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3 'I Conference Proceedings Towards Care Management in Ireland Sinead Quill (Editor) National Council on Ageing and Older People An Chomhairle Naisiunta urn Aosu agus Daoine Aosta Report NO.71 Towards Care Management in Ireland

4 National Council on Ageing and Older People 22 Clanwilliam Square Grand Canal Quay Dublin 2.:: Report No. 71 (c) National Council on Ageing and Older People, 2002 ISBN Cover image kindly provided by Sandwell Third Age Arts: a project serving older people with mental health needs, their carers and care workers. For more information please contact Tel: Conference Proceedings

5 ! I 11 Foreword Ii I As Chairman of the National Council on Ageing and Older People, it gives me great pleasure to present the Proceedings from the National Conference on Care Management in Health and Social Services for Older People. The Conference took place on 21 November 2001 in the Royal Marine Hotel, Dun Laoghaire. At the Conference a study of Care and Case management for Older People in Ireland conducted by the Royal College of Surgeons in Ireland on behalf of the Council was launched. In addition, the Conference provided an opportunity: to promote the benefits of Care Management in the context of a strategy for the provision of a comprehensive continuum of care for older people to explore methods of evaluation for use in Care Management projects to facilitate the development of good Care Management practices through discussion and the exchange of information on Care Management experiences (both national and international) to give consideration to a draft Care Management Implementation Framework. I would like to express my appreciation to the speakers at the conference - Dr Ruth Barrington (CEO, HRB), Professor Hannah McGee (Director, Health Services Research Centre, RCS!), Dennis Doherty (CEO, MHB), Oavid Challis (Director, PSSRU) and Donal O'Shea (Regional Chief Executive, ERHA). Maurice O'Connell and Sarah Marsh (Alzheimer's Society), Dr Ciaran Donegan and Greta Thompson (Beaumont Hospital), Mary Warde and Frank Murray (WHB), and Or Michael Oonnelly (Queen's University of Belfast) presented excellent papers at the workshops and I would also like to thank them, the workshop Chairpersons and rapporteurs for their work. On behalf of the NCAOP, I would like to thank the editor Sinead QUill, and her assistant Dermot Kiely for their commitment and dedication in preparing the Conference Proceedings. I thank the members of the Care Management Consultative Committee who assisted in the planning of this Conference. The members of the Conference Planning Sub-Committee were Professor Faith Gibson, Ann Judge, John Brennan and Rebecca Garavan. I would also like to thank Michelle Rogers of the Council staff who co-ordinated the planning and organisation of the event with considerable assistance from Samantha Kenny. Finally, thanks to Eamonn Quinn who prepared the Proceedings for publication. Or Michael loftus Towards Care Management in Ireland

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7 Contents Opening Address Or Ruth Barrington 1 First Session Care and Case Management for Older People in Ireland: An Outline of CurrentStatus and a Best Practice Model for Service Development Prof. Hannah McGee 6 Second Session Care Management - Pipedream or Prerequisite for Seamless Service Provision? Oennis Ooherty 14 Care Management: Who Needs It? What Makes It Work? Lessons from International Experience Prof. Oavid Challis 19 Parallel Sessions First Steps in Establishing a Dementia Care Management Project: Workshop Summary Maurice O'Connell and Sarah Marsh Home First Pilot Project, Beaumont Hospital, Dublin: Workshop Summary Or Ciaran F. Oonegan Packages of Care, Mayo Community Services: Workshop Summary Frank Murray and Mary Warde Community Care and Care Management in Northern Ireland: Workshop Summary Or Michael Oonnelly Final Session The Way Forward for Care Management in Ireland: Oonal O'Shea 46 Closing Address: Or Mick Loftus 52 Terms of Reference 53 Speakers' Biographies 57 Towards Care Management in Ireland

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10 Opening Address Or Ruth Barrington Chief Executive Officer, Health Research Board Everyone working in health and social services in Ireland is aware that the business of managing these services is about, or should be about caring. Equally, it is recognised that the business of caring needs to be manjged. Therefore, bringing these two concepts of caring and management together in a Care ManagEment framework is timely and appropriate for our health and social services. It is perhaps surprising that it has taken so long for the concept of Care Management to percolate through these services. This Conference will address a number of issues in relation to Care and Case Management, one of which being what exactly are Care and Case Management and what does this approach to the planning and delivery of care for older people involve? The aim of Care and Case Management is to provide more flexible and individualised packages of care for vulnerable older people living on the margins of home and residential care. Care Management essentially proposes the adoption of a care, rather than a cure model for the planning and delivery of services for older people. It involves meeting both health and social needs through an optimal use of the health and social care services in the community. It also requires a radical devolution of decision-making to professional Care Managers and service-users who jointly decide what the most appropriate package of care will be. Care Management consists of service co-ordination and the planning of services for people in a defined area. Case Management is the application, the operationalisation of that planning model, the service model to the individual service-user. The National Council on Ageing and Older People has recommended since 1992 that there should be much more co-ordination in care planning and delivery in Ireland. It proposes that this co-ordination is a key prerequisite for achieving health and social gain for older people, for enhancing the quality of care and for enabling more older people to remain living in the community for as long as is possible or practicable. This report in which the Council first recommended increased co-ordination in care planning and delivery was called Swimming Against the Tide (1992). This tide has begun to turn and the recommendations that the Council has been proposing for the system are increasingly being responded to. Many will be aware of the changes in the management structures of the health boards, the appointment of Directors of Services for Older People and the appointment of area managers who have the responsibility for co-ordinating services for older people. In addition, it has been proposed that person-centred care will be one of the key principles of the new National Health Strategy and the Council can take some credit for familiarising people with this concept and for its promulgation throughout the health system. Conference Proceedings

11 The main purpose of this Conference is to launch a study that was commissioned by the Council on Care and Case Management for Older People in Ireland. This study was conducted by Sarah Delaney, Rebecca Garavan, Hannah McGee and Aodan Tynan of the Department of Psychology in the Royal College of Surgeons of Ireland. It is a first systematic review of health and social services delivery practices in the care of older people and was undertaken in order to identify models of Care Management that were in existence in Ireland. It highlights best practice and makes recommendations in relation to how Care and Case Management may be implemented more effectively in Ireland. The Conference also aims to: promote the benefits of Care Management in the context of a strategy for the provision of a comprehensive continuum of care for older people explore the methods of evaluation for use in Care Management projects facilitate the development of good Care Management practices through discussion and the exchange of information give consideration to a draft Care and Case Management Implementation Framework which essentially is a statement of what good Care Management practices entail. The Council prepared the draft in order to ease the transition of theory into practice. This is clearly a very important Conference for all who are involved in the planning and delivery of health and social services for older people in Ireland. Towards Care Management in Ireland

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14 Care and Case Management for Older People in Ireland" An Outline of Current Status and a Best Practice Model for Service Development Professor Hannah McGee Director, Health Services Research Centre, Department of Psychology, Royal College of Surgeons in Ireland Introduction The original brief for this study proposed an investigation into the attitudes and perceptions that health and social service providers have about barriers to and incentives for the effective implementation of Care Management in Ireland. It also sought to identify potential location(s) for a first pilot project for Care Management in the Republic. However, it was soon discovered that there were already a number of groups working on pilot projects or more extended programmes of Care Management in various locations throughout Ireland. As a result, the brief for the study changed. _ The aims of this study were: to review and to summarise the available literature relating to Care and Case Management to identify care delivery practices that were similar to or near to Care Management to develop one or more best practice models of Care Management which would be suitable in an Irish context to develop an evaluation framework appropriate to the ongoing review of the performance of Care Management projects. _ Care and Case Management involve the co-ordinated planning and delivery of individually tailored care plans. These plans are developed in consultation with older people and their carers and with a range of health and social service practitioners, eg GP, PHN etc. There are numerous debates in relation to the precise definitions of Care and Case Management. The definitions that have been adopted for the purposes of this study were developed by Professor David Challis from the PSSRU in the University of Canterbury in Kent. Professor Challis has defined Care Management as service co-ordination and planning at management level and Case Management as the front-line delivery of a tailored care plan to an individual through a Case Manager and his or her team. Therefore, Care Management takes place at a management or organisational level and Case Management at the level of the interface with the individual. Conference Proceedings

15 Principles of Care Management _.----._-_. This approach to the planning and delivery of health and social care for older people should be underpinned by a set of principles. Principles proposed for Care and Case Management are that service planning and delivery should: be anti-ageist in approach be focussed on the needs of the individual rather than on the services and the structures available be holistic, encompassing both the health and social needs of the individual maintain the self-respect and self-esteem of the older people concerned facilitate the empowerment of care recipients and their carer and family networks, while maximising the health and well-being of those groups be integrated in terms of how the services should be delivered be flexible to accommodate changing needs facilitate choice promote a partnership between the users and providers of services. International Experiences of Care Management In the UK, Care Management was adopted as a strategy for the planning and delivery of health and social care services throughout the 1990s. This was in response to a number of factors such as: the fragmentation of services and the need for more integration the growing costs of long-term residential care as a strategy for the care of older people the need to promote quality and the need to promote competition between providers in order to ensure quality at a good price. In the USA, managed care has very often been accused of focusing too much on acute care to the detriment of chronic care. However, Care Management strategies such as Ageing in Place involve care co-ordinators (typically nurses) who try to manage the services that are available for older people. In Canada, there have been a number of projects. For instance, a Quebec service called SIPA has responsibility for co-ordinated health and social care provision for around 13,000 older people. The aim of this programme is to deliver services to that group within a Care Management framework. In Australia, Care Management was initially developed as an approach to the planning and delivery of care in the disability sector. It has since been extended to particular chronic disease groups and to older people. Does Care Management work? In the UK, the PSSRU at the University of Canterbury in Kent has spent the last two decades evaluating Care Management services. The results of its studies indicate that: it is possible through Care Management to provide home care for a significant proportion of people who would have otherwise needed institutional care the costs of maintaining a person in his or her own home have been found to be reasonably similar to the costs of institutional care with important exceptions. For example, in relation to dementia, it has been found to be more expensive to keep people at home with a high quality managed care programme. However, both patients and carers report greater quality of life in home care. In Italy, it was demonstrated that those who received Care Management were able to stay in their own homes for longer and had admissions to hospitals later than those whose care had not been managed in this way. Towards Care Management in Ireland

16 Ireland - Current Context for Care Management Historically, there has been a dominance of health services over social services. However, Care Management requires holistic care and it is vital to find an appropriate balance between these two types of services for the individual. The health service has been characterised by a focus on acute rather than chronic models of care and this focus typically disservices older people as a group. Care services are often fragmented and communication across agencies can be difficult. Indications suggest that the focus of the National Health Strategy will not only be on health issues but also on social gain and on person-centred care. These are two cornerstones of Care and Case Management. Why Care Management Now? - It was felt that Care Management would be an appropriate approach to the planning and delivery of health and social care in Ireland at the moment because: relative to the working-age population, there are fewer older people in Ireland than in any other EU Member State. From a demographic point of view, Ireland appears to be in the best position to support its older citizens in the EU. Therefore, now is a good time to introduce Care Management there are more older people in Ireland who might avail of State services now than has been realised. For instance about 33,000 people were expected to apply for medical cards when they became freely available for the over 70s in In fact over 53,000 people actually applied in relation to our national finances, there is a low dependency ratio in this country and therefore relatively ample monetary resources to introduce Care Management Care Management will not only benefit older people. If health and social services can be made fit for older people, they will be fit for everyone. In addition, the model of Care Management proposed is applicable for those with disabilities and other chronic conditions..methodology The research consisted of: semi-structured extensive interviews with forty-two health and social services professionals from health board and voluntary agencies. Those interviewed ranged from senior managers to front-line staff and spanned the various professional groups, for example public health nursing, social work, co-ordinators of care for older people two consultative phases: Phase 1 investigated the current level of service provision in order to locate 'near' Care and Case Management projects that were in existence; Phase 2 involved investigating the feasibility and efficiency of two models for Care and Case Management in Ireland. These models were based on international literature and feedback from respondents in consultation with older people which took place within the context of two focus groups - one was convened in Roscommon and the other in Dublin. The proposed Care Management models were described to the respondents and they were asked for feedback in relation to suitability in the Irish context. Results of the Study - Current Service Provision In terms of how health and social services are currently delivered to older people, the following points were noted: there was a clear ethos of trying to enable older people to remain in their own homes for as long as is possible there was a consensus that the model of care currently in operation in Ireland is a relatively narrow medical model rather than a broader bio/psycho/social model of care Conference Proceedings

