Extra Care: A sustainable solution to the care crisis?
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Extra Care: A sustainable solution to the care crisis?

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The launch of new research into the benefits of extra care housing....

The launch of new research into the benefits of extra care housing.

In July 2011, Andrew Dilnot published the report of the Commission on funding of Care and Support. Within the report, the Commissioners highlighted the potential role for extra care housing. They said “the Commission hopes that more people will be able to consider extra care housing in the future, if they are more aware of this type of provision and can be more certain over their financial planning.” Extra care housing represents an integrated model of housing and social care support that potentially holds fiscal and wider benefits for older people and the state. In addition, extra care housing might offer a way of unlocking the housing wealth of the ‘baby boomer’ generation approaching retirement, therefore providing a real alternative to the spectacle of people selling their homes to pay for residential care when their needs become acute. Yet for extra care to be a sustainable option for the funders of care, it is vital that we know more about the cost effectiveness and efficiency of extra care housing as a model.

This event brought together three speakers to review some of the main debates surrounding extra care housing as well as to present some new findings.

Over the last year, ILC-UK has been undertaking a major piece of research into the benefits of extra care housing through examining resident outcomes. Using longitudinal data from 3 providers, Extra Care Charitable Trust, Retirement Security Limited and Audley, with additional funding provided from Housing Learning and Improvement Network (Housing LIN), we have undertaken a review which explores the characteristics of residents, the notion of extra care housing as a home for life, the health outcomes of residents, and patterns of health service usage of residents. We have also explored the costs and benefits associated with our findings. This new research, presented by Dr Dylan Kneale, also explores how the outcomes of residents in extra care could differ from the outcomes of older people living in the community in receipt of domiciliary care.

Since 2004, the Department of Health has funded a large number of extra care schemes. The the University of Kent’s Personal Social Services Research Unit (PSSRU) have been undertaking a major evaluation of these schemes and Robin Darton, Senior Research Fellow and project lead, will present the early findings. Housing LIN has been a long standing proponent of models of housing with care, and Jeremy Porteus, Director of the organisation, will discuss the findings in greater detail and identify future directions for the sector. This event was supported by the Housing LIN. We are grateful to our partners: Extra Care Charitable Trust, Retirement Security and Audley, for making this research possible.

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  • So far, 2010 has confirmed the growth in the number of unique visitors: there has been a general increase of 20% compared with the same months of 2009. October 2010 looks like it will have broken our personal record for the highest number of unique visitors to the website.
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  • 16/09/11
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  • Department of Health (2003) Letter to Chief Executives of Local Councils with Social Services Responsibilities, 21 August 2003. 21/10/2008
  • 16/09/11
  • 16/09/11
  • Changes from bids: Milton Keynes: 250 -> 258 Brighton: 37 -> 38 Havering: 62 -> 64 Staffordshire: 27 -> 42 (replacement) Stoke-on-Trent: 53 -> 75 (replacement) Hartlepool: 225 -> 242 Cheshire: 232 -> 124 (replacement) North Yorkshire: 36 -> 39 Wakefield: 45 -> 45 (replacement) West Sussex (Crawley): 50 -> 39 (replacement) 21/10/2008
