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A survey of local authorities and Home Improvement Agencies: Identifying the hidden costs of providing a home adaptations service
Abstract
Introduction
The Royal College of Occupational Therapists has launched a campaign to demonstrate that occupational therapists improve lives and save money for health and social care services. Occupational therapists play a major part in supporting older and disabled people to remain in their own homes through the provision of home adaptations. Among other benefits, studies have shown that home adaptations can reduce falls in the home and could therefore help reduce hospital admissions. However, to evidence savings, information on the full costs of supplying and fitting home adaptations are needed.
Method
Local authorities and Home Improvement Agencies were surveyed in 2014–2015 to obtain the information required to estimate these costs. Time inputs for staff involved in their provision have been collected and staff costs and total costs calculated for 18 commonly fitted adaptations. The process of obtaining publicly funded home adaptations is also discussed.
Findings
For major adaptations, the total mean cost was £16,647, ranging from £2474 to £36,681. Staffing costs absorbed up to 24% of the total mean cost. The total mean cost for minor adaptations was £451, with average staffing costs forming 76%.
Conclusion
Staff costs are an important consideration when estimating the costs of providing home adaptations.
... It also reflects that other than for intermediate care staff, such as Rapid Response teams, much input is indirect, e.g., sourcing equipment, rather than direct care provision with individuals. 29 Little guiding literature exists around estimation of staff time in such roles. 29 Common practice in such situations is to consult with experienced professionals for guidance. ...
... 29 Little guiding literature exists around estimation of staff time in such roles. 29 Common practice in such situations is to consult with experienced professionals for guidance. 30 Discussion with local OT Team leads produced three broad time bands of low (<5; median 2.5 h), medium (5-9.9; ...
... Equipment (currently provided) costs and adaptations costs (ever provided) were calculated separately to give a total figure, as these were typically one-off, longer term costs. 29 Detailed micro-costing methodology is in Supporting Information. ...
Numbers of people with severe obesity (BMI ≥ 40 kg/m2), with need for community health and long‐term care (LTC) services, are increasing, but documentation is lacking. We identified individuals with severe obesity known to community health and care professionals in a representative United Kingdom region and used an investigator‐administered questionnaire to record needs and use of community health and LTC services. Data were verified against health and LTC records. Local and published sources informed detailed micro‐costing. Twenty‐five individuals (15 women) consented, aged 40–87 (mean = 62) years, BMI 40–77 (mean = 55) kg/m2: 20 participants (80%) were housebound. Twenty‐two different cross‐sector community health and LTC services were used, including community equipment service (n = 23), district nursing (n = 20), occupational therapy (n = 14), and LTC (n = 12). Twenty‐four (96%) participants used three or more services, with longest care episode lasting over 14 years. Total annual service costs incurred by participants varied from £2053 to £82 792; mean £26 594 (lower estimate £80 064; mean £22 462/upper estimate £88 870; mean £30 726), with greatest costs being for LTC. Individual costs for equipment (currently provided) and home adaptations (ever provided) ranged widely, from zero to £35 946. Total mean annual costs increased by ascending BMI category, up to BMI 70 kg/m2. This study provides a framework with which to inform service provision and economic analysis of weight management interventions. People with severe obesity may need sustained care from multiple community care services.
... Delovni terapevti so strokovnjaki, ki znajo dobro oceniti tako človekove sposobnosti za izvajanje vsakodnevnih aktivnosti kot tudi značilnosti posameznikovega okolja, ki izvedbo aktivnosti bodisi vzpodbuja bodisi zavira. Njihove kompetence so lahko ključnega pomena pri oblikovanju varnega okolja, ki podpira samostojnost posameznika in je skladno z njegovimi željami in prioritetami (Curtis in Beecham, 2018). Raziskave kažejo, da storitve delovne terapije lahko pomembno pripomorejo k uspešnemu staranju v domačem okolju in zmanjševanju potreb po institucionalni oskrbi (De Coninck idr., 2017). ...