17 rapid changes in family systems and structures were making it more likely that older people would be living on their own a range of services were identified as being availabie in the community but these services were considered to be seriously under-resourced and under-staffed there was a lack of administrative or IT support in the health and social services in terms of referral pathways, public health nurses and GPs were seen as being the key referral agents for older people when they needed multiple services eligibility for the medical card and level of assessed need were identified as being the main eligibility criteria for various health and social services a variety of assessment tools were in use. These induded the Barthel, the Roper-Tierney and the Winchester tools. It was also reported that there were some other initiatives, particularly suitability of each in the Irish context most respondents indicated that there were no formal guidelines in place for monitoring and evaluation although two health boards (North Eastern and Southern) had plans to develop such guidelines in terms of feedback and complaints systems, two routes were described. The one that was much more likely to be in existence was the informal communication network and that was mainly seen as being delivered through the public health nurse. There were also formal complaints and grievance procedures, although these were considered as being less likely to be accessed in terms 01 services flexibility, the predominant view was that services were severely under-staffed and would not be able to adapt easily to accommodate changing needs it was reported that the most common media for information dissemination were booklets and leaflets there were two types of reporting arrangements in existence in the near Care Management projects - a line management arrangement and an intra-professional management arrangement. With an increased development of multi-disciplinary teams, this dual reporting relationship structure was seen to be a source of conflict in terms of structures, control over budgets rested with senior or middle management. It was felt that there would have to be a devolvement of budgets if Care Management was to become a reality communication took place mainly on an informal basis with some, but not many, formal arrangements. There were very few formal guidelines for consulting with service-users although there were strong informal links with the users and carers links between health and social services within health boards were considered as being underdeveloped and this sometimes resulted in an over-dependence on the voluntary sector it was felt that difficulties in negotiating existing reporting relationships would lead to problems with the adoption of Care Management there was a wide variation reported in relation to what background a Case Manager should have. Nursing and social work were mentioned as suitable backgrounds. It was also felt that a specific background was not necessary but that specific training should be undertaken by those who wished to become Case Managers. _f The research identified nine 'near' Case Management pilot projects and the details of each are outlined in the report. It is hoped that by having these projects listed and the health board regions identified, those interested in developing similar projects will be able to build on their experiences when they are developing programmes themselves..jj Towards Care Management in Ireland.'.

18 1 Focus Groups with Older People The older people that were consulted during this research expressed a clear preference for being able to remain at home with the assistance of a Care Management framework. They felt that the existing barriers to their remaining at home were: changes in family structures difficulties with public transport in accessing services lack of services that were near to them in the community the cost of private services, such as chiropody over-stretched GPs. Older people reacted very positively to the models of Care Management presented to them. They also felt that Care Management should: facilitate the formation of meaningful and trusting relationships with an individual facilitate the transition between different care settings. In addition, they also felt that a Case Manager should promote patient participation and should have very good interpersonal skills. The two models developed are based on international literature and discussions with serviceproviders. Model A proposes that there is one dedicated Case Manager at the front-line within a defined area and that this person reports to a Co-ordinator of Services for Older People. Model B proposes that the role of the Case Manager is not dedicated but assigned on a case-by-case basis by a multi-disciplinary team according to the main needs of the older person. These models were presented to the health and social care professionals and to the older people who participated in the research. Model A was the model that the vast majority of respondents preferred because: older people have complex needs and requirements and a dedicated Case Manager would be more able to facilitate a thorough satisfaction of these needs concern was expressed that service-providers whose role was not dedicated to Case Management would become over-stretched because they were balancing two roles: Case Manager for some clients and a specific professional role such as physiotherapy for others in terms of training, it is not efficient to have a large number of staff trained in Case management. Prerequisites for Care-and Case Management The research concluded that there were prerequisites for Care Management that would have to be fulfilled in order for this approach to health and social care planning and delivery to be implemented effectively. These prerequisites are that: a clear and consistent terminology for Care and Case Management must be developed the principles of Care and Case Management must be adopted locally, regionally and nationally older people and their carers must be supported and consulted during the development of Care and Case Management and throughout its implementation the core skills required for Care and Case Management must be clarified Care and Case Management must be considered as being a new specialisation that requires specific training additional to a range of baseline professional qualifications Care Management is part of a larger continuum of care and should be adopted only when appropriate Conference Proceedings

19 an adequate number of qualified staff is essential to the success of Care and Case Management. Care Management cannot be seen as a substitute for a shortage of staff and services a multi-level training system must be developed and this should be accessible to people who are already full-time professionals a standardised generic assessment tool must be developed reporting relationships and duties must be more clearly defined health information systems must be developed to support Care and Case Management. The possibility of the development of a unique patient identifier must be explored there is a need to form a Working Group to develop an evaluation plan that can be rolled out across the country and this needs to include the service-user perspective as well as information on costings and changes required in the current system to make Care and Case Management a reality resources need to be ring-fenced for evaluation there is a need for a Working Party to be established to monitor the progress of the implementation of Care and Case Management in Ireland. Where Do We Go From Here? The Council has developed a draft implementation framework to help the process of discussion in relation to the next steps in the effective implementation of Care and Case Management in Ireland. The NCAOP is also promoting the establishment of a National Older Persons' Care and Case Management Monitoring and Development Group. Towards Care Management in Ireland

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22 Care Management: Pipedream or Prerequisite for Seamless Service Provision? Dennis Doherty CEO Midland Health Board Introduction Work that has been carried out in the Midland Health Board, work similar to that being done in other health board areas, has demonstrated that there are a lot of advantages in adopting a planning and management approach to care. Even though, to date, Care Planning has been implemented more in the area of services for people with mental illness, children in care and people with disability than with older people, the concept and the approach are transferable across disciplines. It is hoped that the National Health Strategy will place more emphasis on primary care and in that way provide more of an opportunity for Care Planning and Case Management - a more holistic approach than is available at present where general practitioners are contractors to health services and operate separately to a large extent from other services, such as home helps, physiotherapists and public health nurses. An Interrelationshfp Between Need, Demand and Supply An interrelationship exists between need, demand and supply for health and social services, and in an ideal world there should be complete alignment between the three. However, at present, this complete alignment does not exist. In an evidence-based approach to service planning and management, there is a major emphasis on the need for services. In reality, service provision depends as much, if not more, on demand than on assessed need. In addition, the supply of services and facilities in turn also influences demand. This is illustrated by an examination of the demand and supply for nursing home places. The research presented here today has borne out the view that we are already aware of, that older people prefer care at home. Despite asserting this preference, demand for beds in nursing homes still dominates. This has been partly owing to the fact that that there has been significant funding available, particularly on the capital incentives side, for nursing home places. As a result, there has been significant growth in that sector, a trend that is set to continue. It is not surprising, therefore, that as investment in community alternatives has lagged behind, that demand for nursing home places has matched the growth in the number of places in the nursing home sector. As this increased demand for nursing home places is responded to, it reduces funding for community care services and this in turn reduces public confidence in the notion of community care. This is a good illustration of the divergence that occurs between need, supply and demand and this divergence results in much less choice being available for older people themselves. I Conference Proceedings

23 The issue of older people in acute hospitals is often raised, particularly in relation to the difficulties that arise because of the shortage of acute hospital beds. The combination of this shortage and a lack of other health and social services that would be more appropriate to their needs than hospitalisation has resulted in the term 'bed blockers' being applied to older people. However, it must be stressed that increases in dependency levels can arise as a result of the inappropriate hospitalisation that may occur due to the absence of health and social care services that would be more appropriate to their needs. In addition, situations also arise where older people, temporarily requiring recuperation or rehabilitation, are transferred to nursing homes with the intention of returning home when their needs are met. But very often a different sort of dependency develops during that period and those people remain in nursing homes for very much longer than originally had been anticipated. By providing an appropriate response at an appropriate time, unnecessary admissions to hospitals or long-term residential care may be avoided. Community rehabilitation units are an attempt to deal in a different way with the needs of older people who need significant intervention to assist them in recuperating after a particular illness. Upon cessation of a particular treatment in hospital, these units assist the older people to become rehabilitated to a point where they can resume an independent existence. The early results from these units are very promising. The schemes have been extended and now operate in z number of centres in the Midland Health Board area and are considered to be one useful approach towards maintaining the independence of older people. They also allow for the development of a Care Plan that recognises that there is a continuum of care required and a need to respond differently as the needs of an older person change. In this way, these schemes can prevent or delay admission to hospital and to nursing homes which might have been necessary in their absence. Care Planning The Care Plan is essentially a detailed account of what care is to be given and by whom, and it takes into account, or ought to take into account, the wishes of the older person in determining how and what care is given. Research carried out by Mary Dunne, a nurse in the Midland Health Board area, which was based on the views and reactions of staff to Care Planning, described the values that were attributed to Care Planning as follows: it demonstrates accountability. This is very important at a time when it is felt that health services are not as accountable as they need to be it guides the work of a multi-disciplinary team in that it requires a holistic approach to the planning and delivery of care. This requires that professionals who have a contribution to make to the care of a particular older person get together to plan the care that will be provided it also involves consultation with the older person and his/her family it supports a continuity of care it recognises that dependency develops and that the response needs to be timely and appropriate it enhances the autonomy of the older person it reduces dependencies in areas of daily living it helps establish priorities for care and helps staff to set patient-orientated goals from a manager's point of view, the development of Care Plans helps with the planning and management of resources because the aggregation of needs, as identified in the Care Plans for a particular region, equates to both the amount of resources that will be required to implement these plans and how the resources ought to be allocated. Towards Care Management in Ireland ",

24 The steps involved in Care Planning are: assessment observation, including both subjective information, as well as hard information from the patient and his/her family prioritisation of both short-term and long-term needs anticipation of the points at which a change in available resources will be required an attempt to have resources available to apply at the appropriate time monitoring and evaluation from the point of view of both quality and accountability and from the point of view of planning the resources and further refinements that may be required from the health and social care professionals working towards the plan. In general, in the Midland Health Board, the planning of care for older people tends to be conducted in an older person's home by a public health nurse and others, such as hospice nurses. Community rehabilitation units provide, on-site, the opportunity for multi-disciplinary assessment. This is usually led by a nurse and has the advantage of being able to also involve staff working within the community and therefore the assesment can be very comprehensive in addressing needs in a holistic way. Care Planning involves the adoption of a holistic approach. Therefore, it should be based on total patient needs. It must take account of issues such as cultural and religious beliefs, privacy and special preferences including preferences of diet, choice of activities and the structuring of one's day. The consideration of all these needs and preferences is possible through approaches such as Care Planning or Case Management because these involve the users of services in the planning, delivery and evaluation of those services. Advantages of Care Planning The advantages of Care Planning are that: it involves an ongoing process in a structured relationship involving discussion, documentation and recording of what the older persons' preferences are it takes the views of health professionals and family and friends as proxies for the decisions made in certain situations it is important that it is anticipatory and can be triggered by the older person while he or she is still well it involves ongoing dialogue with family and professionals regarding the choices that they have a preference for and the choices that the system can offer it involves a matching between needs assessment that should be sensitive to the preferences of older people so that there is a better prospect of matching the available service with the assessed need it can be successful in the avoidance of over-treatment as well as under-treatment. This is particularly important in relation to services for older people it can offer choices with regard to models of care, and professionals can facilitate this process through structured discussion it can deal with such things as living wills, advanced directives and durable power of attorney. It is not unusual for older people to make plans well in advance for the disposal of their property and arrangements for their funeral and burial. Older people should be given more of an opportunity to trigger initial Care Planning when they are still well and may be better able to contribute to that process than at a later stage, when the system is willing to engage them because they are ill. Conference Proceedings

