This article summarises research on the outcomes valued by older people and lessons learned from authorities developing outcomes-focused services for older people in England and Wales. The research was commissioned by the Social Care Institute for Excellence and carried out by the Social Policy Research Unit and Acton Shapiro.
Research on the outcomes valued by older people and the methods providers use to achieve them is analysed by Jane Maddison
The drive for outcomes-focused care underpins the Commission for Social Care Inspection’s proposed framework for performance assessment of adult social care.(1)
Research has consistently found that outcomes valued by older people are similar to those identified in the 2005 green paper Independence, Wellbeing and Choice.
● Improved physical and mental health and support to manage long-term conditions.
● Improved quality of life, including access to universal services and safety and security inside and outside the home.
● Making a positive contribution to the local community.
● Being able to exercise choice and control.
● Freedom from discrimination and harassment.
● Economic well-being.
● Personal dignity, including cleanliness and comfort.
Outcomes fall into three clusters: “change”, “maintenance” and “process”.(2) Change outcomes concern improvements in physical, mental or emotional functioning. Maintenance outcomes relate to quality of life, such as personal comfort and social contact. Service process outcomes include older people’s experiences of services, such as whether they feel valued and involved.
A postal survey in England and Wales found examples of outcomes-focused approaches to assessment, care planning and review, changes to existing provision, commissioning new services and new monitoring arrangements. Most commonly, this work covered older people living at home or after hospital discharge. Most initiatives were being planned, piloted or rolled out, with social services authorities generally the sole or lead agency and primary care trusts and independent providers the most common partners.
Follow-up case studies of six areas shed light on outcomes-focused assessment, care planning and commissioning and also gathered evidence on impact and key factors which help or hinder an outcomes approach. Outcomes-focused assessments allow individual older people to convey what is important to them and so to identify the outcomes they desire from social care support. The case study sites found it difficult to combine an outcomes approach with the single assessment process, which focused on needs and problems. Adapted paperwork was valuable in prompting an outcomes focus, so a pragmatic solution was to incorporate questions on desired outcomes into care planning.
Intermediate care and reablement services were set up in the case study sites. In one site, the in-house home care service was restructured and an occupational therapist appointed. The team provided intensive support for up to six weeks with weekly reviews. Home care staff were encouraged to comment on the care plans and had considerable autonomy over how they worked with an older person to achieve their desired outcomes. In another site, outcomesbased service specifications were developed for assessment and rehabilitation services in residential and extra-care settings.
Some sites were changing contracts, entrusting independent home care providers to respond more flexibly to users’ preferences.
Each provider was allocated an area with an estimated core level of service agreed in advance. Care plans specified the user’s desired outcomes and the probable number of hours of support required, with providers negotiating the day-to-day service with each user. Older people reported higher satisfaction and providers gained stability from the guaranteed work in a given area, with staff reporting improved job satisfaction.
Older people receiving intermediate care, rehabilitation and reablement services reported meeting outcomes related to physical functioning and confidence. Staff noted the importance of reassessment, since desired outcomes could shift quickly after goals were met. Staff also observed that the value attached to outcomes was not always sustained when older people moved to longer term maintenance-oriented home care.
It was more difficult to identify the impact of services on maintenance outcomes. Some authorities acknowledged commissioning home care services primarily for physical maintenance, leaving aside broader quality of life outcomes.
One older person for whom church was important described being unable to attend because the service clashed with her home care visit. There was more evidence of an outcomes approach in residential and day care. For example, one locality was reviewing its contracts for voluntary sector day care services to incorporate an outcomes focus.
Users emphasised the respectful, personalised and flexible qualities of outcomes-focused services.
The importance attached to these process outcomes could help a service be accepted and so underpin achievement of other outcomes. A non-intrusive approach by a home rehabilitation assistant had helped an older person overcome her reluctance to having “do-gooders” in her home. Together they devised safe ways for her to carry out domestic tasks, as she had identified running her own home as a key outcome.
Factors reported as helping an outcomes approach included:
● National policies such as the older people’s national service framework and Independence, Well-being and Choice.
● New inspection regimes for residential care which encourage an outcomes approach.
● Local vision, leadership and investment in change management.
● Access to resources and skills beyond the traditional remit of social care.
Factors hindering the development of an outcomes approach were:
● The single assessment process, with its needsbased paperwork.
● Performance indicators which do not reflect outcomes.
● Resource constraints.
● Staff culture and attitudes.
● Service-led or dependency-focused assessments.
● Lack of regular review.
● Purchasing arrangements which constrain providers’ flexibility to work in an outcomes focused way with service users.
In practice, the term “outcome” appears most readily understood in the context of services intended to achieve change, which risks older people’s maintenance and prevention outcomes being marginalised. Moreover, not all the outcomes desired by older people are within the current scope of social care services, underlining the importance of partnerships with other statutory and voluntary agencies. Initiatives such as the Department of Health’s Partnerships for Older People Projects should help to stimulate shared understanding and develop services to achieve the full range of outcomes desired by older people.
TRAINING AND LEARNING
The author has provided questions about this article to guide discussion in teams. These can be viewed at www.communitycare.co.uk/prtl and individuals’ learning from the discussion can be registered on a free, password-protected training log held on the site. This is a service from Community Care for all GSCC-registered professionals.
(1) Commission for Social Care Inspection, A New Framework for Performance Assessment of Adult Social Care 2006-7, 2006
(2) H Qureshi, C Patmore, E Nicholas, and C Bamford, Outcomes in Community Care Practice. Overview: Outcomes of Social Care for Older People and Carers. Report 5, Social Policy Research Unit, University of York, 1998
● www.york.ac.uk/inst/spru/pubs For the Social Policy Research Unit’s research and Outcomes into Practice resource pack.
● www.actonshapiro.co.uk/outcomes: For information on training for authorities wishing to develop an outcomes approach.
● www.cat.csip.org.uk/index.cfm?pid=270: Outcomes Network – an exchange of information, mutual support for those seeking ways to implement an outcomes approach in social care.
This article appeared in the 11th January issue under the headline “Positive Outcomes”