Between cases with a diagnosis of an affective disorder and an organic syndrome there was a significant difference in length of contact since first referral up to the index date ( p = <0.05), in contact during the 18 months following the index date ( p = <0.05) and in total contact since first referred ( p = <0.01).

When cases which were open continuously from the index date for 18 months were excluded from the analysis, the lengths of episodes of care could be established. The nearest approximation to a typical completed episode of care can be taken to be the contact starting at the last referral before the index date and finishing at the first discharge thereafter. As shown in Table 3, it was found that the organic group’s mean length of contact was 36 weeks whereas the length for the affective group was 90 weeks ( p = <0.05). For the contact time from the index date until discharge and for the

T H E WORK OF A COMMUNITY TEAM 35

Table 3. Length of contact of the community sample with the team by diagnostic groups expressed as mean number of weeks open on the caseload

Organic Affective Schizophrenias Other Total F* p Group dementias disorders comparisons ( N = 36) ( N = 4 4 ) ( N = 10) ( N = 5) ( N = 9 5 )

Contact from first referral to index date 31 (57) 87 (84) 69 (59) 100 (191) 65 (84) 3.54 0.02 a

Total contact in the 18 28 (24) 44 (29) 48 (33) 24 (34) 37 (29) 2.82 0.04 a months after the sample date

referral Total contact since first 59 (71) 131 (97) I17 (78) 125 (200) 102 (98) 4.1 0.009 a

Average episode of caret 36 (31) 90 (79) 37 (25) 60 (86) 60 (64) 4.68 0.005 a Contact from last referral hefore index date to first discharge after index date

* Analysis of variance. 7 Excluding cases open continuously from the sample date for 18 months

Notes I , Significant differences: a, organic disorders vs affective disorders p = <0.05. Newman-Keuls test 2. Figures in brackets indicate standard deviation.

ensuing episodes of care the indications are that the difference in contact patterns between these two groups continues. For example, for the 15 cases who were discharged and rereferred, the mean length of contact of the organic group was 18 weeks and that of the affective group was 26 weeks. When total length of contact episode from referral to 18-month follow-up is considered, more than three-quarters of those in the organic group are open for less than a year, whereas two-thirds of the affective group remain open for more than a year and one-third for more than 3 years.

Outcomes

Supporting people in their own homes is one focus of the work of community mental health teams, and one indicator of their effectiveness could be seen as the destinational outcomes of their cases. This was the only dimension of outcome available in this study which therefore can take no account of measures of dependency, levels of symptoms, carer burden or satisfaction with the services which would ideally feature in a full-scale study of outcomes. It was found, as shown in Table 4, for the overall community caseload of 95 cases that after a year just under 13% had died and 75% were still living in the community while 13% had been admitted to either

residential or hospital long-term care. After 18 months, 19% had died, the proportion still living in the community had fallen to 65% and 14% were in long-term care.

The difference between the diagnostic groups in both survival and destinational outcomes became more marked over time. In view of the small number of cases with a diagnosis of ‘schizophre- nia’ or ‘other’, exact probability tests were used (Mehta and Patel, 1989). After 6 months the differences were insignificant but after a year a pattern began to emerge. By then 25% of the organic cases and 7% of the affective cases had died ( p = 0.03); after 18 months 36% of the organic cases and 9% of the affective cases had died ( p = 0.01). Mortality was low in the other diagnostic groups. Community tenure also showed significant differences by diagnostic group. This effect was most clearly visible after 18 months, when 82% of cases with an affective disorder were still living in the community, with not dissimilar proportions for the other two ‘functional’ groups, but only 39% of the organic cases were still at home ( p = 0.02).

The difference remains when the higher death rate in the organic group is taken into account. Of those cases who were still alive after 18 months, over 90% of those with affective disorders were living in the community and 8% were in long-term

36 P. BROWN, D. CHALLIS AND R. VON ABENDORFF

Table 4. Destinational outcomes of a community caseload

Organic Affective Schizophrenias Other All diagnoses Significance Yo of O h of Yo of Yo of

No. group No. group No. group No. group No. Yo x2 After 6 months

Dead In the community In residential care In hospital I/t care Not known

After 12 months Dead In the community In residential care In hospital lit care

After 18 months Dead In the community In residential care In hospital I/t care Not known