25 Implications of Care Planning and Case Management in Ireland Management Implications - Potential Resistance and Devolution of Budgets There are many management implications associated with Care Planning and Case Management. It is a different philosophy of care. Managers accustomed to the traditional way of managing may see it as moving from a resource-control type system to a demand-led system. Managers and, in particular, financial controllers, whether at health board level or government level, are always very concerned about a scheme becoming demand-led because it removes the control that managers require in order to be accountable in traditional terms. It is not necessary that Care Planning requires the devolution of budgets to the manager - the devolution of budgets is not a priority for moving towards Care Management. But in a fully developed system and with investment in information technology, it is a possibility. Care Planning allows for the aggregation of needs drawn from service plans and therefore it allows a better estimation of what the overall requirement for services will be in order to operationalise the Care Plans in a particular health board region. This is a powerful tool for managers when seeking resources from the health boards. Care Planning provides accountability from the ground up and the traceability that is so demanded of the public system. But it is equally valid to have traceability in relation to how government policies respond to the needs of particular care groups so that mismatches in the provision of services for them will be highlighted. Care Planning and Case Management facilitate such traceability. Need for Support from Potentially Resistant Professional Bodies Management must seek the support of traditional bodies for the establishment of Care Management in Ireland. Professional bodies generally are slow to change. The medical profession, in many ways, is slowest of all in relation to Care Planning and Case Management. Its support will be crucial after the implementation of the National Health Strategy, given that investment in primary care is going to be a predominant feature in which much more significance will be attached to delivering health care through primary care teams. The proposed primary care teams will be very different from what might hitherto have been called primary care teams. These proposed teams will be genuinely multidisciplined, holistic in approach and not necessarily dominated by medical professionals. Therefore, in the short term, it will be necessary to identify champions who are willing to demonstrate the benefits that can be derived from Care Management and it will also be necessary that the public and older people are informed, included and empowered throughout this process. Need for Greater Investment in Information Technology There must be greater investment in information technology. Historically, throughout the health services, there has been a serious under-investment in such technology. Relative to any other benchmark sector, far too little has been invested and, in many ways, that lack of investment is the reason why it is sometimes difficult to demonstrate value for money and why services are not as accountable as the system would want them to be. Probably everyone has heard the slogan 'protect the front-line staff'. As a result, the emphasis has historically been on retaining front-line staff to the detriment of other areas where cutbacks were allowed to occur. However, the current emphasis on accountability requires that accurate and accessible information be readily available. Given the volume of work that is being handled at the moment, there must be significant investment in information technology. Towards Care Management in Ireland

26 .11 Care Management - Not a Cheap Alternative to Institutional Care There is a significant overhead cost associated with introducing Case Management and Care Planning. It involves.~ completely different philosophy, a very different approach, and it has to be resourced. It is always a slower process and a more costly one to be inclusive, to require participation, than to be prescriptive. Care Management will not come cheaply and Care Plans will definitely not be cheap alternatives to nursing homes and long-stay institutions. High quality care that is responsive to the needs of individuals, that involves good planning to ensure that need is matched by supply, costs a lot of money and certainly a lot more than has been invested in services for older people until recently. 1 The theme of the conference is Towards Care Management and this research is a good way to move the process on. There is a great deal of work already being done officially, some of it in the context of Care Planning and Case Management. However, there is also a lot of work being done informally according to the philosophy of Care Planning and Case Management. The system has already begun to move Towards Care Management. I Conference Proceedings

27 r...a.l Care Management: Who Needs it? What Makes it work? Lessons From International Experience Professor David Challis Professor, Community Care Research and Director, Personal Social Services Research Unit, University of Manchester Why Are We Interested in Care Management? Internationally, the systems that care for older people are changing. There has been a movement away from a reliance on institutions as the main source of care for older people and an attempt to develop home-based care as an alternative. In order to make home care a substitute for older people who previously would have been cared for in institutional settings, there needs to be more integrated and co-ordinated service provision. Care Management is an approach to Care Planning and delivery that co-ordinates these fragmented systems. In addition, there is another function of Care Management which is sometimes overlooked. It also requires, and should facilitate, service development. Therefore, it should enable a reshaping of how services are being delivered in the system. Regarding the definitions of Care and Case Management, by 1991 in England, lots of different perceptions had led to the relabelling of the term Case Management to Care Management. For example, managers of services did not want to use the term Case Management. They felt that Care Management was acceptable because care was managed anyway. This happened in alliance with user movements and others who did not want to be referred to as a case. Care Management has arisen because of fragmentation and the need for co-ordinated care. It has arisen as a result of cost control because the level of provision of residential and nursing care was spiralling out of control and that made it difficult to manage the care of an ageing population within a budget. That problem was not unique to anyone country. But underlying Care Management is an attempt to shift the balance of care, to enhance human care, to enable people to remain at home and to make services more person-responsive through extending a range of choice to individuals. What is Care Management Trying to Achieve? It is difficult to define what Care Management is trying to achieve because it is a multi-dimensional phenomenon that is often only described in terms of one of the tasks or features. It is often described in terms of what people do when they act as Care Managers. They assess, they develop Care Plans, they monitor and review the Care Plans and they reassess people's needs. For something to be called Care Management it needs to possess some definite facets. These can be listed in terms of: functions goals core tasks Towards Care Management in Ireland ",

28 target group the factors that make it different from what professionals normally do in the community service dc,felopment and articulating needs. Functions The key to Care Management is co-ordination and the linking of services. Instead of services acting in isolation, both the perspectives of the service-providers and the users are taken into account by the Care Manager, who brings preferences and provision together in the development of a tailored Care Plan. Goals Care Management has particular goals. These include facilitating continuity and integrated care, increasing the opportunity for people to remain in their own homes when that is their choice, promoting the well-being and functioning of older people, making better use of resources and enabling people not to be admitted to high-cost care settings unnecessarily. Core Tasks Care Management also has a set of core tasks such as case findings, screening, assessment, Care Planning, monitoring, review and closure. Target Group One of the key features of Care Management that is cited in most of the international literature, but that service-providers in England failed to realise, is that there are certain characteristics of people who need long-term Care/Case Management. The target group for Care Management consists of persons with long-term care needs, people whose problems are so chronic that the alternative to home-based care is probably high-cost care in some less appropriate long-term setting. It is important to realise that not everyone is eligible for Care Management. Factors that make it Different from what Professionals Normally do in the Community What makes Care Management different from what nurses and social workers do on a single day-to-day basis? Three things are cited continuously: intensive human involvement - clients are seen with a great deal of regularity. A Care Manager is not just responsible for the services that he/she controls but for the care network that the person is receiving to help them cope within the community the duration of involvement with a client is not short-term, but long-term Care Management is a multi-level response and involves linking practice level activities with broader resource and agency level activities. Service Development and Articulating Needs In England it was recognised that there existed a phenomenon called 'unmet need' and a key challenge for Care Management is to find a way of articulating the myriad of individual unmet needs into a way of reshaping services so that they begin to meet those needs. In order to do this, the Care Manager must operate in two directions simultaneously - upwards towards reshaping the system, and downwards towards improving what services actually do. Lessons from International Experience I Care Management in the UK Care Management in the UK began in the 1980s with a series of studies for which the PRSSU was Conference Proceedings

29 responsible. These studies were called Intensive Care Management Studies. They were carried out in different settings. A very specific model of intervention was used in each study. Care Management was provided only to people on the margins between home and institutional care. The Care Managers had small caseloads. They were experienced, had well trained staff, they controlled resources and they had the authority to decide how to spend money in any way that was legal as long as it could be justified to their managers as a means of delivering better care at home for vulnerable people. There were much closer links between health and social care, a structured and standardised assessment procedure was employed and pre-computer, systematic case recording was a prominent feature. It was found that this type of intervention could reduce institutional care placements. It could improve quality of care and quality of life for older people and for their carers at similar and sometimes lower cost, although in relation to dementia care the cost was higher. The important message that has been learned from these interventions was that the results of the studies, which were broadly positive, could be attributed only to the particular model of intensive Care Management that applied to a particular and highly vulnerable population of people. This implies that Care Management is not an appropriate or cost effective response for every older person needing care. In 1991, the British government issued a Guidance on the Implementation of Care Management that contained a definition of Care Management as the process of tailoring individual needs and stating that assessment is an integral part of Care Management. Psychology, like nursing, medicine and social work, is the process of tailoring services to individual needs. In other words, according to this definition, Care Management could be a proxy for most forms of caring activity. It was a necessary but not entirely sufficient condition for a definition. The British government also defined the core tasks of Care Management. However, the key pointers that should have been highlighted were hidden. Among these were the scope and pace of development of Care Management - how fast it should be developed and for whom. It should also have been stressed that service Care Managers should be very clear about why they are adopting this approach and what they are seeking to achieve by doing so. Another key pointer that was overlooked was the need to identify the target group for Care Management. It should also have been highlighted that there needs to be an appropriate devolution of budgets to the people who are Care Managing and that accountability should be built into this system. However, these key pointers were placed in the small print. As a result, there was a much wider theoretical definition of Care Management proposed than was actually implemented in practice. Therefore, most people got access to something called Care Management. To quote from an actual government Inspector, 'most older people got access to a Care Management system, too many people got access to a Care Management system, and not enough people who needed it received proper Care Management'. Consequences of Poor Implementation of Care Management Some broad findings from a national study carried out by the PRSSU have illustrated the consequences of the poor implementation of Care Management in England. This study investigated how organisational structures evolved in the response to the introduction of Care Management, what the variety of forms of Care Management in existence were, how service integration existed or how it was varied, and what typologies or models of provision currently existed. Conclusions based on UK Experience There are four conclusions that can be made based on the results of this study, these include a: need for standardised assessment procedures need for clearer definition of form, content and purpose of Care Management Towards Care Management in Ireland

