Title: Housing with care for later life: A literature review
Authors: Karen Croucher, Leslie Hicks and Karen Jackson
Affiliations: Joseph Rowntree Foundation
Support for independent living is at the heart of the government’s strategies for adult social care, health and well-being. There is increasing interest in the role of housing, particularly for people needing high levels of support. The concept of “extra care” housing is relatively new and is in many ways an attempt to clear up the considerable confusion that has bedevilled terminology around sheltered housing, very sheltered housing, housing with care and so on. The literature review provides a helpful summary of research evidence to-date on whether these housing schemes promote independence, reduce social isolation and reduce the use of institutional care.
The report for Joseph Rowntree Foundation (JRF) draws together findings from research undertaken since 1999. The toolkit produced by the Care Services Improvement Partnership is designed to assist the development of extra care housing in the context of the wider accommodation and support needs of older people. These two publications can be seen as complementary: while the former is mainly concerned with identifying the evidence base for extra care housing, the latter focuses on a structured approach to developing policy and local initiatives around extra care in the light of such evidence.
Croucher et al argue that extra care housing might be defined in terms of schemes which:
● Promote independence.
● Reduce social isolation.
● Provide an alternative model to residential or institutional care.
● Provide residents with a home for life.
● Improve the quality of life for residents.
The CSIP toolkit similarly identifies three key principles underpinning extra care housing based around the promotion of independence, empowerment, and accessibility.
As this document points out, understanding definitions is more than semantics. Clarity is needed around the meaning of “extra care” in terms of “furthering its development, being clear about its regulation and conveying a clear image to the general public, older people and the range of professionals who may be involved in its development or in the provision of services.” The defining features are identified here as:
● It is first and foremost a type of housing. It is a person’s individual home and it will be occupied on the basis of ownership, lease or tenancy (there are some examples where there has been a deliberate strategy to develop mixed tenure in extra care schemes).
● It is accommodation that has been specially designed, built or adapted to facilitate the care and support needs of owners/tenants.
● Access to care and support is available 24 hours a day either on site or by call.
Croucher and colleagues point out that there are “great expectations of housing with care”, and indeed it might be argued that the pace of investment and development in extra care housing is moving in advance of the evidence about what actually works. The diversity of schemes also means that it is hard to generalise and that findings from one scheme are not always directly transferable to other models.
But the literature reviewed by Croucher et al indicates that, for many older people, housing with care does offer a valued combination of independence and security, together with opportunities for companionship and mutual support, and high levels of satisfaction are consistently reported by residents.
What is much less clear is how successful the model is for people with greater frailty, and whether housing with care is able to offer an alternative to institutional support and a home for life (or “ageing in place”).
There are also questions about the costeffectiveness of housing with care, and other issues such as the “balance” between fit and frail residents, end of life care, and support for older people from black and ethnic minorities.
While housing with care can offer greater opportunities for social interaction and companionship, the studies reviewed found that people with physical, cognitive and sensory impairments were consistently identified “on the margins of social groups and networks, and in some cases the focus of hostility”. This is a worrying finding that suggests that the balance of residents does not always work well, and the authors suggest that the social well-being of frail older residents in particular needs to be actively promoted. These findings also raise the question (although largely unspoken in the review) of the limits of extra care, and whether there are dangers in seeing this model as a panacea and a general alternative to residential care.
If housing with care is to be developed more extensively it is important to understand what it can, and perhaps can not, achieve. Certainly the research evidence indicates that in some circumstances housing with care can provide an alternative to residential care, but it is equally clear that this is not always the case and people do leave housing with care for residential and nursing home provision.
Of the schemes reviewed, only the one which had an on-site care home (the care community “Hartrigg Oaks” run by JRF) was able to offer something that might be described as a home for life. Elsewhere, people with challenging or high-risk behaviour (associated with advanced dementia) were not easily accommodated within extra care housing. The decision to move to alternative support is clearly influenced by increasing care needs, as well as by residents’ and relatives’ preferences.