... Raziskave kažejo, da storitve delovne terapije lahko pomembno pripomorejo k uspešnemu staranju v domačem okolju in zmanjševanju potreb po institucionalni oskrbi (De Coninck idr., 2017). Strokovno znanje delovnih terapevtov je pomembno na različnih področjih, na primer pri prilagoditvah domačega okolja in preprečevanju padcev v domačem okolju (Curtis in Beecham, 2018; Elliot in Leland, 2018). Pomembne so tudi njihove intervencije na področju izvajanja aktivnosti ter vključevanja v družbo (Turcotte, Carrier in Levasseur, 2019). ...
... Occupational therapy is a health discipline that can significantly contribute to successful and safe ageing in the home environment (De Coninck et al., 2017;Curtis and Beecham, 2018;Elliot and Leland, 2018). Occupational therapists have the expertise to evaluate a person's abilities to perform everyday activities as well as his or her environment (person-environment fit). ...
Although most older people want to remain in their home environment for as long as possible, there is a shortage of community care services that would enable that in Slovenia. We wanted to examine the situation surrounding community-based occupational therapy in Slovenia and find strategies that could improve the recognition and availability of occupational therapy for community-dwelling older adults. We employed a qualitative research design – a case study. Four occupational therapists participated in the study; two from Slovenia and two from abroad. Data were collected using semi-structured interviews and organized into four categories: strengths, weaknesses, opportunities and threats. Based on the findings, the SWOT analysis was used as a strategic tool for the development of actionable strategies. The strategies that emerged from the analysis highlighted the need for additional training in the areas of fall prevention, home adaptations and dementia care, as well as the need for promotional and research work. Occupational therapy is a health discipline that could significantly contribute to successful and safe ageing in place.
... In a related vein, regarding the types of economic evaluation used, although certain approaches provide more advanced findings, more descriptive approaches (e.g., cost studies) can also be very useful, particularly given the general need for the profession to build capacity in this area. For example, as reported in the home care illustrative case, Curtis and Beecham's (2018) estimate of the total costs associated with supplying and fitting commonly used home adaptations provides highly useful information. Being able to accurately describe the real costs associated with providing occupational therapy services is a logical place for therapists to begin in advancing their economic evidence capacity. ...
Background. Given the necessity to demonstrate that occupational therapy services are a good use of resources, understanding the state of economic evidence is essential. Purpose. This article presents a rapid review of this evidence. Method. Relevant articles were identified using SCOPUS. Eligible studies included economic analyses of interventions that included occupational therapy and were published in English or French after 1999. The findings were synthesized and then appraised using the Quality of Health Economic Studies (QHES) template. Results. The 135 studies identified were conducted in 23 countries and most commonly: with adults/older adults; in home, inpatient, outpatient, and rehabilitation centre settings; with individuals with cerebrovascular accident and orthopaedic conditions. The specific occupational therapy role was specified in 60% of the studies. Approximately 50% of the investigations used a randomized controlled trial and a cost effectiveness analysis, and 40% used a societal economic perspective. The average QHES score was 74.4/100 (reasonable quality). Implications. This review has revealed areas of relative strength, some important gaps, and potential directions for future action. Economic evidence that specifically identifies the occupational therapy contribution must continue to be gathered. The profession should consider the strategic alignment of its economic research (e.g., home care) to maximize its impact.
... In health economics, effectiveness analysis is often utilized to comparatively evaluate the performance of alternative arrangements (Cookson et al., 2017; Chiatti and Iwarsson, 2014) [37,38]. Among others, Curtis and Beecham (2018) estimated the cost composition of home adaptation schemes in the United Kingdom and found that DFG schemes spent more than they should due to a high staffing component accounting for 76% of the total cost [39]. Zhou et al. (2019) explored the causes of time delays of housing adaptations and also found that DFG schemes were understaffed and the resources were not enough to process the applications [19]. ...