30 f :, ' '1'. '. need for differentiation in Care Management need for more co-operation and collaboration..~- - ; Need for More Standardised Assessment Procedures Assessment, a critical part of Care Management, was found to be highly variable in content. The information that was sought about needs and how that information was recorded was highly variable. Assessment was also found to be variable in form, specifically in relation to how and by whom it was carried out. It could therefore be concluded that there is a great need for a further standardisation of assessments. The current government has brought forward what is called a Single Assessment Process and this is described in terms of the domains of assessment that have to be covered and the types and ways in which this coverage will be achieved. This is detailed in the National Service Framework for Older People, published in 2001, and it is very clear about what the specific elements of assessment must be. Therefore, it is a move towards standardisation. The main problem with assessment tools used in England was that they did not integrate health and social care and very few were useful once people were admitted to nursing or residential care homes. Carers' needs were not addressed, which was particularly regretful given the fact that England has a Carer's Act. Measurement of mental health needs - depression, anxiety and cognitive impairment was also very poor. Only activities of daily living (ADL) were reasonably measured. However, the measurement of ADL is necessary but not sufficient. Need for Clearer Definition of the Form, Content and Purpose of Care Management There was a lack of clear definition of form, content and purpose of Care Management. People did not know what it was, why they were doing it or what the care components should be. In the study, people were asked for their definition of Care Management: 'Care Management is an activity by which needs are assessed and costed Care Plans are implemented': 91 per cent of agencies agreed with this statement and this statement is true 'people coming ta the agency are assessed and a response is made to their needs by Care Management' - 89 per cent agreed with this statement because this is what had always been done only 19 per cent referred to the idea that Care Management requires a targeted and focussed intervention only 9 per cent spoke of Care Management as being an activity involving the co-ordination, delivery and maintenance of services to a degree of complexity such as caseloads being necessarily small. The original definition of Care Management was only being taken seriously in a small number of agencies and, as a result, too many people were getting a diluted form. Need for Differentiation in Care Management Differentiation of Care Management is required to link responses to different levels of need. In other words, Care Management is not suitable for everybody, and even if you provide it to a lot of people, different types of people with different types of needs will require different kinds of Care Management. Although it sounds obvious, the study found that it was not being applied this way. As a consequence, the government came to the conclusion that if every type of intervention was going to be called Care Management, then there would have to be process subtypes and so it developed three kinds of Care Management processes: Conference Proceedings

31 the first one is a process that they referred to as administrative and this is a screening process the second kind consists of co-ordinating a large volume of referrals that need either a single service or a range of fairly straightforward services which have to be properly planned and administered the third process is intensive Case Management (which is the traditional form of Case Management) where there is a designated Care Manager who combines planning and co-ordination with a therapeutic supportive role for a much smaller number of people with complex and frequently changing needs. The policy documents have said that the future of Care Management in England should require social services departments to differentiate between co-ordinating and intensive forms of Care Management. They should ensure that intensive Care Management is provided only to those people who need it. This was recommended by the Department of Health in In the new National Service framework issued in March 2001, it was stated that while the care of all older people should be managed appropriately and effectively, the most vulnerable often require fuller assessment and more intensive forms of Care Management. In other words, differentiation of response to each according to his or her needs is becoming an increasingly strong philosophical statement. The Scottish Executive, which produces its own policy on such matters, elaborated in terms of differentiation. In its review of community care in Scotland from 1993 to 2000, it became clear that there was a lack of consistency in the services that were being provided to people and a lack of inter-agency collaboration in the provision of these services. It was noted that, as a result, the expected shift in the balance of care away from institutional care towards home care had not in fact materialised. That was partly because Care Management was not providing what it was supposed to provide - a real alternative. The Executive's perspective was that Care Management needed to be redefined and to be provided only to people with complex and ever-changing needs, the original core population of people. It also proposed the introduction of Care Management training so that only properly trained staff would undertake intensive Care Management. So, the Scottish example was a bit more explicit but the same message was there that differentiation, and therefore quality assurance, is vital to good Care Management. Need for More Co-operation and Collaboration The fourth conclusion relates to the need for more co-operation and collaboration between health and social care professionals in the community. If Care Management is to be differentiated, then this requires the existence of differentiated links with different health and social care elements as well. One of the most fascinating features of aged care and community care reforms in Australia has been that it has brought geriatric medicine into the community as part of the community care assessment process. In many parts of Australia this has led to links between intensive Case Management and geriatric medicine. Points to Note from UK Experience There are two main points from the implementation experience in the UK that need to be highlighted. One of them is the lack of evidence of intensive Care Management targeted at high-risk people and providing very high levels of support. Intensive Care Management was being provided to too many people and then diluted. That was a serious error. The other error was a failure to engage key health care professionals, such as geriatricians, in the long-term care,of older people in the community. Towards Care Management in Ireland

32 I I, I \I The factors associated with good Care Management outcomes are: the capacity of Care Managers to make variable and flexible responses, such as those associated with controlling devolved budgets the identification of the population to receive Care Management a focus that is broader than just patient-centred is crucial to good Care Management. The focus must be on three interlocking systems: the person in need, the carers, and the care services that support both the cared-for and the carers trained and skilled workers with a knowledge of the particular needs of the population that they are trying to help, such as people with dementia. A great debate in the USA has been; whether Care Management is a clinical or an administrative process. The evidence suggests that a combination of the two is more effective than one skewed towards the administrative end good links between health and social care to pull together the packages that are needed system level and practice level integration Care Managers who are able through their decisions, to reshape the service system. Questions To Be Asked During a Care Management Audit in Ireland in Five Years When looking at any Care Management programme, the following questions will need to be answered: what are the aims and goals of this Care Management Programme? who is it for and what does it aim to achieve for those people? whose budget is it coming out of and what incentives arise as a consequence of that funding? whose budget is being protected and not protected? (This is related to issues of cost shunting.) what is the internal logic of the relationship between process and outcome in this? what are the resources given to certain providers actually going to achieve? How are they going to be put together in ways that actually lead to good care outcomes, or not? what is it about this way of doing things that is better or will lead to better ways of doing things than at present? who are the people who are going to receive this and what is the population? How will you find them and how will you know if they are the right people to receive Care Management? who is going to undertake the assesment, do the Care Plans and carry out the reviewing and the monitoring? What resources are they going to do these things? where are you to locate this Care Management programme and why? what is the case-mix or the staff-mix and what specific goals do each of them have? how will the programme contribute to and integrate with the pattern of long-term care in a particular locality? How is it going to fit in with what is already there? You need to be sure how it will fit in with, contribute to and enhance the locality system finally, how will it be managed, maintained and quality assured? '" Conference Proceedings

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34 First Steps In Establishing a Dementia Care Management Project Maurice O'Connell Chief Executive/The Alzheimer Society of Ireland Sarah Marsh Case Manager The Dementia Care Project was born out of a need to focus on the person with dementia whose needs are many and various. The Alzheimer Society's philosophy of care puts the person at the centre of our services. It has been found that the carer finds it very difficult to access services after diagnosis and is often the victim of lack of co-ordination on the ground. The other significant backdrop for this project consists of the strong recommendations in the Action Plan for Dementia, especially the recommendation on Case Management. The Society's helpline has highlighted the need to advocate on behalf of people who are caught in the maze of confusion regarding their rights, benefits and services. The proposal for the project was put to the Pharma Industry and the South Western Area Health Board. Seed capital was given by private industry. The health board accepted the Pilot in 2000 and committed revenue for part of Recruitment in 2001 was slow and was delayed until the autumn. The Dementia Services Information and Development Centre was invited to oversee the professional supervision and the monitoring and evaluation of the Pilot. As a non-government organisation, the Society felt it important to network with the key personnel within the community care services. This meant that it had a significant role in establishing and integrating our ethos through the Case Manager. Partnerships are key to the success of this Pilot and the South Western Area Health Board has committed resources to this project What is Case.Management? (Dementia Specific Case Management) Coping with Alzheimer's disease or a related dementia is very challenging on many levels for both the person with the disease and the family or carer. People with dementia have needs which change over time. This means that there are a myriad of services, that must be accessed, from sourcing suitable day care to dealing with legal issues. Community-Based Case Managers work in the local community and liaise with all professionals who provide services. In this way, Case Managers act as co-ordinators of care. _r I" In the first instance, the Case Manager would meet with the person with dementia and his/her family/carer in order to assess the needs of the person. A Care Plan would then be drawn up, Conference Proceedings

35 utilising the full range of community services available in the area; this plan would be co-ordinated by the Case Manager. Some needs may not be met by existing services and in this instance the Case Manager acts as an advocate for the client and carer. GElDr The Case Manager draws up an individualised package of care that is tailored to the needs of the person with dementia. In this way the client should receive a flexible package of care rather than be slotted into existing services, regardless of need. _f Case Managers come from a range of professional backgrounds such as social work, nursing and occupational therapy. Furthermore, Case Manager's liaise with a number of disciplines to provide the latest information on services/health care for people with dementia. _ The Care Plan is devised with a holistic assessment, to take account of the whole person. This aims to meet the physical, emotional and spiritual needs of the person with dementia and his or her carer. This approach is used throughout the Case Management intervention, allowing for greater flexibility _r as the person's needs change. Case Managers fulfil the following criteria. They: provide a needs-led assessment devise a Care Plan co-ordinate services monitor/reassess the Care Plan provide emotional support advocate on behalf of the person with dementia and his or her carer.. What are the Benefits of Case Management Case Management maintains the person with dementia in the community for as long as possible, but can also facilitate a move to long-term care as smoothly as possible. This offers a lot of support to carers and families, who often suffer with feelings of guilt. A planned intervention, coupled with early diagnosis, ensures greater choice. For example, Case Managers can do life-story work with those people in the very early stages of dementia. This provides carers and professionals with a detailed biography of the person's hopes, fears, desires, motivations and tastes - which can be essential at a later stage when the person is no longer able to articulate his or her needs. Also, it is the experience of many that this process in itself is deeply therapeutic since it helps the person come to terms with the diagnosis. Evaluation is a necessary component of Case Management and is to be built into the process from day one. This enables best practice principles and highlights gaps in provisions. Towards Care Management in Ireland

36 Workshop Chair: Dr Eamonn O'Shea, Department of Economics, National University of Ireland, Galway and author of An Action Plan for Dementia Rapporteur: John Heuston, National Council on Ageing and Older People Workshop discussion The workshop discussion focussed on two main areas: implementation issues in relation to the Dementia Care Management Project broader implementation issues. Key Issues The key issues that were identified in implementing this project were: the lack of proper and adequate training of nurses and other professionals involved in caring for older people is the greatest drawback to effective implementation. Unlike other disciplines, such as oncology, there is no equivalent investment in gerontological nursing there is a need to clarify who is responsible for initiatives and who will define policies the concept of holistic care is unrealisable without having a specific area within nursing that is devoted to treating special needs ther-= is a pressing need to bring the Care Plan to a point where the dignity of the older person with special needs is fully respected and his/her sensitivities responded to early and proper diagnosis is crucial. Assessment is too often based on a bio-medical model rather than being made from a gerontological perspective there is a greater need for anticipatory care that the philosophy of Care Management should inform the process consultation is critical partnership is fundamental to the success of beginning a Care Management project. It is necessary to integrate the process from within the family to primary care to secondary care to the hospitals - this is a difficult but a critical task resources are vital. We need to be realistic and what is achieved will depend on resources and how those resources are used and allocated we need to challenge negative attitudes towards older people if we are to be successful in changing the kind of care that we want for older people Implementation Issues The following points were raised in relation to broad implementation issues: there is the need to be clear about what we want Care Management to achieve and this is a process that has not yet been fully worked out there is a crucial need for assessment that goes beyond the medical assessment. There is a need for some sort of homogenisation with respect to assessment, beginning, at the very least, with some agreed principles more resources are necessary there is a need for education and training there is also a need for the statute right for Care Management. Conference Proceedings

