Supporting and caring for older people is the largest part of adult social care work, and, as we experience more people living for longer, it will most likely remain that way.
We continue to learn much about this phenomenon of ageing in society through such studies as the English Longitudinal Study of Ageing. We know there is a great deal to be celebrated for society, communities, families and individuals. There are, though, also risks and challenges, including, for example, likely greater demands on health and social care services.
So, how do we best arrange care and support for more fragile older people? One significant issue in this question is how as a society we organise the overall planning and coordination of care and support.
Personalisation through personal budgets given to people eligible for services to plan their own care and support is an approach to doing this that has come to the fore in fairly recent times. I have blogged on here about research highlighting some of the challenges of applying this to supporting older people . Research by the NIHR School for Social Care Research has added to our understanding of this area of policy in to practice and some of the continuing challenges it presents (you can find examples here and here).
Case management has a longer history as an approach to planning the overall organisation of individual’s care and support. There is no one definition of case management that encapsulates all aspects of how it works, but it is based on a philosophy of trying to integrate services, in community settings, around the needs of each individual (Ross et al, 2011; Challis & Hughes, no date given).
Care coordination and intensive case management are related concepts that I will also use here to refer to this broad approach to planning people’s care.
Case management has been well researched and it has been seen that it can be effective in helping people to access community-based care services. In some cases it can also led to financial savings by reducing the use of more expensive, often institutional, services. The idea has been widely applied in adult social care practice, but local authorities have had freedom to choose how best to implement the approach in their own localities.
In the article I am discussing in this blog, Chester and colleagues examined how case management has been applied in Local Authorities (LAs) to help support older people, and its effects.
Chester et al. had two aims:
- to examine the key features of care coordination for older people in service delivery arrangements.
- to explore the links between these and service level outcomes
The team collected a range of data from a survey of LAs and data routinely collected by them. They sought to use this to both describe care coordination practices in LAs, and seek to explain what factors in this practice contribute to service level outcomes.
A framework of what constitutes good practice in care coordination was derived from previous policy and research literature. The factors in this were then turned in to variables that could be measured in the data they collected. These were as follows:
- Flexibility in response to need
- Continuity of support
- Joint working between health and social care
- Differentiation between arrangements
The service level outcomes were drawn from existing, routinely collected data. They included percentages of people receiving specific things like statements of needs, and measures of the satisfaction of people receiving services and of their wellbeing – these later areas being composite measures developed by the team based on variables in the existing data.
The variables and related data were then statistically modeled. A hierarchical cluster analysis was used to identify groups of LAs with similar care coordination practice.
The grouping of LAs was then analysed using the service level outcome variables to see if the types of practice models the researchers had identified had a statistically identifiable impact on these outcomes.
Chester et al. found 9 groupings of LAs representing 9 models of how care coordination is being applied in practice.
This represents significant difference in practices across the country. This is consistent with other research, but it has not been clear how much of this variation is justified.
The analysis explored the implications of the variation on the service level outcomes, but their findings are tentative in terms of trying to draw firm conclusions about the relative merits on one of the models of care coordination compared to others in terms of impact on service level outcomes.
Only one outcome measure – households receiving intensive home care per 1000 population aged 65 and over – was found to significantly differ across clusters.
The authors then refined the analysis by taking one LA for each of the 9 models of care coordination – the exemplar LAs that most closely matched each model. This confirmed the diversity of models of care coordination in practice.
When the outcomes for 4 of these LAs were then compared they found that broadly similar levels of outcomes were evident across them.
Chester et al. discuss the finding from other research that factors beyond the control of the LA (‘exogenous factors’) significantly shape care coordination practice and its impact. An example here is control over aspects of the degree to which care is integrated between health and social care to best support older people, especially to receive care and stay in their own homes. These exogenous factors were ones they had no data on and, so, could not include them in the modeling.
In summary, they found in their analysis that
(l)inks between service level outcomes and different types of care coordination arrangements were generally weak (p.14).
This may have been because of limitations in the data they used, the diversity of care models making it hard to identify links, the greater importance of exogenous factors they could not model, or several other reasons.
The authors concluded that
using agency level data, confirmed the variability in care coordination arrangements and the relative absence of intensive care management, central to shifting the balance of care from residential and nursing provision to care at home.
Strengths and limitations
The research team was a very strong one for this area of research and the methods used. They drew together a sensible set of variables for good care coordination practice and service-level outcomes that makes good use of the existing evidence and the data they could collect.
Using routine data can be a strength for research, but can limit what is actually used as variables in the analyses. This is most evident in this study in terms of how the team had to define the outcome of wellbeing for older people using services. A recognised measure of this concept could not be used as it was not in the data collected by LAs.
Having said that, the team has developed sensible variables and they are very transparent in the paper in describing what they did and how they did, which would make it easy for others to critique and/or replicate the analysis.
Chester et al. are also transparent in commenting on some potential limitations of the study. This includes the fact that their survey of LAs and their care coordination practices is a snapshot at one point in time, which may not be representative of practice across time in each authority.
They were not able to provide strong insights into the degree to which this variation has an impact on the outcomes they were able to examine.
However, they most clearly add to the evidence about the diversity of care coordination practices across LAs.
Care coordination has been in existence for so long in adult social care in England and it is clear that practice remains very variable. How much of this is justifiable variation contributing to better outcomes is not clear.
It is important to have evidence-based information to help us continually strive to improve this area of practice and its contribution to better outcomes for older people receiving care and support from services.
This paper by Chester et al. provides a framework that LAs can use to robustly and systematically examine their own care coordination arrangements. By working through the framework, an authority can examine its local arrangements and most likely provide additional data to closely scrutinize local practice and its impact. Most especially, they will have insights on local exogenous factors that Chester et al. could not model.
One particular aspect of good care coordination – joint working across health and social care – was especially noted as being variable across LAs. Given that this is an enduring problem across services and with how they are experienced by many service users, and that such integration is often held up as a means of improving the effectiveness and efficiency of care, it would be a good area for all authorities to start to examine their own care coordination practice and look to see if improvements can be made.
In terms of policy implications, this paper provides an opportunity to overview care coordination practice, where there are consistent strengths across LAs in terms of the framework and where there are frequently occurring gaps. This would then guide what policy developments might help ensure a robust development of care coordination across the country.
The authors also begin to explore the implications for care coordination practices in a world of personal budgets, and these thoughts could also help to guide policy developments at the interface of these two areas.
Chester,. H, Hughes, C., Sutcliffe, C., et al. (2015) Exploring patterns of care coordination within services for older people. International Journal of Care Coordination, 18 (1) 5–17 [Abstract]
Ross, S., Curry, N. & Goodwin, N. (2011) Case management: What it is and how it can best be implemented London: King’s Fund [Full Text]
Challis, D. & Hughes, J. (no date given) Intensive care/Case management Manchester: PSSRU [Full Text]