Total

3 8.3 27 75.0 4 11.1 1 2.8 I 2.8

9 25.0 21 58.3

5 13.9 1 2.8

13 36.1 14 38.9 6 16.7 2 5.6 1 2.8

36 100.0

1 2.3 40 90.9

3 6.8 - -

- -

3 6.8 37 84. I 4 9.1 - -

4 9.1 36 81.9

3 6.8

I 2.3

44 100.0

- -

- -

8 80.0 2 20.0 - -

- -

- -

8 80.0 2 20.0 - -

I 10.0 7 70.0 2 20.0 - -

- -

10 100.0

6.95 4 4.2 NS

79 84.3 9 9.5 1 1.1 I 1 . 1

12.94 12 12.6 NS 71 74.7 I I 11.6

1 1.1

22.0 1 18 18.9 <0.01 62 65.4 11 11.7 2 2.2 2 2.2

95 100.0

Note: Exact probability test (Mehta and Patel, 1989).

care, whereas only 64% of the organic cases were still at home and 36% were in long-term care.

DISCUSSION

This study of two community mental health teams for the elderly has shown that there was clearly a marked difference between those cases who were seen and assessed and those which following this process remained on the caseload. This reflects the initial sifting of work by a team and makes the distinction between studies of referrals and case- loads important. An analysis of referrals clearly provides a picture of the overall demand on the service and highlights the assessment, screening and more short-term aspects of the work. However, the subset of the referral group, those who following referral and assessment remain on a team’s caseload, are likely to reflect the ongoing demands upon that service and therefore much of the use of its resources for long-term support. These are the cases where the work of a team needs to be most clearly dovetailed with care manage- ments arrangements (Onyett et af., 1994b). This analysis of caseloads indicates other opportunities for research. For example, in service audit the

degree of congruence between referral population, caseload mix and area morbidity might be an indicator of the effectiveness of case-finding and screening, while differences between referrals and caseloads may be used to indicate the nature of the selection process in screening.

Although the pattern of referrals and rereferrals of those individuals on the caseload prior to the index date did not appear to differ by diagnosis, there were differences by diagnosis in the follow-up period, with the organic disorders less likely to be kept on the caseload continuously and showing more frequent closure and rereferral. There were clear differences in the duration of time open, and therefore presumably in the amount of contact. While there was much wider variation in the length of contact with the team for cases with a diagnosis of an affective disorder, with about a third having quite brief episodes, the majority of these cases received more lengthy episodes of care and had been open for longer overall; this would suggest that the community team provided them with more of a continuing treatment and support role, as they had with those individuals with a diagnosis of schizophrenia, perhaps associated with the provision of maintenance medication. Conversely, the shorter duration of involvement and greater

T H E WORK OF A COMMUNITY TEAM 37

uniformity in this aspect of care for cases with organic disorders may reflect a greater emphasis upon assessment, diagnosis and short-term inter- vention with subsequent earlier closure. It may be that the nature of the problems for which they were referred, such as specific behavioural difficul- ties, diagnosis and advice, may be amenable to relatively swift resolution; or it may be that the referral is directly related to accessing practical help from other sources such as day or residential care. Nonetheless, despite the differences between groups, it would appear that these teams do provide a substantial length of contact for cases with dementia compared with a more traditional assessment service. Of course, length of contact may not necessarily indicate intensity of involve- ment and the present data do not permit disaggregation of the content or amount of contact during the period when cases were open.

It is not possible in a study of this kind to relate outcomes directly to patterns of intervention but it is likely that they intersect on a number of levels. Different patterns of survival were observed between diagnostic groups, with the functional disorders having a higher rate of survival than the organic, and this may be a contributory factor in explaining the longer contact of the team with cases carrying an affective diagnosis. It is not surprising to note that there were differences in the pattern of institutionalization between diagnostic groups, those with an organic syndrome being far more likely to move into long-term care than other diagnostic groups. It is possible that the emphasis on short-term intervention for these cases might be heightened by assessment work prior to their placement in nursing or residential settings. Several studies have indicated relatively high rates of entry to institutional care for cases with an organic disorder (Bergmann et al., 1978; Reddy and Pitt, 1993; Juma et a/., 1994). Nonetheless, these studies show considerable variation in rates of admission to long-term care which probably reflect area resource mix and case mix as well as style of service provided. For example, only 17% of cases in the current study were in long-term institutional care after 1 year while the corre- sponding figures were 36% in a study of a day hospital service (Bergmann el al., 1978) and 45% in an audit of a traditional psychogeriatric service (Reddy and Pitt, 1993).