37 Home First Pilot Project, Beaumont Hospital, Dublin Dr Ciaran F Donegan Consultant Physician in Geriatric and General Medicine, Beaumont Hospital Introduction One of the great successes of the twentieth century was the increase in life expectancy for both men and women. This has led to one of the challenges for the twenty-first century with which we are all familiar - changes in demography with growing numbers of older people. These population numbers are increasing, and over the next decade or so there will be a large increase in the number of people aged over eighty years. Studies of older people have shown that there are higher levels of disability, handicap and dependency with ageing. We know that such disabled people benefit from multi-disciplinary assessment and planning and we also know that the onset of disability does not presume a loss of independence or rights, especially in relation to the choice of remaining at home. Many of the agencies involved in the care and delivery of services for older people acknowledge these facts and seek to adopt a needs-led, patient-centred model, as opposed to a service-driven approach to the planning and delivery of this care. This ethos underlies the principles of care for older people in the Eastern Regional Health Authority. The aim of the provision of services to older people is to maintain the individuals at home and to restore to independence older people at home who lose their independence or who become ill. It is also important to encourage and support the care of older people in their own communities by neighbours, voluntary bodies and reiatives. When this is no longer possible, the aim is to provide high quality residential or nursing home care. This collaborative project between the Northern Area Health Board and Beaumont Hospital, under the aegis of the Eastern Regional Health Authority is an action plan to deliver services to older people in their own homes and in their community. Specifically, the project aims to facilitate the discharge of frail, more dependent older people from hospital and to help them remain at home if it is their wish to return there. However, there is an acknowledgement that the organisation of existing services in the community cannot cater for all older people who express a desire to return home and wish to remain at home. Therefore, the Beaumont project started with the core idea of looking at models of care that would compliment current service provision. Objectives of the Project The key objectives of the project are: to enable older patients to return home to assist in maintaining them at home to strengthen the partnership of care between community groups, hospital and patient I to empower older people to develop quality assurance systems in all care settings. The input of older people is vital in order to recognise their choice and to identify their needs. Towards Care Management in Ireland

38 Home First Project Set-up A steering committee management group was set up to formulate, co-ordinate and operationalise care plans. The steering committee continues to meet monthly in order to monitor progress, express any concerns and to plan for the future. It was agreed at the outset that the project would be a one-year observational pilot project. The project commenced officially in March The funding to provide the extra packages of care came from the Eastern Regional Health Authority and the extra staff required came from Rehab Care. In terms of monitoring the project, there are weekly hospital and community reviews and staff liaisons. The patients for this project were recruited from those referred to the Department of Geriatric Medicine. These patients then took part in a multi-disciplinary assessment that forms the basis of a Care Plan problem list. The discharge planning process proceeds through an established system in the Department of Geriatric Medicine, where weekly case conferences take place with input and attendance from hospital and community health care professionals. Most of the people who were recruited for this project were in-patients, but there was also a mechanism for people living in the community to attend the day hospital and for assessment. When patients were assessed and deemed to be suitable for the project, they were placed randomly in one of two groups. It was decided to have thirty people in each group - one group would receive their care through the existing services and the other an enhanced care package (Home First). Criteria for Patient Selection Project Participation The patient characteristics and criteria for selection required that: they should be living in close proximity to the hospital they would all be in a certain age group ( >65 years) they had to consent to inclusion in the project they expressed a preference for remaining at home most of them had some needs in relation to activities of daily living and mobility they could either live alone or with their families they were medically stable. It was felt that the project should be as inclusive as possible and that the criteria should not be too restrictive. As a result, all patients referred were considered for randomisation. Patients with terminal illness or advanced dementia were excluded. Role of the Care Organiser The theoretical framework for the project proposed that the role of the Care Organiser was to: help the older person with the assessment of his/her needs by ensuring that the appropriate package of care was drawn up and monitored and reviewed regularly be the principal contact and maintain a supportive caring relationship with the older person and act as a broker between the different service-providers ensure that the nature of need presented was matched to the appropriate service and community service. Differences Between a Care Organiser and a Care Manager A Care Organiser differs from a Care Manager in that: the term Care Organiser sounds better as it is less threatening to older people and gives the Conference Proceedings

39 impression of working in partnership, enabling older people to take control of the care process the Care Organiser does not control the budget and therefore is not limited by resources and monetary concerns when making assessments. This ensures that assessments are needs-led and not biased in any way usually the Care Manager does not actually become involved with the older person until the assessments have taken place. A Care Organiser is present for the assessment and that makes it easier to build up a working relationship with the client. It also provides a continuum of care beginning when the person is first identified through to the discharge position and while they are at home. Pre-discharge Procedures Before discharge, there is a meeting between the Care Organiser and the client and family in which consent for project participation upon discharge is ascertained. After consent is gained, meetings and liaison take place with the hospital and community teams. The multi-disciplinary teams are comprised of occupational therapists, physiotherapists, nursing staff, medical staff and staff from other professionals that are involved from speech therapists to dieteticians. The multi-disciplinary team is asked to carry out assessments of the patient under the co-ordination of the Care Organiser. The next stage involves organising a home visit and, where possible, this is done before the person is discharged from hospital. Again, where possible, the home visit is attended by a representative of the community and the hospital multi-disciplinary team, usually the occupational therapist or the physiotherapist. The person's family is also present. Normally after the home visit the Care Organiser meets with the family to discuss issues that arose during this visit. The Care Organiser carries out an assessment of the family's needs based on their suggestions. Following that the Care Organiser meets with the Care Plan team who create a Care Plan for the older person. This plan is then presented to the family and, when they agree to the measures involved in it, the multi-disciplinary team is asked how feasible the plan is. If the plan is deemed feasible, an agreed discharge date is arranged. Post-discharge Procedures After the client has been discharged, the Care Organiser keeps in regular contact with him/her and the family. Weekly care team meetings take place which involve a review the case of each client. In addition, there are regular meetings with community staff. The review of the Care Plan takes place automatically. It is required to be formally reviewed every three months, but this happens more frequently because of the regularity of team meetings. If changes to the Care Plan are required, they are dealt with as soon as possible and as they arise. The Benefits of a Care Organiser The benefits of involving a Care Organiser include: empowerment of the older persons in the care process by working in partnership with them and giving them control of the care process ensuring that the assessment is determined by the particular needs of the older person. negotiating with service-providers because there are sometimes so many professionals involved, it can be quite daunting for older people advocating on the person's behalf providing a link between hospital and community because both teams must be involved and there Towards Care Management in Ireland

40 has to be a continuum of care between the two. The links between the community and the hospital should be strengthened and maintained and both teams are vital because they are not exclusive to each otller. -~ Issues arising from the project are as follows: sometimes there is a fine balance between support and creating over-dependence family dynamics can be a problem and can impact on the Care Planning stage and the time involved in that because a lot of community and hospital staff are involved, it is quite time consuming to keep everyone informed and to co-ordinate meetings so that everyone can attend them the therapeutic and organisational skills of the Care Organiser must be given equal prominence and equal exposure - one must not become dominant, to the detriment of the other. _f Standardised assessments are employed to assess all patients including: the Barthel Index the Mini Mental State examination the Geriatric Depression score the Easy Care standardised instrument which was agreed between the hospital and community therapy staff. It has modalities for assessing physical, mental and social well-being and has been well validated in community studies. This information is collected at base line, six months and twelve months. In terms of outcome and evaluation, both qualitative and quantitative outcome measures are assessed. The quantitative component assesses: how many people survive their ability to survive at home the need for institutional care or placement people's functional status the need for hospital readmission if people are readmitted, if their readmission is for a shorter period if they have this package of care in place and other methods of clinical well-being. The qualitative component includes a structured questionnaire and interview with patients and clients from both groups and with informal carers. It is also hoped to have a focus or workshop group to allow project and existing service staff to get feedback. This component will look at: the evaluation of the structures of the service how this sort of service can be managed how the roles of particular individuals develop and change, particularly that of the Care Organiser analysis of the cost-effectiveness of this type of model. Conference Proceedings

41 Summary of Home First Project The main features of the project are: it is a collaborative project it involves partnership in planning, care and follow-up the Care Organiser plays a key role it involves a continuum of patient care it is patient-centred it aims to maintain older people in their own homes the Care Plan that is developed for the older person is dynamic and responsive, It is hoped that when the full data are collected and analysed, the policy implications arising from this pilot study and the recommendations based on these findings will contribute to the development of this model or a similar model. Towards Care Management in Ireland.',

42 Chair: John Brennan, Senior Social Worker, Tallaght Hospital Rapporteur: Sarah Delaney, Royal College of Surgeons in Ireland Workshop Discussion The workshop discussion focussed on six main points: the source of resources for pilot projects the Care Plan the requisite skills of a Care Organiser the need for collaboration between agencies the importance of negotiating skills the draft Care and Case Management Implementation Framework. Source of Resources for Pilot Projects During the discussion there was a lot of interest expressed in relation to where extra resources (both personnel and financial) for such projects would come from and this echoed some of the discussion that took place during the morning session in relation to funding and also personnel. In terms of the Home First Project, the extra personnel come from a private agency called Rehab Care. The Care Plan The project demonstrated the need to have flexible and responsive Care Plans. Requisite Skills of a Care Organiser One point to note was that the Care Organiser, who is a social worker, felt that her therapeutic skills, were neglected to an extent because of the organisational demands put upon her. This is something that more consideration needs to be given to because, if a Care Organiser is working with the older people at the centre of the whole process and working therefore in partnership with them, this therapeutic role is very important and needs to be exercised. Need for Collaboration Between Agencies Links with other care agencies and the hospital community link was certainly demonstrated as being very important in this project and it tied in with the research reports notion of the need for a seamless service from A to Z. Importance of Negotiating Skills The other role or skill that was emphasised as being important was negotiating and the need to be able to negotiate within a multi-disciplinary team. Draft Care and Case Management Implementation Framework There was a question raised in relation to the implementation document and more specifically in relation to the monitoring and development group proposed in this document. It was felt that this was a question for the National Council on Ageing and Older People itself to respond to. Conference Proceedings

43 Packages of Care, Mayo Community Services Frank Murray General Manager, Mayo Community Services Mary Warde Co-ordinator, Packages of Care, Western Health Board _ Packages of Care for older people was an innovative strategy established by Mayo Community Services in Castlebar in October The impetus for this pilot study came from two sources: the changes that had occurred in the traditional role of the family as carers which altered the way in which older people were cared for in the community recognition of the need to provide care for an increasing population of older people in County Mayo and, more specifically, an increase in the incidence of older people living alone in rural areas. Sixteen per cent of the Mayo population is above 65 years of age (the national average is 11 per cent) and 7.4 per cent is above 75 years of age (the national average is 4.8 per cent). A commitment from existing health board staff to participate in the project was secured and this was crucial as existing staff resources were relied on to meet the needs of older people in their own homes. The co-ordinators of the project also succeeded in securing the support of the _f voluntary sector and the other agencies in the county. The aims of the project are: to maintain older people in their domiciliary environment and thereby to reduce their need for admission to care to facilitate early discharge to enhance the quality of life for patients who wish to remain in their own home. C!IIIBDf Older people are eligible for the programme if they: are aged 65 years or more have a demonstrated health care need live in County Mayo have a level of disability that prevents independent living. GBf The referrals come from: public health nurses general practitioners Towards Care Management in Ireland

44 ..I I..,....[ I :.1 i, I, "1 f!': i, I voluntary/statutory organisations family/carers assessm(,'1t committee meeting/consultant geriatricians ,---- others. The referred client's needs are assessed according to the Roper, Logan and Tierney model of nursing. Clients are encouraged to express what they see as their needs. An individualised Package of Care is then drawn up according to these needs. This is done in consultation with the public health nurse. Co-ordination of Services Services are co-ordinated among the following: health board - public health nurse, meals-on-wheels, day care, home helps voluntary bodies - social service council statutory bodies - Mayo County Council links between the community services and the hospitals. A Co-ordinator of Packages of Care works in conjunction with a multi-disciplinary team and the services available for the programme include: meals-on-wheels occupational therapy physiotherapy respite care general practitioner family support day hospital home help public health nursing. The Co-ordinator works under the guidance of the Director of Public Health Nursing and the General Manager of Mayo Community Services In deciding on the Package of Care to be made available, the older person and the family are consulted to ascertain what is required to keep the older person in the community. Thereafter, needs are categorised and co-ordination of services begins to meet those needs. The programme operates on the principle of least intrusive intervention A commitment from health board management to the project was demonstrated through an allocation of a budget. The project co-ordinators made a proposal for funding which they received in 2001 to carry out this project and, to date, they have spent 140,000 on Packages of Care. Additional finance may be sought for setting up services over and above what is already available such as meals from hotels, extra home help, transport, house cleaning, physiotherapy, hedge cutting etc. Conference Proceedings