The ability to live independently plays a crucial role in the mental and psychological wellbeing of the disabled. To achieve this goal, most governments spend a substantial budget on home adaptation projects. It has been observed that schemes with different target clients (residents versus landlords) are different in efficiency and effectiveness. To understand why and how these schemes differ in performance, this paper develops and applies a generic economic evaluation framework for government-funded home adaptation schemes. Based on the individual-level surveys collected in the United Kingdom, an empirical model was formulated to quantify the determinants for various performance indicators, including money costs, time costs and client satisfaction. Robust estimation procedures were applied to deal with the heteroscedasticity and outlier problems in the data. Results showed that a specialized independent living scheme dedicated to disability adaptations (e.g., the Physical Adaptations Grant, PAG) had higher efficiency and effectiveness than general-purpose schemes (e.g., the Disabled Facilities Grant, DFG), because the funds were provided to the landlords who had a stronger motivation to minimize the time cost in the short run and maximize the future rent potential in the long run. A "unified system" approach to adaptations should be a guiding principle for policy development, regardless of who actually delivers the service.
Background. Many occupational therapists make home modification recommendations; however, it is unknown if sustainability considerations (i.e., economic, social, and environmental) are contemplated during this process. Purpose. To understand occupational therapists’ perceptions regarding the sustainability of home modifications. Method. This study adopted a qualitative description approach. Researchers utilized semistructured interviews as the primary means of data collection. Findings. The ten female occupational therapists interviewed had three or more years of experience working with home modifications. The analysis identified three themes: It's not easy being green: environmental sustainability, stretching a dollar: financial inequities, and barriers and benefits in the home modification process. Implications. Findings suggest OTs have a varied and a general understanding of how to implement sustainability concepts in their practice. There is also a need to make access to home modifications more equitable. Further research is needed to build a more robust understanding of how OT recommended home modifications can contribute to sustainability.
Purpose
The ageing and disabled population is fast growing, which emphasises the need to effectively modify current homes and environments to support healthy ageing and increasingly diverse health needs. This paper aims to bring together findings and analyses from three adaptations-focussed projects, drawing on perspectives from key stakeholders alongside the lived experiences of service users acquiring adaptations.
Design/methodology/approach
Following an Adaptations Framework developed from interviews and focus groups with older people and key stakeholders, the paper discusses barriers experienced by older people and front-line workers in receiving and delivering adaptations through all stages of the process.
Findings
This paper reveals how experiences around adaptations might diverge with unseen, hidden investment and need amongst individuals, and how conceptual and cost-focussed evidence gaps impact wider understandings of adaptations delivery. In so doing, this paper highlights how the adaptations process is perceived as a “fight” that does not work smoothly for either those delivering or receiving adaptations services.
Research limitations/implications
The paper suggests a systematic failure such that the adaptations process needs to be rehauled, reset and prioritised within social and public policy if the housing, health and social care sectors are to support healthy ageing and prepare for the future ageing population.
Originality/value
The paper brings together insights from key stakeholders alongside service users' experiences of adaptations to highlight key policy drivers and barriers to accessing and delivering adaptations.
Purpose
The majority of older Australians prefer living in their own home. Home modifications support older adults' ageing-in-place through mitigating environmental hazards of their home, and there is an increased interest in modifying older adults' residential environment in sustainable ways. However, an in-depth understanding of sustainability perceptions of home modification service providers (HMSPs) is lacking in Australia. Thus, the study aims to address this research gap.
Design/methodology/approach
Qualitative content analysis was adopted to identify sustainability perceptions through analyzing the retrieved home modification business information from the selected HMSPs' official websites. The results of qualitative content analysis were further analyzed by using independent-samples t -test and chi-square contingency table analysis to investigate the relationships between HMSP type and sustainability.
Findings
In total, 54 sustainability perceptions were identified, with the crucial ones being safe living environment, independent living and service diversity. Overall, there are no significant differences in sustainability perceptions between charitable and non-charitable HMSPs. Nevertheless, charitable HMSPs place more importance on social sustainability in comparison with non-charitable HMSPs.