There are a number of possible explanations for the difference in patterns of response of the service by diagnosis. One is that length of contact may be

related to the lower probability of mortality or institutionalization of patients with affective disorders. Another factor may be the different patterns of activity of different team members. For example, von Abendorff et al. (1994) found that ‘extended role’ team members, such as consultants, whose role encompassed ward or managerial duties associated with the wider psychogeriatric service as well as duties solely related to the team, had a lower proportion of dementia cases on their caseload. The fact that they did not take on so many new cases but received more secondary referrals from within the team or from the wards, a large proportion of which then received an outpatient type of service involving long-term follow-up and regular review of medication, could be part of the reason for the different populations of the cases remaining open on a long-term basis in the teams.

The lack of a long-term supportive and case coordinative responsibility for those with organic disorders may well reflect a response to what is perceived as feasible and possible. Providing long- term support for cases suffering from dementia is likely to require a considerable amount of social care services (Livingston et al., 1990). These are not readily available to the team nor to its existing social work members, who, like the team members, can only access such services through another section of the social services department. Lacking control over the relevant services and faced with a continual flow of new cases for assessment and diagnosis, it is not surprising that the team would be unable to undertake the long-term support and coordination of care for such cases, which would be seen as possibly the province of other workers (Ovretveit, 1993). Conversely, providing long-term support for people with affective disorders is more likely to be perceived as within the remit and available resources of mental health team rnem- bers. In a similar way, the Gospel Oak study found that in Inner London depressed residents were in more contact with GPs and hospital outpatient clinics while patients with dementia were more in contact with the social services (Livingston et a/., 1990). Unfortunately it was not possible within the remit of this study to establish whether or not cases were discharged to the care of other parts of the service or other agencies such as the social services.

The findings raise the question whether the balance of emphasis of effort between the organic and affective diagnostic groups should shift so as

38 P. BROWN. D. CHALLIS A N D R. VON ABENDORFF

to give more support to those with dementia and particularly their unpaid carers. This would be a response which would closely link the work of teams into the goals of community care (Cmnd 849, 1989). However, given the suitability of an open access clinical team for case finding and assessment, it might equally be that such a response is better provided by the social services in a separate but linked fashion, for example with case managers being part of the teams so as to meet the long-term support needs of patients with dementia and their carers (Murphy and Challis, 1993). It must also be noted that teams do take on carers as cases in their own right when they require psychiatric support, and this is an aspect of work not captured in this study.

Particularly with the development of community care, an important function of a community mental health team’s work is also likely to involve offering support, advice and guidance to the providers of services for frail elderly people. Interestingly, 21% of the caseload of the teams studied were individuals who were in some form of residential care. Although there appeared to be no differences in diagnosis or age between those in contact with the teams who were in residential care and those in the community, it did appear that some degree of complexity differentiated them. The presence of multiple diagnoses, or concomi- tant physical disability, was more common in the residential care group. This suggests that either these people posed management problems in terms of behaviour or extra care needs beyond the capacity of the community care system or that the team only retained contact with this particu- larly needy subset of cases in institutional care. A similar association between physical disability and institutionalization was found by Reddy and Pitt (1993) in their audit of referrals of cases with a diagnosis of dementia to a hospital psychogeriatric department and also by Lindesay and Murphy ( 1 989).

However, teams organized with a community focus and open access for referrals would appear to be in a unique position to identify cases and to provide a wide range of relevant expertise for community care assessments and inform decisions about institutional placement (Macdonald, 1991). It is this opportunity which has made them a base for experimentation with care managers who are members of the team and who hold devolved budgets (Murphy and Challis, 1993). The role of such secondary care services in the provision of

community care is an area ripe for further experimentation (Challis et al., 1995).

Related to these considerations of the future role of community teams in community care are the current pressures which exert influences upon the patterns of their operation in two different directions. On the one hand, the growth of GP fundholding and closer linkages with primary care are likely to increase demand for a consultation and assessment-based style of response, with a predominantly short-term and crisis focus (Jack- son et al., 1993). On the other hand, the influence of the NHS and Community Care Act, linkages with care management (Onyett et al., 1994b) and the care programme approach are likely to increase demand for activities such as providing continuing support to elderly people with organic disorders and their carers, and thereby act as an impetus towards long-term work. How these pressures are resolved by community teams is likely to be a major determinant of the way in which referrals are filtered to caseloads and upon caseload mix in the future, as well as the future structure of services.

ACKNOWLEDGEMENTS

The authors wish to thank Dr Alastair Mac- donald, Dr Michael Philpot, administrators Ms Betty Balbastro and Ms Barbara Clayton and all members of Community Mental Health Teams B and C, Guys and Lewisham NHS Mental Health Trust, for their help and cooperation in this study.

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