45 Desired Impact of the Pilot Project The impact on patients for whom care was co-ordinated, or who received financial help, was to reduce bed utilisation for the period in question by approximately 2,200 bed days. This freed up beds for patients whose need for care had greater priority. Evaluation of the Project Evaluation is built into this project clearly and record-keeping processes have been developed to carefully record and document the services that have been provided. This allows for better accountability. Quality indicators are also being considered for inclusion in evaluations, thus making it a client-focused service. Main Advantages of Packages of Care The main advantages are: flexibility of service delivery patient consultation and participation speed of response the quality of life of older person is enhanced.. Future Plans for Packages of Care for Older People Future plans include the following: local authority will become involved at the committee level staff requirements and manpower will change in the long run formal evaluation is underway in conjunction with the Department of Public Health. Towards Care Management in Ireland

46 dq, Workshop " Chair: Janet Convery Member, National Council on Ageing and Older People Rapporteur: Deirdre Fitzpatrick, National Council on Ageing and Older People Workshop Discussion The workshop discussion focussed on six issues: the need for a further definition of terms the need for more clarity in relation to the main drivers of the project the need to address quality of life and individual choice issues for the client the need to clearly identify the target population the adequacy of present assessment tools the importance of housing in the continuum of care. The Need for a Further Definition of Terms A further definition of terms is necessary in relation to what the projects are trying to achieve. It was also felt that a further refinement of the costing of services was required. The Need for More Clarity in Relation to the Main Drivers of the Project There was the feeling that more thought needs to be given to what actually drives the projects in terms of what they are trying to achieve. Is it mainly cost savings or is it early discharge of people from hospital. thus freeing up hospital beds? The Need to Address Quality of Life and Individual Choice Issues for the Client It is important to look at the projects from the clients' perspective to ascertain what they prefer and want in terms of health and social services. This is not a simple, straightforward task. The Need to Clearly Identify the Target Population More thought needs to be given to what the most appropriate target population should be for the projects. In relation to the Packages of Care project, at the moment the target population is very general and that is appropriate for a pilot project, because unless referrals are taken from all parties, identification of need will be difficult. The Inadequacy of Present Assessment Tools The assessment tools were discussed generally and also more specifically in relation to the need for these tools to adequately reflect mental health issues or social circumstance. The Importance of Housing in the Continuum of Care Housing was discussed as an important constituent part of the continuum of care. Housing is a very important factor in older people's welfare which for too long has been separated from health and welfare. This situation needs to be rectified. Conference Proceedings

47 Community Care and Care Management in Northern Ireland Or Michael Donnelly Reader, Department of Epidemiology and Public Health, Queen's University of Belfast Northern Ireland's four integrated health and social services (HSS) boards were established in 1973, soon after the beginning of civil rights demonstrations and the start of 'the troubles'. Each board had responsibility for delivering health and social services at an 'area' level and a 'district' or local level. The integrated structure seemed to aid inter-professional collaboration in community care and other fields, such as child protection procedures. In the early 1990s, the HSS boards became commission2rs of health and personal social services and smaller sub-organisations known as Trusts assumed responsibility for the provision and delivery of services. There are eleven Trusts (out of a total of nineteen plus one ambulance Trust) that deliver health and social services. Some of these Trusts also deliver acute hospital services. Services in community trusts, such as elderly care, may be managed by individuais from any disciplinary background, although separate iine management arrangements for each profession operate up to senior management level. In particular, there is professional social work line management in order to meet child care statutory requirements. The Audit Commission's (1992) report, Community Care: Managing the Cascade of Change, described Northern Ireland as a successful example of structural unification of local health and social services. Many benefits have been attributed to the 'Northern Ireland model of joint commissioning boards for health and social services', including: the creation of a framework for comprehensive care reducing organisational problems simplifying resources allocation difficulties. _ Following the White Paper on community care in England, Caring for People (1989), the DHSS (NI) published People First - Community Care in Northern Ireland for the 1990s in which it stated that the central objectives of the community care reforms were: to make proper assessments of need and good Case Management the cornerstones of high quality care to promote the development of services so that people may live in their own homes to Ensure that service-providers make carers a high priority to promote the development of an independent sector alongside good quality public services. A central theme in Caring for People was the need for stronger links between health authorities and local authority social services departments, and improved co-ordination between health and Towards Care Management in Ireland

48 - social service professionals. Owing to the existing integrated organisational structure in Northern Ireland, People First stated that it was not necessary to introduce arrangements such as those set out in Caring for People for joint working and planning between health authorities and social services. In addition, responsibilities for the co-ordination of assessment and provision and delivery of community care were not assigned to a specific professional discipline. It was left to the HSS boards, and then units of management, and now, Trusts to implement community care and Care Management in the context of the organisationally integrated service. Factors Contributing to People First The factors contributing to People First were: most people prefer to live at home residential and nursing home admissions were not based on assessed need residential and nursing home costs were ever-increasing and were funded from the public purse the existence of an imbalance in public expenditure towards institutional home care in comparison with community care assessment of need tended to be influenced by the historical and current configuration of resources and services this new system would allow budget-holding Case Managers to buy a 'package' of services matched to individual needs in a more cost effective way. Care Management: Guidance on Assessment and the Provision of Community Care (DHSS, 1991) distinguished between Care Management and Case Management and did not advocate anyone model. In contrast, this Guidance proposed that it was the responsibility of each respective board to decide which of the Care Management models was best suited to its own needs in trying to: make the most efficient use of resources promote close collaborative working care for people whose needs were the greatest. Structure of Community Care and Care Management The structure and organisation of the integrated service varies between community HSS Trusts. For example, one Trust provides health and social care via 'integrated teams' comprising nurses, social workers, Care Managers and other specialist staff. The management of each team is undertaken by a nurse-social worker dyad; when the disciplinary background of the manager is social care, the assistant manager is selected and recruited from the nursing profession and vice versa. Each team is 'attached' to one or more GP practices and cover a 'patch' or a 'natural community', encompassing GP practices and their lists of patients. There are six natural communities, ranging from 16,000 to 42,000 patients on the lists of between ten and twenty nine GPs. The manager is responsible for a devolved budget, encompassing primary health care and social care including community care and for the management of the Assessment and Care Management Team. The manager determines eligibility for assessment, the required level of assessment and then allocates the case to a Key Assessor, who is usually a care manager from the Assessment and Care Management Team but may be any member of an integrated team. The Key Assessor requests and co-ordinates contributions to the assessment from the GP and appropriate members of the integrated team, as well as from the client and his/her carer. A Care Plan is devised, based on assessed need, and matching services are commissioned or purchased from the Trust and/or the independent sector. The Care Manager reviews clients' needs regularly.

49 One of the alleged benefits of the integrated system in the context of Care Management is the way in which it facilitates multi-disciplinary working and enables funding to be managed and used by multidisciplinary teams. It is notable that the Care Management system appears to work in the integrated system without the need for the Care Programme Approach, which has been the subject of much debate in Britain. However, there is little or no empirical evidence for the benefits of the integrated service has been noted in, for example, local policy documents and reports. Empirical research in Care Management is also lacking. Care Management Inspections A number of Social Services Inspections of Care Management have been completed. In 1995 Muttidisciplinary Inspection of Assessment and Care Management (551, 1995) reported that good progress had been made in all the Trusts. However, some were experiencing difficulties coping with unexpected volumes of work. For example, there were approximately 1,000 new cases every three months and this report concluded that 'resources may have to be spread too widely [and] achieving the objectives of People First may be seriously damaged'. Community Care from Policy to Practice: The Case of Mr F J McLernon - Deceased (551, 1998) and the SSI Audit of Care Management (1999) drew attention to the importance of giving due consideration to risk assessment protocols and procedures and the importance of developing comprehensive guidance on risk assessment and validated assessment tools. 'Good Practice in Care Management,. Based on the Northern Ireland experience, Good Practice in Care Management requires the ability to: respond flexibly and sensitively treat clients and carers with dignity and respect explore a range of care options focus on enabling people to go on living at home intervene no more than is necessary encourage and equip clients and carers to play an active part in the process target those in greatest need. I Concluding Comments In summary, it can be said that: much good progress has been achieved with Care Management in Northern Ireland positive views about Care Management have been expressed by both users and carers there is still a need for increased funding to match the demand for community care and Care Management Care Management is an essential component in a whole system of care for older people but its effectiveness is related to the available spectrum of services and resources a need exists to develop procedures and information systems to fully assess the nature and extent of need (including unmet need) there IS a need to assess the needs of carers and to provide them with support the encouragement of the development of a range of providers is crucial there is a need to develop further the range of domiciliary and daytime services service attention (rehabilitation) should be focussed at the 'threshold' of entry to Care Management. Towards Care Management in Ireland

50 :=lj j J! Chair: Ann Judge, Management Development Specialist, Office for Health Management Rapporteur: Sinead Quill, National Council on Ageing and Older People Workshop Discussion The workshop discussion focussed on two main areas: the lessons learned from the Northern Ireland experience of Care Management the draft Care and Case Management Implementation Framework. Lessons Learned from the Northern Ireland Experience of Care Management The lessons that were learned from the Northern Ireland experience of Care Management were that: assessment is key to effective Care Management the extent to which we can transfer lessons learned to health and social care is vital - have we got a better evidence base now, do we have pointers to allow us to do better? it is very important to get to grips with unmet need and to increase the packages of care to reflect this. also we have an integrated system, but on the ground, integration is not as good as at management level. The more integrated the system, the better Care Management will be. For example, in relation to the home-from-hospital inspection, there is not enough medical involvement. Tris is because Care Management development and hospital discharge procedures developed independently of one another the number of Care Packages has increased but the number of those availing of domiciliary packages has decreased. This is a failure on the part of policy. The objectives of policy have not been achieved because of a number of things - the key one being funding and resources. It is less expensive to care in a residential than a domiciliary setting there is a problem with recruiting of staff, and in particular occupational therapists, and this has an impact on assessment. The Northern Ireland Social Care Council was' established as the government body responsible for the training of social care professionals and Care Managers so there is recognition of the need for more training the programme is client-centred so information about satisfaction and needs should be. in-built and registered. There are the traditional formal mechanisms of monitoring and review such as an audit and these vary from Trust to Trust. In addition, the Social Services Inspectorate carries out monitoring exercises. Draft Care and Case Management Implem~ntation Framework In relation to the draft framework, the following points were raised: there is a lack of co-ordination and designated care workers for older people. Nobody is taking responsibility for their needs - the issues of co-ordination and ownership in the draft framework should be dealt with in relation to the selection of patients for Care Management, it is difficult to glean who would be appropriate. It would increase the value to the draft framework if more about assessment and who Care Management is for, were added Conference Proceedings

51 there is a concern in relation to Care Management that the more dependent being cared for at home are being cared for in a reactive way, rather than a planned way, and this may result in failure, resistance and disillusionment. There is the need for a structure, adequate personnel and time. Care Management needs to be top-led and requires a strategic approach to help it occur in a planned way. Therefore there is a need for an overall strategy that is owned at the top level there is no mention in the framework of a legislative base for the implementation of Care Management. In Britain, Care Management was driven by the Community Care Act. In addition, there should be more discussion in relation to the rights of older people in order for Care Management to be effective, there needs to be a sanction for it from some authority. Towards Care Management in Ireland

52 < i :i I ii 11. u ili Conference Proceedings

53 ~~~,~'1I"ti ""!.'.~. 'i~'-:.r' -..,.