  • 16/09/11
  • 1170 includes: 178 refusals (15%) 47 not able (4%) 77 deaths (7%) Response = residents assessed/(permanent/care units) 16/09/11
  • Barthel Index for 221 of 281 at 6 months Change 4+ likely to represent genuine change (Collin et al, 1988) 1995 longitudinal survey of care homes: 1366 in residential care (1091 with 6 month data/died) Including deaths for care home residents (25%): 41% deteriorated/died 42% no change 17% improved 16/09/11
  • 16/09/11
  • 16/09/11
  • Importance of mobility in use of facilities Association between refusals & dependency for some schemes, e.g. Havering (33%, highest mean Barthel = 16.4), but Wakefield (49%, lowest mean Barthel = 10.9) & Northamptonshire (40%, mean Barthel = 12.5) 16/09/11
  • Importance of mobility in use of facilities Association between refusals & dependency for some schemes, e.g. Havering (33%, highest mean Barthel = 16.4), but Wakefield (49%, lowest mean Barthel = 10.9) & Northamptonshire (40%, mean Barthel = 12.5) 16/09/11
  • Importance of mobility in use of facilities Association between refusals & dependency for some schemes, e.g. Havering (33%, highest mean Barthel = 16.4), but Wakefield (49%, lowest mean Barthel = 10.9) & Northamptonshire (40%, mean Barthel = 12.5) 16/09/11
  • 21/10/2008
  • Importance of mobility in use of facilities Association between refusals & dependency for some schemes, e.g. Havering (33%, highest mean Barthel = 16.4), but Wakefield (49%, lowest mean Barthel = 10.9) & Northamptonshire (40%, mean Barthel = 12.5) 16/09/11
  • Importance of mobility in use of facilities Association between refusals & dependency for some schemes, e.g. Havering (33%, highest mean Barthel = 16.4), but Wakefield (49%, lowest mean Barthel = 10.9) & Northamptonshire (40%, mean Barthel = 12.5) 16/09/11
  • 16/09/11

Extra Care: A sustainable solution to the care crisis? Extra Care: A sustainable solution to the care crisis? Presentation Transcript

  • Tuesday 13 September 2011 Extra Care – A Sustainable Solution to the Care Crisis? www.ilcuk.org.uk
  • Baroness Sally Greengross ILC-UK Extra Care
  • Dylan Kneale ILC-UK Extra Care
  • Establishing the extra in Extra Care: Perspectives from three Extra Care Housing Providers Dylan Kneale International Longevity Centre, September 13 th 2011
    • Housing:
      • Lived in same house for 40+ years (17% 1993/4; 24% 2007/8)
      • Rising levels of under occupancy?
      • Rising levels of housing wealth?.....Rising inequality? (Older people still biggest consumers of social housing)
      • Less retirement housing being constructed
    • Health care:
      • Compression of morbidity? (Zaninotto et al 2010)
      • Non communicable diseases (stroke, dementia)
    • Social Care:
      • Rising cost; Unequal provision; Who pays?
      • Rates of receipt of domiciliary care at home declining…
    Health, social care and housing among the ageing population
    • What is it? Little consensus….
    • Wide spectrum of self-designated extra care housing
    • Some common principles of extra care housing:
    • Ergonomically designed
    • Flexible and continually adapting care packages delivered onsite
    • Communal facilities
    • Group activities
    • Independent homes within small-medium sized retirement communities
    • Usually age specific
    • Leasehold tenure as well as rental tenure
    • Community balance of care needs
    Extra care housing
  • Extra care housing What do we know about extra care housing?
  • Research Questions
    • 1. What is the social profile of extra care housing residents and how does this compare with residents in the community setting?
    • 2. Can extra care housing be considered a home for life for older people?
    • 3. Does residence in extra care housing facilitate healthier and more independent life?
    • 4. What impact does residence in extra care housing have on the uptake of overnight hospital beds?
    • 5. What inferences can be made about the costs and benefits of extra care housing?