Originality/value
The study results facilitate understanding about HMSPs' sustainability perceptions and sustainable home modifications in the ageing society, which facilities theory advancement and industry practice in the home modification area.
Background: One-fifth of all disabled children have mobility limitations. Early provision of powered mobility for very young children (aged < 5 years) is hypothesised to trigger positive developmental changes. However, the optimum age at which to introduce powered mobility is unknown.
Objective: The aim of this project was to synthesise existing evidence regarding the effectiveness and cost-effectiveness of powered mobility for very young children, compared with the more common practice of powered mobility provision from the age of 5 years.
Review methods: The study was planned as a mixed-methods evidence synthesis and economic modelling study. First, evidence relating to the effectiveness, cost-effectiveness, acceptability, feasibility and anticipated outcomes of paediatric powered mobility interventions was reviewed. A convergent mixed-methods evidence synthesis was undertaken using framework synthesis, and a separate qualitative evidence synthesis was undertaken using thematic synthesis. The two syntheses were subsequently compared and contrasted to develop a logic model for evaluating the outcomes of powered mobility interventions for children. Because there were insufficient published data, it was not possible to develop a robust economic model. Instead, a budget impact analysis was conducted to estimate the cost of increased powered mobility provision for very young children, using cost data from publicly available sources.
Data sources: A range of bibliographic databases [Cumulative Index to Nursing and Allied Health Literature (CINHAL), MEDLINE, EMBASE™ (Elsevier, Amsterdam, the Netherlands), Physiotherapy Evidence Database (PEDro), Occupational Therapy Systematic Evaluation of Evidence (OTseeker), Applied Social Sciences Index and Abstracts (ASSIA), PsycINFO, Science Citation Index (SCI; Clarivate Analytics, Philadelphia, PA, USA), Social Sciences Citation Index™ (SSCI; Clarivate Analytics), Conference Proceedings Citation Index – Science (CPCI-S; Clarivate Analytics), Conference Proceedings Citation Index – Social Science & Humanities (CPCI-SSH; Clarivate Analytics), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), NHS Economic Evaluation Database (NHS EED), Health Technology Assessment (HTA) Database and OpenGrey] was systematically searched and the included studies were quality appraised. Searches were carried out in June 2018 and updated in October 2019. The date ranges searched covered from 1946 to September 2019
Results: In total, 89 studies were included in the review. Only two randomised controlled trials were identified. The overall quality of the evidence was low. No conclusive evidence was found about the effectiveness or cost-effectiveness of powered mobility in children aged either < 5 or ≥ 5 years. However, strong support was found that powered mobility interventions have a positive impact on children’s movement and mobility, and moderate support was found for the impact on children’s participation, play and social interactions and on the safety outcome of accidents and pain. ‘Fit’ between the child, the equipment and the environment was found to be important, as were the outcomes related to a child’s independence, freedom and self-expression. The evidence supported two distinct conceptualisations of the primary powered mobility outcome, movement and mobility: the former is ‘movement for movement’s sake’ and the latter destination-focused mobility. Powered mobility should be focused on ‘movement for movement’s sake’ in the first instance. From the budget impact analysis, it was estimated that, annually, the NHS spends £1.89M on the provision of powered mobility for very young children, which is < 2% of total wheelchair service expenditure.
Limitations: The original research question could not be answered because there was a lack of appropriately powered published research.
Conclusions: Early powered mobility is likely to have multiple benefits for very young children, despite the lack of robust evidence to demonstrate this. Age is not the key factor; instead, the focus should be on providing developmentally appropriate interventions and focusing on ‘movement for movement’s sake’.
Future work: Future research should focus on developing, implementing, evaluating and comparing different approaches to early powered mobility.
Study registration: This study is registered as PROSPERO CRD42018096449.
Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology programme and will be published in full in Health Technology Assessment; Vol. 24, No. 50.