54 .; The Way Forward for Care Management in Ireland Donal O'Shea Regional Chief Executive, Eastern Regional Health Authority What is Care and Case Management? Care and Case Management are methods of planning and providing services to vulnerable individuals, so that their individual health and social needs are met. Care Management provides the framework that ensures that these services are properly co-ordinated and planned at management level to offer a flexible, holistic and integrated service. Case Management is the process that assesses an individual's needs, tailors them to his or her requirements and ensures the delivery of the appropriate services. There is increasing recognition in Ireland of the need to co-ordinate health services and to promote a person-centred approach to care. This is evident both in the range of strategies for older people which have been produced by the health boards and in the core principles of the new National Health Strategy. In consideration of the way forward for Care Management in Ireland, it is important to place this initiative alongside recent thinking and discussion on the development of services for older people. Maintaining Older People in their Own Homes Older people want to remain in their own homes and it must be asked why health and social care professionals find it so difficult to tailor services to this single aspiration? The answer to this challenging question is that the care of older people has been heavily over-institutionalised and somewhat 'over-medicalised'. Until recently, older people have not been prominent in articulating their needs, or in exercising influence over the decisions that affect the services they receive. However, by putting older people first, and at the centre of service planning and development, the health service will need to accept that the wish of people is to live at home for as long as possible. Health services have given lip service to this principle for many years. It is thirteen years since the report The Years Ahead enunciated the principle: 'To maintain older people in dignity and independence at home in accordance with the wishes of older people for as long as possible'. This principle has been restated in other documents and in the health strategy Shaping a Healthier Future (1994). Care Management is our 'wake-up call', and the health service will be judged by its response. The hope is that in the future, it will be seen that the health services took tangible measures to implement this principle. At the moment, approximately 95 per cent of people over 65 years of age live outside institutional care, and there is no reason to believe that this trend will not continue. Whilst the structure and function of family, as we have known it, is under considerable stress and change, there is evidence to suggest th3t the family continues to be the primary source of ballast and support to its members. Internationally, the family remains the main source of care and support for older people. The modern view of ageing should challenge and inspire us to give older people the franchise to Conference Proceedings

55 decide, as the users of the service, and involve their families as the informal carers, Both should be meaningfully involved in the planning and delivery of services, and the older users should be empowered to make choices concerning the decisions that affect their lives, There is a growing appreciation among service-providers that establishing a good quality of life for older people requires the involvement of the older person in the planning of the services that are important to them and which support their choices, The perspective of the older users and their carers needs to be understood and appreciated, Service planning is often task-orientated and service-driven, However, to grasp comprehensively the issues of significance for older users, we need to 'see it their way', and to understand how they feel. 'Hold fast to that which is good' are familiar words to many people, The opportunity should be taken to listen and understand what 'good things' older users of services wish to retain, and how their individual needs can be met at home and in their community, This will include broadening the possibilities of financial support and income, In some regions, financial support is given to the older persons to arrange his/her own care, This practice should be more Widely available, This is a very significant initiative with the potential to keep people who do not wish to go into residential care at home, It costs money to care for older people in hospitals and in nursing homes, and it costs money to keep people at home, but if this is what the older person wants, the money should be spent to provide home support, 'Importance of the Community in the Maintenance of Older People in their Own Homes However, what of the vulnerable who live at home and who wish to remain at home and receive care there? Many vulnerable older users have lost, through death, a spouse, and their children have often moved to live elsewhere, The community in which they live, where they belong, where they feel secure, where they are known, has the potential to offer the support they require and compensate them for the loss of their loved one's company, We must also acknowledge the valuable contribution that families make to the care of their older members, They should be able to depend on the community to help provide the enrichments and enhancements they need to maintain a good quality of life, To move from their home at such a time often creates emotional and spiritual impoverishment, which leads to isolation, Yet this sad, silent emigration of old people is happening all the time, Communities must be given support and also we must not forget to support the carers in the work they undertake, Multi-faceted Needs Require a Multi-level Response and Co-operation This new public health paradigm moves away from the medical model and into a broader definition of the needs of individuals, Within the conceptual framework of the new social model of health is the notion of health encompassing all facets of our daily lives, In that sense, issues such as pollution control, environmental protection, food safety and social well-being are intimately involved with physical, mental and psychological well-being, Effectively, this acknowledges that health is not solely an activity and a responsibility of health and social care professionals, Each facet of the environment contributes significantly to good health, The task of providing good health care, which encompasses the total needs of the individual, belongs to everyone in the community, Cultural factors also need to be recognised in order for us to understand health behaviour, Towards Care Management in Ireland

56 i This ushers in an era of new partnerships that are socially inclusive. The outcomes of these partnerships promote service integration and cross-departmental initiatives, the development of links with other information-giving bodies and build and strengthen the relationships between voluntary and statutory providers. Traditional attitudes to ageing will also have to change, since these attitudes are at variance with the concept and practice of Care Management. Those who cling to these attitudes need to be persuaded of the merits of Care Management in delivering services; the benefit to older people should act as an effective change agent. _ The adoption of Care and Case Management as the fundamental philosophy and organisational imperative in the preparation and delivery of health and social care to older people within a framework that promotes positive, preventative approaches to healthy, active ageing is a challenge. A comprehensive response will see radical changes because the configuration of the current health services will be fundamentally restructured. Many of the health boards, health organisations and social service agencies have already given a higher priority to the importance of providing services in the community. For instance, the home help service has been expanded, but a lot more needs to be done to ensure that community services are in line with the preferences of older people and provide an alternative to residential care. I I 1 1 I The way forward, therefore, should involve the identification of further policy initiatives and the practical steps necessary to implement the principles of Care and Case Management in the Irish health service. Next Steps - Establishment of Working Group on Care Management A Working Group in each area should be quickly established, with representatives from the main providers. The Working Group should agree the broader policy initiatives that are required to support the integration of services, the development of community-based care and the reduction of unnecessary admissions to institutional care and acute hospitals. Secondly, the Working Group should oversee the implementation of Care and Case Management as the means through which care for older people will be delivered. The Working Group should provide the opportunity for staff from different sectors and different professions to agree their role and contribution in the development of Care and Case Management. The Working Group should identify: innovative approaches in the delivery of services locally staff training needs and the implementation of a training and information programme to meet the needs,. the definitions and the terminology to be used. As we move Forward towards the implementation of care management, we have the opportunity to examine the language and terminology used in healthcare. The language we use is important the language to be used. Language is also important in fostering positive attitudes to ageing. The views of the older European population were in some countries, there seems to be a reaction against connotations of 'oldness'. We need to be careful when labelling care groups the nature of comprehensive assessment of need and also should agree the screening protocols, to ensure the most vulnerable receive care. Conference Proceedings

57 In order to avoid drift and a lack of focus, the Working Group should work to a fixed timetable and report on the broader policy changes. It should bring forward an action plan for implementation within a defined period. Grmf The research has outlined the key features and current status of nine pilot projects around the country which are seeking to develop Care and Case Management. In order to lay the groundwork for this approach, we have embarked in recent months on a number of projects in the Eastern Regional Health Authority. The projects are known as Home First. These projects seek to establish how services could be more effectively organised to meet the holistic needs of older people. Pilot projects, which have been shown to be successful, can be further expanded and developed without delay. These pilot projects should endeavour to implement the principles of care and case management locally. Key features will be: home support and care Care Management in long stay residential care the use of information technology to support the independence of the vulnerable older person local resource centres for all ages dialogue and discussion between older users, their families and service-providers to examine how services can be more effectively delivered, and to explore how older people can be involved in the planning of services to meet their needs publicity and information. :Home Support and Care For Care and Case Management to work effectively, staff need to be available to provide the services older people require at home and in the community. These staff will be drawn from a number of sectors, including health and social services. Care Management can be carried out by an experienced practitioner from any professional background. The practitioner is responsible for co-ordinating the comprehensive assessment and for drawing up and ensuring that Care Packages are monitored and reviewed regularly. In the Home First pilot projects, this practitioner is referred to as the Care Organiser. Packages of home care and support will all be different, depending on the circumstances and needs of the individual older person. Each pac.kage will support the wish of the older person to remain at home in safety, independently, and with dignity. Services at home will be available, seven days a week, twenty-four hours a day, as and when required. Care Plans for older people will be tailored to their individual needs and will be drawn up with the involvement of the older users and their carers. The Care Plan designed for the older person should aim to preserve or restore independent living and will be reviewed regularly with the older people and his/her carers. Towards Care Management in Ireland.'.

58 'II I' I 1 1.' d id. :: Care Management and Long-Term Residential Care 4 Care and Case Management should include older users in continuing long-stay care settings, because 11!!!! : ~ j, their qualily of life is as important as that of other users. The approach to long-term care should be to help people to lead the kind of fulfilling lives they want to lead and to contribute, in a meaningful way, to the management and organisation of their care. A new relationship of trust among clients, carers and services should be created. A growing number of service providers want to see significant changes and will support new initiatives. One firm objective should be to make it possible for older people in residential care to return to their homes if that is their Wish, and if it is practical. However, for this to happen, we need to look beyond our current and predictable provision. While recognising that many older people will remain in residential care, every opportunity should be taken to examine and assess their needs, to see if they require further services to enrich their lives. This task could be carried out by a Care Organiser or a Case Manager. Technology to Support the Independence of the Vulnerable Older Person A significant development that we should acknowledge, and which should become an integral part of the development of Care Management, is the advance made by technology to support the independence of the vulnerable older person. The Rowntree Foundation in England has developed an integrated interactive system, which is installed unobtrusively in the home. The effectiveness of this system can close curtains, open windows and doors, lower sinks and cupboards, turn on taps and lights, raise the alarm in the event of an emergency and, with many other functions, support an older person at home. Surprisingly, the cost of installation is relatively modest. This advance should be a significant support to the establishment of Care Management. Each region should install integrated interactive systems in a number of homes to demonstrate how this service can be made widely available to older people and their families. Local Resources and Centres for all Ages Reports and research highlight older people's desire for local services, that can be accessed easily. Many health boards and health organisations are considering plans for local day and assessment i :i :1 '1 1 centres, and other services. However, the development of local resource centres for all ages in the community should be researched and pursued. Such centres would support the United Nations' view of 'a society for all ages', and the thinking in Europe on the importance of inter-generational contact and solidarity. Local resource centres could help to meet the problems older people face with transport and accessibility. The potential for providing services to meet local needs is clearly evident, and already, of course, some pilot work is examining the effectiveness of integrated information centres. From the health perspective, local resources could be developed to meet the needs of all ages in the community and support the independence of older people. A Dialogue Between Users, Carers and Service Providers The involvement of service-users in all aspects of their care is important. To facilitate this, and to include service-users in the planning of the services and in the decisions that affect their lives, a new dialogue among users, carers and service-providers needs to be initiated. This new dialogue may well Conference Proceedings