  • Data and Methods
    • Data: Longitudinal data from 3 partners on almost 4,000 residents of extra care housing since 1995;
    • British Household Panel Survey; English Longitudinal Survey of Ageing; Survey of English Housing (descriptive)
    • Limitations/Challenges
    1. Characteristics of residents Descriptive analysis 2. Extra care housing as a home for life Event history analysis (Lognormal and Competing Risks); Propensity Score Matching 3. Extra care housing as a healthy home for life Event history analysis (Competing Risks); Propensity Score Matching 4. Extra care housing and hospital beds? Zero inflated negative binomial regression; Propensity Score Matching 5.N Inferences on the costs and benefits of extra care housing? Descriptive analysis
      • Gender
      • Age
      • Living arrangements
      • Additional care needs
      • Health shocks that may predict entry to extra care housing:
        • Stroke
        • Dementia
        • Parkinson’s disease
    Characteristics of residents
  • Characteristics of residents
  • Extra care as a home for life I   Length of time until exit (all exits)   First quartile (25%) Median (50%) All residents 3.1 6.5 Gender Male 2.6 6.0 Female 3.4 6.7
  • Extra care as a home for life II: Competing Risks Framework   Risk 1: moving to an institution Risk 2: death All residents 8.2% (6.7-9.9) 25.0% (22.4-27.5) Gender Male 6.4% (4.3-9.1) 30.6% (26.0-35.3) Female 9.1% (7.2-11.3) 22.0% (19.2-25.1) Health Status/Care Needs on Arrival No additional support package 5.5% (4.0-7.3) 16.8% (14.2-19.6) Level 1 (very low package needs) 12.8% (6.8-20.8) 29.6% (20.0-39.7) Level 2 (low support package) 17.5% (11.7-24.4) 39.8% (31.6-47.6) Level 3 (moderate support package) 11.9% (5.2-21.5) 41.0% (28.3-53,1) Level 4 & 5 (high or very high support package) 9.9% (4.9-17.1) 56.9% (46.1-66.3) Age Group 50-64 6.8% (2.8-10.9) 10.2% (5.8-16.3) 65-69 6.2% (3.1-11.0) 13.0% (8.2-19.1) 70-74 6.0% (3.4-9.8) 18.2% (13.3-23.7) 75-79 9.0% (5.8-13.0) 24.6% (19.4-30.2) 80-84 8.0% (4.8-12.3) 27.2% (21.3-33.5) 85+ 12.7% (8.5-17.7) 49.0% (41.8-55.8) N 1,189 1,189
  • Extra care as a home for life III   All community match sample Domiciliary care match sample   Age 65+ Model 1 Age 75+ Model 2 Age 80+ Model 3 Age 65+ Model 4 Age 75+ Model 5 Age 80+ Model 6 Models adjusted for Age, Sex, Living Arrangements, Year Sub-hazard ratio of moving to an institution Sub-hazard ratio of moving to an institution Sub-hazard ratio of moving to an institution Sub-hazard ratio of moving to an institution Sub-hazard ratio of moving to an institution Sub-hazard ratio of moving to an institution Extra care housing 1.776 1.216 0.905 0.694 0.532* 0.316** (0.659) (0.471) (0.463) (0.207) (0.167) (0.121) N 1714 1034 624 1630 1028 634
    • Diminution in loss of functional ability?
    Extra care as a healthy home for life
    • Conceptualising ‘risk’ of health improvement
    Extra care as a healthy home for life   Risk: improvement in health (decrease in care needs) All residents 24.0% (20.6-27.5) Gender Male 25.7% (19.5-32.3) Female 23.8% (19.3-27.5) Health Status/Care Needs on Arrival No additional support package 30.8% (24.7-37.1) Level 1 (very low package needs) 16.3% (9.4-24.8) Level 2 (low support package) 26.0% (19.1-33.5) Level 3 (moderate support package) 15.3% (7.5-25.6) Level 4 & 5 (high or very high support package) 14.9% (7.9-24.0) Village or Court development Court 9.2% (5.8-13.7) Village 32.1% (27.4-36.8) N 603
    • Falls (fractures), stroke and heart disease account for the main financial burden of older people’s health care
    • Within extra care setting, most accidents represent falls (“loss of balance”, “got up too quick”, “turned around”)
    • Ergonomic adaptations? Group exercise classes?
    • Compare rates for small sample size with sample from ELSA
    • Matching indicative of a lower rate in extra care (49% vs 31%)
    • Sample size – caution – indicative evidence
    • Men susceptible to falls in extra care setting?