Home modification or adaptation is an important global issue, especially for older people living with disabilities in ordinary housing of varying ages, and pre-dating concerns about accessibility in design. Comparisons of research from five developed nations identify common themes: variation in integrated service development; public and private financial investment; deferred health costs; workforce expansion and training; and the value of the user perspective. Further discussion identifies the importance of retrofitting alongside new build, and argues for sustainable housing that recognizes population aging but also issues of climate change and the need for more inclusive design of housing for all ages.
With ageing populations, social changes and rising public expectations, many countries
are exploring ways of developing a more preventative approach within their health and
social care services. In England, this has become a growing priority over time—made
even more significant by recent economic change and by the urgent need to reduce
public sector spending. However, a key dilemma for policy makers and managers is
the patchy nature of the evidence base—with a lack of certainty over how to reform services
or prioritise spending in order to develop a more genuinely preventative approach.
Against this background, this commentary reviews national and international evidence
around ten policy measures and interventions, highlighting some of the most promising
approaches as well as the fragmented and contested nature of the evidence base.
In 1999–2000 a team of professionals and researchers carried out the largest research study so far undertaken with recipients of housing adaptations in England and Wales to discover how effectively the adaptations had achieved their objectives. Amongst the findings was evidence that well‐designed adaptations had beneficial, and/or preventative effects on both physical and mental health; that these benefits were long‐term and that they extended beyond the disabled person to help the health of other family members. The evidence presented is linked with key themes from other research to trace in detail the pathways that lead from unadapted or badly adapted housing to mental and physical ill health. It is suggested that these themes, including the meaning of home and the concept of intrusion are vital to understanding how health gains may be achieved through adaptation, and are useful and relevant to the broader debate on links between housing and health.
Background
Little is known about day-to-day procedures in conducting predischarge home visits in occupational therapy. The aim of this study was to identify current practice in relation to people with stroke.
Method
A questionnaire was designed and piloted; 184 were posted to stroke units in England.
Results
Responses were analysed from 85 stroke units from 10 regions. The main reason for conducting visits was to ‘assess or practise activities of daily living in the home environment’ (93%), closely followed by to ‘identify or address safety issues’ (92%). Wide variations exist in time spent on the actual visit (range 10–135 minutes), with a mean time of 63 minutes (SD 20.36), and a mean time of 61 minutes (SD 33.13) for writing a report. Visits were generally conducted by an occupational therapist, with an occupational therapy/physiotherapy assistant. The majority (95%) of therapists reported having a home visit bag and the most common item included was incontinence pads (83%).
Conclusion
This research has provided valuable information on, and highlights the variation in, day-to-day predischarge home assessment visits for patients after stroke. The next step must be to use this knowledge to evaluate patient selection and to examine the costs and effectiveness of such visits.
Delayed patient discharge will likely exacerbate bed shortages. This study prospectively determined the frequency, causes and potential cost implications of delays for 83 consecutive patients, who were inpatients for a total of 888 days. 65% of patients experienced delay whilst awaiting a service. 48% of patients experienced delays that extended their discharge date. Discharge delays accounted for 21% of the cohort's inpatient stay, at an estimated cost of 565 sterling pounds per patient; 77% of these hold-ups resulted from delays in the provision of social and therapy requirements. Discharge delays are costly for hospitals and depressing for patients. Investment is required to enable health and social-care professionals to work more closely to improve the patient journey.
The delay in discharge or transfer of care back to the community following an acute admission to the hospital in older adults has long been a recognized challenge in the UK. We examined the determinants and outcomes of delayed transfer of care in older adults.
A prospective observational study was conducted in a district general hospital with a catchment population of 250,000 in England, UK. Those >or= 65 years admitted to two care of the elderly wards during February 2007 were identified and prospectively followed-up till their discharge. Data was presented descriptively.