The CSIP toolkit points out that in planning the development of extra care housing the range and volume of services required needs to be estimated prior to development. But it is also noted that extra care does not always mean an increase in service provision and some schemes have reported reduced demand. It is believed that this may arise from the improved health and mobility of some residents, or from a more rehabilitative approach adopted by staff.
None of the studies reviewed by Croucher and colleagues addressed end of life or palliative care issues in housing with care settings. The authors comment that if providers promote their schemes to residents as “homes for life” they must consider the implications for services to support high levels of need. It is hard to envisage that a home for life can be achieved for all residents without access to nursing home level support services.
Cost-effectiveness is an important consideration in the development of any model of care. There is little evidence available on the cost-effectiveness of housing with care, and what evidence does exist is contradictory. But Croucher et al conclude that it seems to indicate that housing with care is more expensive overall than residential care, and possibly cheaper than home care. Such conclusions are difficult because they fail to allow for the improved outcomes for residents in terms of better quality of life, independence and autonomy, as well as high levels of reported resident satisfaction. The CSIP toolkit points out that despite shortcomings with effective costing comparisons, it does appear to be the case that older people with low incomes living in extra care “are left with considerable more personal allowance after meeting housing and care costs” compared with those living in residential care.
GAPS IN EVIDENCE BASE
The review indicates considerable gaps in the UK evidence base, and indeed as the authors caution: “Existing and newly developing services cannot therefore rely upon an extensive evidence bank.” The implications of research findings for practice are critical. Despite the fact that Croucher and colleagues rightly emphasise the limitations of current evidence, there are nonetheless some obvious issues that need to be addressed in planning further development of extra care housing. Many of these are explored within the CSIP toolkit. In particular, there needs to be a strategic approach to the commissioning of extra care development to ensure it fits with other housing and care provision.
CSIP also emphasises the importance of strong and effective partnerships since a range of agencies will be involved. In addition to health, social care and housing, it is argued that the development of extra care also requires the engagement of other local authority departments (planning, community leisure, transport and adult education, for example), and independent sector providers (building and care), architects, voluntary agencies, and potential service users and their carers.
Melanie Henwood is an independent health and social care consultant
LINKS AND RESOURCES
● The report from Croucher et al can be downloaded from www.jrf.org.uk
● The Extra Care Housing Toolkit is available from the Care Services Improvement Partnership (CSIP) www.icn.csip.org.uk/housing
● Additional resources are available from the Housing Learning and Improvement Network, now hosted by the Integrated Care Network www.cat.csip.org.uk/housing
The housing LIN has undertaken a range of work on extra care housing, including exploration of the issues for rural communities. A number of factsheets have been produced and are available through the ICN website.
What is the role of extra care housing
In any local development of extra care housing it is important to be clear about what the scheme is trying to achieve and for whom. In particular, is it intended as an alternative to residential care and as a home for life? If so, how to address increasing care needs on-site must be considered.
Extra care for people with dementia or disabilties
Commissioners and providers needs to consider the implications both for the physical design of schemes and for the services provided. In addition, the implications of mixing people with physical, sensory or cognitive impairments with others need to be addressed. Is extra care appropriate for all people with dementia?
How should extra care development be approached? The CSIP resource includes detailed checklists and tools to guide demand forecasting, reviewing and mapping community support, designing extra care housing etc.
Extra care housing and ethnic minorities
Demand for extra care black and ethnic minorities housing significantly outstrips demand. Local developments need to address how best to support BME elders who enter extra care schemes, as well as stimulating markets to develop extra care housing provision for ethnic minorities.
Monitoring and evaluating extra care
Monitoring whether local extra care developments are successful requires clarity from the outset around objectives, as well as appropriate measurement tools and analysis of outcomes.
Telecare and assistive technology
What is the contribution of assistive technology and telecare to extra care housing? What role does telecare in extra care schemes have in supporting people in the wider community?
This article appeared in the 19 July issue under the headline “Extra care housing”