    Falls in extra care
    • Number of available beds for geriatric medicine declined by 61% (1987-2008); Bed blocking an issue
    • Comparison group
    • Inverse care law – evidence in BHPS (or other effect?)
    • Incidence rate is higher than in overall community sample BUT reflects length of stay
    • Number of episodes of admission consistently lower in extra care sample i.e. less people go to hospital in the extra care sample, but those that do stay longer
    • Closely matched comparison group overall incidence lower in extra care sample
    • Mechanism?
    Extra care and overnight hospitalisation I
  • Extra care and overnight hospitalisation II
    • Social care costs (median community care package and extra care)
    Extra care and inferences on costs
    • Initial social care costs of extra care housing may be higher than if remaining in the community
    • But, because of higher probability of transition to institutional accommodation , long-term costs lower
      • Planning for retirement
    • Cost of lower rate of hospitalisation
    • Cost of reduction in package
    Extra care and inferences on costs II
    • Extra care housing:
      • Supports some of the most vulnerable in society
      • Appears to be a home for life for the vast majority
        • Compared to those with similar characteristics appears to be lower rate of transition to institution; plausible mechanism (age, living arrangements, gender, in receipt of care at home)
      • 3. Associated with fewer inpatient stays
      • 4. Associated with fewer falls
      • 5. Is a healthy home for life
    Conclusions
  • Policy Recommendations I
    • Policy-makers need a co-ordinated response to providing housing, health care and social care for our ageing population.
    • Policy-makers should make specific pledges to increase the level of provision of extra care housing.
    • The proposed National Planning Policy Framework should champion far more robustly the housing needs of older people.
    • Policy-makers should recognise and encourage private sector development of extra care housing.
    • The findings in this report suggest that policy-makers drafting the Health White Paper should explicitly consider and make specific pledges to increase the role of housing with care.
  • Policy Recommendations II
    • 6. Policy-makers should enhance and sustain programmes of education and information for those who are retired and newly retired to plan their housing and financial futures. Furthermore, consumers need reassurance that policy changes will not negatively impact their retirement decisions.
    • 7. Any National or Local Falls Prevention Strategy should include housing as a key component of preventing further falls.
    • 8. Receipt of Attendance Allowance opens a gateway for many older people to access extra care housing, through helping to finance monthly care costs and to help access other benefits. We would urge policy-makers to ensure that all who are eligible to claim Attendance Allowance do so which could enable greater numbers of older people to support a stay in extra care housing.
    • 9. Further research is needed into the extra care housing sector.
    • Full report available:
    • www.ilcuk.org.uk
    • Further information:
    • Dr Dylan Kneale, International Longevity Centre
    • [email_address]
    Thanks for your attention
  • Robin Darton PSSRU Extra Care
  • The PSSRU Evaluation of Extra Care Housing Robin Darton Extra Care ‒ A Sustainable Solution to the Care Crisis?, International Longevity Centre ‒ UK, 13 September 2011
  • Presentation
    • The PSSRU evaluation
    • Characteristics of residents
    • Outcomes for residents
    • Costs and cost-effectiveness
    • Social well-being
    • Other issues
    • Summary and discussion
  • PSSRU Project Team
    • Professor Ann Netten
    • Robin Darton
    • Theresia Bäumker
    • Lisa Callaghan
    • Jacquetta Holder
    • Ann-Marie Towers
    • Jane Dennett
    • Lesley Cox
    • 26 local researchers
  • The Extra Care Housing Fund: Aims
    • To develop innovative housing with care options
    • To stimulate effective local partnerships between the NHS, local housing authorities, social services authorities, care providers, housing associations and private sector and other developers of extra care housing in the interests of older people