36.7% (58/158) of patients had a delay in transfer of care. They tended to be older, had poorer pre-morbid mobility, and were more likely to be confused at the time of admission. Compared to the 2003 National Audit Report, a significantly higher percentage (29.3%vs.17%) awaited therapist assessments or (27.6%vs.9%) domiciliary care, with a lower percentage (< 1%vs.14%) awaiting further NHS care. Of 18 in-patient deaths, five occurred during the delay. Seven patients developed medical conditions during the delay making them unfit for discharge. The number of extra bed days attributable to delayed discharges in this study was 682 (mean = 4.8) days.
Awaiting therapy and domiciliary care input were significant contributing factors in delayed transfer of care. Similar local assessments could provide valuable information in identifying areas for improvement. Based on available current evidence, efficacy driven changes to the organisation and provision of support, for example rapid response delayed discharge services at the time of "fit to discharge" may help to improve the situation.
Home modifications are part of the occupational therapy interventions provided to persons with functional limitations in the home environment. Home modification services often involve many different actors, and persons experiencing a need for home modifications have to navigate through a network of service organizations and professional actors. The aim of this study was to explore and describe how older adults in one Swedish municipality tried to find their way and navigate through the service system in order to receive home modification services that could meet their experienced needs. A case study design was used, including four older adults with different experiences and expectations of home modification services. The relationship between the participants' expectations, experiences, and their ways to navigate through the service system was described through the metaphor of a "geographical map". Satisfaction with the service process was found when there was a match in understandings of responsibilities and eligibility between what could be read from the older persons' map and the professionals' perspective. The findings have implications for client-centred occupational therapy practice, indicating that this match can be achieved when professionals translate clients' experienced problems in everyday life into a terminology that fits into the service system.
The aim of this work is to examine the relationship between aspects of objective and perceived housing and aspects of healthy aging, defined as independence in daily activities and subjective well-being. Furthermore, this research examined the comparability of relationships between housing and healthy aging in the five European countries.
Data were drawn from the ENABLE-AGE Project, from home interviews with a sample of 1,918 very old people aged 75 to 89 years living alone in their own homes in Swedish, German, British, Hungarian and Latvian urban areas.
Participants living in better accessible homes, who perceive their home as meaningful and useful, and who think that external influences are not responsible for their housing situation are more independent in daily activities and have a better sense of well-being. Moreover, these results apply to all five national samples.
The findings can widen the perspective when striving for barrier-free building standards, to encompass a holistic approach that takes both objective and perceived aspects of housing into account. Home modification and relocation should not be prescribed, but need to be negotiated with older adults to take into account their personal preferences.
Whilst community equipment and adaptations promote the independence of millions of people,
ongoing problems have been identified with the delivery of such services by local authorities.
Self-assessment has been identified as one possible means of improving service effectiveness,
giving service users more choice and control and providing faster, easier access to services.
However, little is known about the use of self-assessment in social care. Against this
background, this paper reports the findings of a mixed methods evaluation of the use of selfassessment
in five local authority occupational therapy services. This drew on internal
documents, management interviews, service user and administrative records, and a service user
satisfaction survey. Important insights are provided about the operationalisation and possible
functions of self-assessment in local authority occupational therapy departments; the
characteristics of service users for whom self-assessment may be suitable (and those for whom it
may not); the range of equipment suitable for provision via self-assessment; the costs of selfassessment;
and service users’ experience of self-assessment. The results are discussed in the
context of the relevant policy and legal framework and a number of important lessons are
highlighted for service commissioners and providers.
Background:
Despite the considerable injury burden attributable to falls at home among the general population, few effective safety interventions have been identified. We tested the safety benefits of home modifications, including handrails for outside steps and internal stairs, grab rails for bathrooms, outside lighting, edging for outside steps, and slip-resistant surfacing for outside areas such as decks and porches.
