Assessing the mental health needs of older people
Mainstream, specialist and alternative services
Specifically targeted services appear to work best for older people with mental health needs (see Research Summary 4 ).
The number of specialist schemes are relatively limited and most older people with mental health needs use mainstream services. The full range of community care services should be available to older people with mental health needs without discrimination. It is essential, therefore, that all service providers understand mental health issues, and ensure their staff are specifically trained to provide an appropriate service.
A number of social services departments have commissioned specialist home care or day care services, training staff to work with people with dementia and to offer a sensitive, safe and acceptable service. Examples include Dudley, Waltham Forest and Milton Keynes. In some places, specialist hospital discharge services for people with dementia have been set up, to ensure appropriate, safe and supported discharge home from acute hospitals. Ealing's Enhanced Discharge Scheme is an example.
It is not only traditional services which can be used to meet needs. For instance, going by taxi to a further education art class might be more acceptable to an older person than being taken by local authority transport to a traditional day centre, and might meet the same objectives. When considering widening the choice and availability of services it is important to make sure that service providers and other service users are understanding towards and supportive of service users with mental health needs. Careful planning may be required to ensure older people with mental health needs 'don't feel out of place or disregarded, or encounter dismay, hostility or rejection from other service users. This may also entail providing support and advice to service providers, families and neighbours.
National guidelines stress that care plans for older people with dementia should aim to promote and maintain independent functioning, and should include:
- consistent and stable staffing, retaining a familiar environment and minimising relocation
- occupational therapist advice and input regarding skills training in activities of daily living and adapting the environment
- enjoyable activities and physical exercise.
Key research finding
The community care changes have created a greater range of service providers, but there has not been a corresponding increase in the type of service generally available.
For younger adults with learning disabilities, for example, access to community facilities and 'normal' services is frequently assisted by an enabler, support worker or volunteer, and there is no reason why older people with mental health needs should not be considered for the same sort of support if appropriate. For example, a service run by South Cambridgeshire Crossroads, as part of their support to carers, provides specially trained care assistants to accompany older people with dementia to activities.
From an older person's perspective, an effective service is one which enables them to achieve quality of life and treats them with respect and dignity. Many older people value 'low level' services offering practical help, such as shopping, housework, and home and garden maintenance. Increasingly statutory agencies are withdrawing these services, even within a package of care. Sometimes people receiving high levels of personal care are expected to arrange and pay for such other forms of practical help themselves. For many older people with mental health needs, this is just not realistic. Care packages need to encompass the totality of a person's life and needs, regardless of how the individual elements are provided or funded.
There are inevitably problems for assessors and care managers with limited resources and competing priorities. Professionals have to be able to deal realistically with the conflicts and pressures involved in resource allocation and unmet needs without losing their determination to achieve the best outcome possible for each individual. This may involve a more imaginative use of existing resources or working to develop more appropriate responses.
For some examples of service innovations, see the Health and Social Care Change Agent Team's Bright Ideas section.
Key research finding
Although older people with mental health needs are at increased risk of admission to long-term care, care home staff tend not to be well informed about residents' mental health needs.
- In Warwickshire, one locality used Joint Finance to put on a programme of dementia awareness training available free of charge to staff from any home care agency, care home or housing provider in the locality.
- Housing 21, a housing association providing extra care sheltered housing, appointed a Dementia Services Advisor in 2004 to provide professional advice and support to their scheme managers in identifying and supporting tenants with dementia and promoting good practice in dementia care.
Residential care used to be seen as the only option for older people with mental health needs if they were no longer able to care for themselves or their families could no longer cope, particularly if an older person was considered at risk. Residential care, in a general care home or specialist unit, may still be the most appropriate solution for people who require very intensive personal care or supervision. For people with mental health needs in residential units, the built environment should aid orientation and enable independence, and the care provided should be supportive, stimulating and therapeutic.
Community-based alternatives are increasingly seen as appropriate for older people with mental health needs. Many services such as sheltered and extra care housing which would not previously have accepted people with, for example a diagnosis of dementia, (see below ) or intermediate care, now accept people with a wide range of needs. The Department of Health has issued guidance on establishing Intermediate Care services for older people.
Key research finding
There are strong links between housing quality and mental health.
The role of housing, and housing-related services, in helping to meet older people's health and social care needs is too often neglected.
Care and Repair England's 'Healthy Homes, Healthier Lives' programme aims to raise awareness of the ways in which poor or unsuitable housing can have a negative effect upon older people's health and well-being, and to increase understanding of the services and resources available for improving housing conditions Home Improvement Agencies exist to help older and disabled people maintain their independence by giving advice, support and practical help on repairs, maintenance and adaptations. Increasingly, Home Improvement Agencies are becoming involved in wider services such as hospital discharge schemes, 'handyperson' services and housing options advice. Research by the University of the West of England highlights the challenges for Home Improvement Agencies in developing their work with older people with mental health needs. (33)
Extra Care Housing (ECH) - also called very sheltered housing - is a new development in service provision. It is increasingly popular amongst older people and policy makers because it has the potential to replace residential care. It also plays a useful role in providing respite care and a base for intermediate and rehabilitative care. More importantly it has the flexibility to provide added health gains and reduce pressures on acute services, such as tackling delayed discharges from hospital. ECH is difficult to define as it covers a variety of schemes in which housing and care are integrated. It may be particularly relevant to extending community-based living for older people with mental health problems.
The availability of Housing Benefit has been central to the development of ECH. In 2003 Housing Benefit was replaced by the 'Supporting People' budget, a funding stream that provides housing related support services to vulnerable adults. It is particularly targeted at older people.
If services you think are needed are not available:
- Talk to existing providers about what adapting their services would involve. How difficult would it be? What are the barriers? Is there anything you can do to help?
- Identify any additional costs for providers, and ask your manager how these could be funded. See if you can use your team's care budgets to negotiate directly with providers. What source of funding might there be for new providers?
- Make it your business to understand any difficulties service providers have, and your own organisation's financial limitations. What could be done differently to overcome these?
- Get to know the strengths and resources of your local community. Are voluntary organisations looking to expand their remit? Does the local place of worship visit and befriend older people? Can the local vet's surgery tell you of anyone who would volunteer to help an older person care for their pet? Would the local radio station be interested in doing a programme to attract care workers?
- Keep a record of situations where you feel you have been unable to find the right service despite your efforts. Tell your manager, and encourage colleagues to do the same. Remember, new and better services are unlikely to be commissioned unless someone has identified the need. You are one of the people best placed to do this.
For a discussion of the issues concerning the appropriateness of extra care housing for people with dementia, see The Challenges of providing extra care housing to people with dementia by Sue Garwood of Hanover Housing Association. (34)
The Office of the Deputy Prime Minister and the Department of Health have issued joint guidance on the preparation of Older people's strategies that link housing to health, social care and other local strategies.
The website of the Office of the Deputy Prime Minister has more information about the 'Supporting People' budget.
The 'Housing with Care' Learning and Improvement Network (LIN) brings together stakeholders across the country to explore and develop service provision. It has produced a range of factsheets including: Supporting people with dementia in extra care housing and Extra care housing options for older people with functional mental health problems. For more details, and other relevant resources, see the Older people - Housing page on the Health and Social Care Change Agent Team website.
The Housing and Older People Development Group has published a helpful report entitled Directory of housing advice and information services for older people.