    • (Department of Health, 2003)
  • PSSRU Evaluation: Aims
    • Evaluation of 19 new build schemes supported by the DH Extra Care Housing Fund (2004-2006)
    • Main evaluation:
      • Short- & long-term outcomes for residents & schemes
      • Comparative costs
      • Factors associated with costs & effectiveness
      • Role in overall balance of care
  • PSSRU Evaluation: Linked Studies
    • Extension to additional schemes:
      • Wakefield
      • Birmingham & Plymouth (Thomas Pocklington Trust)
    • JRF-funded study of social well-being
    • JRF-funded study of Rowanberries, Bradford
    • EVOLVE: EPSRC-funded study of design evaluation (Sheffield/PSSRU)
  • PSSRU Evaluation: Extra Care Schemes
    • 2004/05
      • 2 retirement villages: 258 & 270 units
      • 7 newbuild: 344 units (38-75)
      • 2 newbuild/remodelled delayed: dropped
    • 2005/06
      • 1 retirement village: 242 units
      • 9 newbuild/remodelled: 372 units (35-48)
      • 1 retirement village delayed: dropped
  • PSSRU Evaluation: Data Collection
    • Resident data
      • Functioning, services, expectations & well-being
      • Moving in; 6, 12, 18 & 30 months later
    • Schemes
      • Contextual information on opening
      • Social activities at 6 months
      • Costs and context a year after opening
      • Fieldworker questionnaire at end of data collection
  • PSSRU Evaluation: Response (November 2010) No. No. resids No. with data No. with Res Q No. with Ass Q No. Ass Q + 6m No. Ass Q + 18m No. Ass Q + 30m Smaller schemes 16 996 680 620 645 390 187 114 Villages 3 896 568 562 172 63 61 9 Total 19 1894 1248 1182 817 453 248 123
  • Entrants to Extra Care (2006-10): Require Help with IADLs
  • Entrants to Extra Care (2006-10): Require Help with ADLs
  • Entrants to Extra Care (2006-10) & Care Homes (2005): Barthel Index of ADL
  • Entrants to Extra Care (2006-10) & Care Homes (2005): MDS CPS
  • Entrants to Extra Care (2006-10): Change in Dependency by Follow-Up Follow-up % deteriorated % improved Barthel Index of ADL 0‒6 months 9 12 0‒30 months 22 8 MDS CPS 0‒6 months 8 6 0‒30 months 6 14
  • Entrants to Extra Care (2006-10): Location at End of Study Number % Still in scheme 458 56.1 Moved 69 8.4 Nursing home 29 3.5 Care home 16 2.0 Elsewhere/not known 24 2.9 Died 161 19.7 Died in scheme 62 7.6 Died elsewhere 99 12.1 Lost to follow-up 129 15.8
  • Entrants to 11 Extra Care Schemes (2006-07): Mortality & Survival Number of individuals 374 Number of deaths 115 Mean time to death 20 months % died by 30 months (≥65) 34% Predicted median (50%) survival from model: Extra care (≥65) 32 months Care home (2005) 21 months Nursing home (2005) 10 months
  • Cost Variations: Factors Associated with Higher Costs
    • Individual factors:
      • Living alone
      • Higher levels of physical and cognitive impairment
      • Need for nursing care
      • Long-standing illness
      • Higher levels of well-being
    • Scheme-level factors:
      • Separate housing management and care arrangements
      • Higher staff turnover
      • Larger housing providers
      • London location
  • Cost-Effectiveness
    • Rowanberries study: higher cost/person associated with improved social care outcomes and quality of life
    • Comparisons of costs and outcomes with matched sample from 1995 care home survey:
      • Lower costs: £374 vs £409 pw
      • Slight improvement in physical functioning and cognitive functioning stable for extra care
      • Slight deterioration in functioning for care homes
    • Restricting comparisons to more dependent (2005 cases):
      • Outcomes for extra care remain better
      • Less evidence of cost savings
  • Social Well-Being Study
    • Role of communal facilities in friendship development:
      • Smaller schemes: restaurants and shops – lunchtime
      • Villages: indoor street and role of resident volunteers
    • Villages well-suited to more active people
    • Poor health and receipt of care could hinder social involvement – importance of staff support
    • Links with local community valued – importance of location
    • Attitudes to other residents’ frailty and community use of facilities
  • PSSRU Evaluation: Other Issues
    • Timescale of developments (resiting, redesign)
    • Mixed tenure (demand)
    • Future proofing (1-bed flats)
    • Communal facilities and links with community