59 challenge the priorities set by service providers and well-established patterns of delivering care. This dialogue should lead to the development of inter-agency partnerships and multi-sectoral service provision. The new dialogue should start as soon as possible and support should be available to older users to facilitate their involvement. This will include examining payments t.o users and carers for their participation in the planning process. Publicity and Information Many health and social care professionals recognise that information regarding health and social services is hard to access. Yet, accurate information is a prerequisite for effective health and social care. Information must be accurate and be disseminated in a proactive fashion, using multiple modalities and with multiple points of access, such as booklets, advertising and local radio and television. Accurate, accessible and timely information on Care Management is essential if older users are to be made aware of it. The forthcoming Health Information Strategy indicates a recognition that the availability of information on health for clients will help empower them to have a more active role in their health care and promote self-care. 'Resources to Support Care Management Care Plans offer real choice to service-users if the range of service is available. At the moment, difficulties in some areas of recruitment may limit the choice available. The issue of resourcing Care Management needs to be carefully examined. With a reorganisation and co-ordination of current services in the country, better use could be made of current resources which could be used to develop Care and Case Management. I think it is obvious that even where additional funding may be required for Care and Case Management to support the needs of older people, this could offer better value for money and certainly a better outcome for the older person. In some countries, financial budgets are devolved to Care Managers to enable them to obtain the services they require without _ recourse to senior management. Should we follow this practice? The Years Ahead (1987) recognised the importance of independence in older life, mainly through its emphasis on the 'staying put' policy. The strategy that was subsequently developed is grounded in, and informed by, a positive vision of ageing and older life. The initiative on Care and Case Management has been inspired by this thinking, and encompasses the potential to deliver effective care, involving the older user in the planning and delivery of the services intended for them. The contribution of older people to the present generation is enormous. Many of today's older people left school with little education, have experienced urban migration and high emigration levels in the 1940s and 1950s, and have helped fund the country's education, health and infrastructure systems, the benefits of which will be reaped for decades to come. When cider people were asked to nominate the issues that most affected their quality of life, family and health were the most commonly mentioned concerns. Priority should be given to strengthening home, community and hospital services to provide much needed support to older people who are ill or dependent, and to assist those who care for them. Care Management can go a long way to help achieve this goal. In conclusion, 'Care flourishes when creativity is nurtured, different solutions are accepted and in this climate of care, flexibility and new partnerships take root'. Towards Care Management in Ireland

60 Closing Address Or Mick Loftus Chairman, National Council on Ageing and Older People At the end of our discussions today, what strikes me most particularly is that Care Management and Case Management, however they are defined, are not just about how we organise our health and welfare services for older people. They are just as much about an ethos of service provision and how we think about the work that we do on behalf of our older clients. In this sense Care and Case Management are not just the concern of certain health and social service managers and some front-line staff. These concepts must inform the thinking of all health and social care planners, organisers and providers. Practically speaking this will mean that staff will need to appreciate: that one never thinks of one's work in isolation from the work of other staff colleagues that rather than seeing the limitations of the particular service one provides, staff will put themselves in the shoes of the client to see how his/her care preferences can be addressed co-operatively. At the same time, clearly, without adequate funding, staffing and services provision, Care and Case Management cannot be the panacea that will cure all ills. There are, however, important signposts for the development of health and social care services. That is why the Council produced a draft Care Management Implementation Framework to assist in the erecting of these signposts. The Council has made it clear in the draft that it will seek to promote the establishment of a National Older People's Care and Case Management Monitoring and Development Group to carry this work forward. It is therefore our intention to continue to assist in progressing Care and Case Management for older people within the Irish health and sociai care system. Conference Proceedings c~~_,

61 r '(!'f.r'.:~~~., '...

62 The National Council on Ageing and Older People was established on 19 March 1997 in succession to the National Council for the Elderly (January 1990 to March 1997) and the National Council for the Aged (June 1981 to January 1990). The functions of the Council are as follows: 1. To advise the Minster for Health on all aspects of ageing and the welfare of older people, either at its own initiative or at the request of the Minister and in particuiar on: (a) measures to promote the health of older people; (b) measures to promote the social inclusion of older people; (c) the implementation of the recommendations contained in policy reports commissioned by the Minister for Health; (d) methods of ensuring co-ordination between public bodies at national and local level in the planning and provision of services for older people; (e) methods of encouraging greater partnership between statutory and voluntary bodies in providing services for older people; (f) meeting the needs of the most vulnerable older people; (g) means of encouraging positive attitudes to life after 65 years and the process of ageing; (h) means of encouraging greater participation by older people; (i) whatever action, based on research, is required to plan and develop services for older people. 2. To assist the development of national and regional policies and strategies designed to produce health gain and social gain for older people by: a) undertaking research on the lifestyle and the needs of older people in Ireland; b) identifying and promoting models of good practice in the care of older people and service delivery to them; c) providing information and advice based on research findings to those involved in the development and/or implementation of policies and services pertaining to the health, well-being and autonomy of older people; d) liaising with statutory, voluntary and professional bodies involved in the development and/or implementation of national and regional policies which have as their object health gain or social gain for older people. Conference Proceedings

63 3. To promote the health, welfare and autonomy of older people. 4. To promote a better understanding of ageing and older people in Ireland. 5. To liaise with international bodies which have functions similar to the functions of the Council. The Council may also advise other Ministers, at their request, on aspects of ageing and the welfare of older people which are within the functions of the Council. Membership Chairman Dr Michael Loftus Director Bob Carroll John Brady Noel Byrne Kit Carolan Janet Convery John Cooney Jim Cousins Paul Cunningham Dr Davida De La Harpe Joseph Dooley Iarla Duffy James Flanagan John Gibbon Prof Faith Gibson Frank Goodwin John Grant Eamonn Kane Patricia Lane Ruth Loane Leonie Lunny Mary McDermott Dr Diarmuid McLoughlin Sylvia Meehan Mary Nally Paddy 0 'Brien Pat 0 'Leary Mary 0 'Neill Martina Queally Peter Sands Bernard Thompson Towards Care Management in IrelancJ

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66 ~f Ruth Barrington is Chief Executive Officer of the Health Research Board. She was Secretary of the Working Part)' on Services for the Elderly, that was responsible for the report The Years Ahead, which _ has been national policy for the elderly since John Brennan is a Senior Social Worker in Age Related Health Care in Tallaght Hospital. He is currently a member of the Executive Committee of the Irish Association of Social Workers and chair of its Special Interest Group on Ageing David Challis is Professor of Community Care Research and Director of the PSSRU at the University of Manchester. He was previously Professor of Social Work and Social Care at the University of Kent. He has published some 12 books and over 100 articles in journals in the field of community based care of older people. Recent publications in relation to care management include a series of publications relating to national surveys in England and Northern Ireland and Care and Health Care of Older People Ashgate, 1995 and Care Management in Social And Primary Health Care, Ashgate, A social worker by profession, Janet Convery worked in (health board) community care services in Wicklow for 14 years. She formally lectured full-time in the Social Studies Department at Trinity College Dublin. She has carried out research on day care, mental health services for older people, social exclusion of older people, and on the private nursing home subvention system in Ireland. Janet was a member of the National Council on Ageing and Older People, and a member of the Working Group on Elder Abuse, established under the aegis of the Council by Dr Tom Moffatt TD, Minister of State with responsibility for older people. She is currently Directoy of Services for Older Persons in the East Coast Area Health Board. Denis Doherty Denis is now Director of the Health Board Executive (HeBE). He has had a career long interest in the human relations aspect of the health services, and is a former chief executive officer of the Midland Health Board. He worked as Personal Officer of the North Western and Midland Health Boards and is a Fellow of the Institute of Personnel and Development. He is the head of the Irish Delegation and immediate past President of the Standing Committee of the Hospitals of the European' Union. -~ Dr Ciaran F Donegan, Consultant Physician in General and Geriatric Medicine, Beaumont Hospital and James Connolly Memorial Hospital. He trained in Mater, Richmond, JCMH and St James's Hospitals in Dublin and spent 10 years in Nottingham, initially as Senior Registrar and later as Consultant at the Queen's Medical Centre Nottingham (the second largest general hospital in the U.K.) Interests include: Falls, Stroke Care and Rehabilitation, Day Hospital and service development, particularly in the delivery of care for older people in the hospital and community. Conference Proceedings

67 _ Michael Donnelly is a Reader in the Faculty of Medicine and Health Sciences and a Senior Lecturer in the Department of Epidemiology and Public Health at Queen's University Belfast. Previously he held the post of Research Programme Leader at the Health and Social Care Research Unit, QUB where he had responsibility for a wide range of studies designed to assess the effectiveness and efficiency of community care in the North. It was during his time as Research Programme Leader that he began discussions with Professor David Challis and these led to the survey of care management arrangements in the North. Early findings from the survey will form the basis of his presentation. -~ Ann joined the Office for Health Management in February 1999 from The Royal Hospital Donnybrook, where as Assistant Director of Nursing she had responsibility for research, education and development of staff and the nursing service. Ann is a Registered General Nurse and a Registered Midwife and has worked in the Blackrock Clinic, Dr Steevens Hospitai and St. James's Hospital. She was Secretary to the Nursing Education Forum and Chairperson of the Irish Nursing Research Interest Group. She has a Masters Degree in Business Studies specialising in Management and Organisation Studies from University College Dublin. _f Dr Loftus is a practising General Practitioner in Crossmollina, Co. Mayo, where he is also Chairman of the local Community Council. Well-known for his sporting involvement, he played on the great Mayo team of the 1950s and subsequently became President of the Gaelic Athletic Association. He is Chairman (D6thain), which means 'enough' - the organisation which highlights issues relating to the abuse of alcohol, and as Coroner for North Mayo, he is well acquainted with suffering cause to so many as a result of this serious problem in Irish society. He has also a keen interest in issues affecting the health and well-being of older people and is particularly enthusiastic of health promotion in later life. He is currently Chairman of the National Council on Ageing and Older People, having being appointed by the Minister for Health and Children in December _f Sarah Marsh is the newly appointed case manager for the Alzheimer Society of Ireland. She is a professionally qualified Social worker with experience in working with older people in a community setting. Her appointment is the first specifically dedicated to people with dementia and their families. Prof. Hannah McGee Professir Hannah McGee is a health psychologist at the Department of Psychology, Royal College of Surgeons in Ireland (RCSI). She is the founding Director of the Health Services Research Centre at RCSI. The Centre was established as the first such multidisciplinary centre in Ireland in its focus is on promoting quality in Irish healthcare through research. The Centre conducted a recent National Council on Ageing and older People report on older people's experiences of health and social services in Ireland (the HeSSOP Study). Professor Mcgee's particular research interests concern factors influencing health service use and experience, quality of 'Iife assessment, ageing and Towards Care Management in Ireland

68 cardiovascular disease/. She is principal investigator of a recently funded cross-border Health Research Board Programme Grant on Ageing, Health and healthcare and she is the lead researcher on a number of projects concerning sensitive heakth issues of importance in the Irish context, e.g hepatitis C and sexual abuse. Maurice O'Connell Maurice O'Connell is the Chief Executive of The Aizheimer Society of Ireiand. He has been involved with the Independent Living Movement; a consumer led organisation for people with disabilities, where he was general manager of its training and management support company. He was Director in the Barrett Cheshire Homes where his focus was social housing and residential care. He received his Masters in Applied Psychology from Loyola University in Chicago. _ Donal 0' Shea has retired from his position as the Regional Chief Executive Officer of the Eastern Regional Health Authority. _ Dr Eamon O'Shea studied economics at University College Dublin, the University of York and the University of Leicester. His research interests include health economics, the economics of ageing and the economics of the welfare state. His work in these areas has been pubiished in severai journals. He has also published a number of reports and poiicy documents in Ireiand, mainly in the fieids of ageing and disabiiity, Current research projects inciude an analysis of the applicability of willingness-to-pay methodologies for health-care priority settings, a review of public subventions of nursing homes in Ireland, and a study of mortality differences by socio-economic group in Ireland. He is currentiy writing a book entitled Growing Old in Ireland: An Economic and Social Analysis. Eamon is the author or co-author of a number of studies prepared for and published by the National _ Council on Ageing and Older People. Prior to taking up the post of Co-ordinator for Packages of Care, worked as a staff nurse in the Sacred Heart Hospital, Castlebar - Geriatric Long Stay facility. Conference Proceedings

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