Methods:
We did a single-blind, cluster-randomised controlled trial of households from the Taranaki region of New Zealand. To be eligible, participants had to live in an owner-occupied dwelling constructed before 1980 and at least one member of every household had to be in receipt of state benefits or subsidies. We randomly assigned households by electronic coin toss to either immediate home modifications (treatment group) or a 3-year wait before modifications (control group). Household members in the treatment group could not be masked to their assigned status because modifications were made to their homes. The primary outcome was the rate of falls at home per person per year that needed medical treatment, which we derived from administrative data for insurance claims. Coders who were unaware of the random allocation analysed text descriptions of injuries and coded injuries as all falls and injuries most likely to be affected by the home modifications tested. To account for clustering at the household level, we analysed all injuries from falls at home per person-year with a negative binomial generalised linear model with generalised estimating equations. Analysis was by intention to treat. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12609000779279.
Findings:
Of 842 households recruited, 436 (n=950 individual occupants) were randomly assigned to the treatment group and 406 (n=898 occupants) were allocated to the control group. After a median observation period of 1148 days (IQR 1085-1263), the crude rate of fall injuries per person per year was 0.061 in the treatment group and 0.072 in the control group (relative rate 0.86, 95% CI 0.66-1.12). The crude rate of injuries specific to the intervention per person per year was 0.018 in the treatment group and 0.028 in the control group (0.66, 0.43-1.00). A 26% reduction in the rate of injuries caused by falls at home per year exposed to the intervention was estimated in people allocated to the treatment group compared with those assigned to the control group, after adjustment for age, previous falls, sex, and ethnic origin (relative rate 0.74, 95% CI 0.58-0.94). Injuries specific to the home-modification intervention were cut by 39% per year exposed (0.61, 0.41-0.91).
Interpretation:
Our findings suggest that low-cost home modifications and repairs can be a means to reduce injury in the general population. Further research is needed to identify the effectiveness of particular modifications from the package tested.
Funding:
Health Research Council of New Zealand.
Aims. This article is a report of a study of the association between skill mix and 14 nursing-sensitive outcomes following implementation of the nursing hours per patient day staffing method in Western Australian public hospitals in 2002, which determined nursing hours by ward category but not skill mix.
Background. Findings from previous studies indicate that higher nurse staffing levels and a richer skill mix are associated with improved patient outcomes. Measuring skill mix at a hospital level for specific staffing methods and associated nursing-sensitive patient outcomes are important in providing staffing for optimal patient care.
Design. The research design for the larger study was retrospectively analysing patient and staffing administrative data from three adult tertiary hospitals in metropolitan Perth over 4 years.
Methods. A subset of data was used to determine the impact of skill mix on nursing-sensitive outcomes following implementation of the staffing method. All patient records (N = 103,330) and nurse staffing records (N = 73,770) from nursing hours per patient day wards from October 2002–June 2004 following implementation were included.
Results. Increases in Registered Nurse hours were associated with important decreases in eight nursing-sensitive outcomes at hospital level and increases in three nursing-sensitive outcomes. The lowest skill mix saw the greatest reduction in nursing-sensitive outcome rates.
Conclusions. The skill mix of nurses providing care could impact patient outcomes and is an important consideration in strategies to improve nurse staffing. Levels of hospital nurse staffing and skill mix are important organizational characteristics when predicting patient outcomes.
To assess the effectiveness of an environmental falls prevention intervention delivered by qualified occupational therapists or unqualified trained assessors.
A pilot three-armed randomized controlled trial.
Airedale National Health Service Trust catchment, North and West Yorkshire, England.
Two hundred thirty-eight community-dwelling adults aged 70 and older with a history of falls in the previous year.
Assessment and modification of the home environment of people at greater risk of falls.
Fear of falling was the primary outcome measure, and an analysis of covariance was conducted on the area under the curve at 12 months. As a secondary outcome, falls were analysed using negative binomial regression. Quality of life and independence in activities of daily living (ADLs) were also measured.
The intervention had no effect on fear of falling (P=.63). The occupational therapy group had significantly fewer falls than controls 12 months after the assessment (incidence rate ratio (IRR)=0.54, 95% confidence interval (CI)=0.36-0.83, P=.005). There was no significant effect on falls in the trained assessor group (IRR=0.78, 95% CI=0.51-1.21, P=.34).