    • Setting-up and participation in social activities
    • Transport within and outside scheme
    • Division of responsibilities for housing and care
    • Expectations of partner organisations
  • PSSRU Evaluation: Summary
    • Average level of dependency lower than in care homes
    • Substantial need for help with IADLs & mobility
    • Very few with severe cognitive impairment
    • Cost-effectiveness analysis demonstrates potential as alternative for proportion of care home residents
    • Follow-ups demonstrate that can be home for life, but support for cognitively impaired less certain
    • Relationships between fit and frail, social groups etc: importance of support and managing expectations, especially in villages
  • Discussion
    • Sustainability of extra care model:
      • Pressure resulting from local authority nomination rights
      • Maintenance of facilities (e.g. restaurants)
      • Development of new schemes (provision relatively limited)
      • Public understanding/demand (downsizing)
      • Local authority staff understanding and expectations
      • Impact of policy developments (e.g. personal budgets)
    • Other issues:
      • Management turnover and stability
      • Relationships with local community
    • Is it expected to do too much?
  • Contacts
    • PSSRU publications on the evaluation:
        • www.pssru.ac.uk/projects/echi.htm
    • Housing and Care for Older People Research Network:
        • www.hcoprnet.org.uk/
  • Jeremy Porteus Housing LIN Extra Care
  • Extra Care – a sustainable solution to the care crisis? Jeremy Porteus 13 September 2011
  • The economic case for independence at home?
    • A fall at home that leads to a hip fracture costs the state £28,665 on average – over 100 times the cost of installing hand and grab rails
    • Where it is appropriate, postponing entry into residential care for one year saves an average of £28,080 per person
    • A hospital discharge service that enables older people to return to a safe and suitable home environment saves over £100 per day – the amount charged to local authorities when patients ‘block beds’
    • (source: Fit for Living Network Position Statement.
    • hact, 2010)
  • The challenges facing health and social care
    • 2.4million more older households by 2026
    • Two thirds of older people with dementia live in their own homes, with one third in care homes
    • At least two thirds of people in care homes have dementia
    • There are approx 18,450 care homes in England
    • There are approx 4,897 home care agencies providing support to people living at home
    • People with dementia over 65 years of age are currently using up to one quarter of hospital beds at one time
  • Key policy developments and reports
    • Dilnot Commission on Paying for Care & Support
    • - the Commission hopes that more people will be able to consider extra care housing in the future, if they are more aware of this type of provision and can be more certain over their financial planning.
    • - ..there is also an indication that they help people to avoid moving into more intensive residential care settings
    • Age of Opportunity (CSJ)
    • - .. We believe that as as country we have not yet realised the potential of extra care
  • Some questions when thinking about solutions for independent living for an ageing society
    • How might accommodation and care for older people change over next 20-30 years to cater for ‘baby boomers’?
    • What impact will changing wealth and tenure on accommodation and services older people might want as opposed to might need
    • What will the implications of levels of equity held by older people, estimated to be £1trillion
    • How best to use the considerable asset of sheltered housing in the UK, estimated to be £40billion
    • And finally, why should our options for assisted living and lifestyle be limited as we get older? The market will demand a growing variety of independent living choices to meet the diverse of needs and aspirations of older people.
    • Thank You
    Jeremy Porteus Housing LIN c/o EAC 3rd Floor, 89 Albert Embankment London, SE1 7TP UK email: [email_address] email: [email_address] tel: 07899 652626 tel: 020 7820 8077 website: www.housinglin.org.uk
  • Tuesday 13 September 2011 Extra Care – A Sustainable Solution to the Care Crisis? www.ilcuk.org.uk