Environmental assessment had no effect on fear of falling. Environmental assessment prescribed by an occupational therapist significantly reduced the number of falls in high-risk individuals whereas that prescribed by a trained assessor did not. Further research in other settings is needed to confirm this, to explore the mechanisms, and to estimate cost-effectiveness.
To evaluate the effect of an intervention by a multidisciplinary team to reduce falls in older people's homes.
Randomized, controlled trial with follow-up of subjects for 1 year.
University-affiliated geriatric hospital and older patients' homes.
Three hundred sixty subjects (mean age +/- standard deviation = 81.5 +/- 6.4) admitted from home to a geriatric hospital and showing functional decline, especially in mobility.
The participants were randomly assigned to receive a comprehensive geriatric assessment followed by a diagnostic home visit and home intervention or a comprehensive geriatric assessment with recommendations and usual care at home. The home intervention included a diagnostic home visit, assessing the home for environmental hazards, advice about possible changes, offer of facilities for any necessary home modifications, and training in the use of technical and mobility aids. An additional home visit was made after 3 months to reinforce the recommendations. After 12 months of follow-up, a home visit was made to all study participants.
Number of falls, type of recommended home modifications, and compliance with recommendations.
After 1 year, there were 163 falls in the intervention group and 204 falls in the control group. The intervention group had 31% fewer falls than the control group (incidence rate ratio (IRR) = 0.69, 95% confidence interval (CI) = 0.51-0.97). The intervention was most effective in a subgroup of participants who reported having had two or more falls during the year before recruitment into the study. In this subgroup, the proportion of frequent fallers and the rate of falls was significantly reduced for the intervention group compared with the control group (21 vs 36 subjects with recurrent falls, P =.009; IRR = 0.63, 95% CI = 0.43-0.94). The compliance rate varied with the type of change recommended from 83% to 33% after 12 months of follow-up.
Home intervention based on home visits to assess the home for environmental hazards, providing information about possible changes, facilitating any necessary modifications, and training in the use of technical and mobility aids was effective in a selected group of frail older subjects with a history of recurrent falling.
Health and social care agencies in the UK. have been under pressure for some time to reduce delayed transfers of older people from hospital because they absorb scarce health service resources and incur a human cost through inappropriate placement. A local study based on an analysis of records and interviews with managers showed that delays reflect the complex needs of older people, and arise from financing and organisational problems at both the planning and implementation stages of a discharge. Family resistance may also be a factor. Budgetary constraints result in delays in confirming public support for some clients. Shortages of professional staff and care assistants limit the provision of domiciliary packages. The contraction of the residential sector has reduced the availability of beds and increased the cost of care home placements. Scope exists for expediting administrative aspects of transfers by coordinating health and social services. More recent legislation that imposes fines on social service departments for delayed transfers does not address underlying causes.
• Cost containment through the most effective mix of staff achievable within available resources and organisational priorities is of increasing importance in most health systems. However, there is a dearth of information about the full economic implications of changing skill mix.
• In the UK a major shift in the primary care workforce is likely in response to the rapidly developing role of nurse practitioners and policies aimed to encourage GP practices to transfer some of their responsibilities to other, less costly, professionals.
• Previous research has developed an approach to incorporating the costs of qualifications, and thus the investment required to develop a skilled workforce, for a variety of health service professionals including GPs.
• This paper describes a methodology of costing nurse practitioners that incorporates the human capital cost implications of developing a skilled nurse practitioner workforce. With appropriate sources of data the method could be adapted for use internationally.
• Including the full cost of qualifications results in nearly a 24 per cent increase in the unit cost of a Nurse Practitioner.
• Allowing for all investment costs and adjusting for length of consultation, the cost of a GP consultation was nearly 60 per cent higher than that of a Nurse Practitioner.
/17 Better Care Fund, Policy Framework
- Department
- Health
The cost-benefit to the NHS arising from preventative housing interventions
- H Garrett
- M Roys
- S Burris
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