Purchase of care home beds \200\224 often with multidisciplinary or social worker input of ten for step-down of patients awaiting social care provision or care home placement Intermediate care can occur in different environments, eg: \200 Nursing outside the acute care setting in traditional community/cottage hospitals, nursing homes, or even residential homes Patient \200\231s own home \200 DH or other therapy-based sites INTERMEDIATE CARE 27 Interventions in intermediate care are often based around a comprehensive geriatric assessm ent (see b \200\230Comprehensive geriatric assessment \200\231, p.70) by a multidisciplina ry team. However, more specialized services can be pro- vided by individuals or teams that are missing some vital members (particu- larly medical or social work) and care is needed t hat important interventions (such as treatable illnesses or unclaimed bene \201 ts) are no t overlooked. The variety of different models makes it very hard to promote equity of access or research into the effectiveness and cost-effectiveness of the service. While it has been shown possi ble to provide almost all kinds of geriatric care in a community setting this does not nece ssarily mean that it is more effective, cost-ef \201 cient, or even preferable for patient , family, and staff. Research designed to answer these questions is sparse and contradictor y. Single assessment process This term was introduced in the NSF for older people. The idea is a simple one \200\224 \200\230multidisciplinary, interagency assessment of needs ensurin g that the elderly receive the relevant services, in an integrated way \200\231. The main a im was to avoid professionals duplicating their assessments, eg when a patient moves betwee n hospital and community settings. The initial milestone for introducing single assessment process (SAP) was April 2004. Unfortunately the assessment systems at the heart of health and social security proved much more resistant to change than was anticipated. Geographical variations in systems, distrus t between different agencies, as well as antiquated technology, has meant that the SAP curr ently exists only as multiple pilot schemes throughout the UK. Further reading Steinher A . ( 2001 ). Intermediate care \200\224 a good thing ? Age and A geing 30 \200\223 S3 : 33 \200\223 39 . Young JB , Robinson M , Chell S , et al . ( 2005 ). A whole system study of Intermediate care services for older people . Age and Ageing 34 : 577 \200\223 583 . 28 CHAPTER 2 Organizing geriatric services The National Service Framework for Older People This huge document (over 200 pages) was pub lished by the Department of Health in March 2001. It was one of the \201 rst NSFs to be p roduced and set out the government \200\231s agenda to improve health and social services f or the elderly with milestones (ie deadlines for service changes) stretching over the follo wing 4 years. There are eight standards. 1 Rooting out age discrimination \200\230NHS services will be provided, regardless of age, on the basis of clinical need alone. Social care services will not use age in their eligib ility criteria or policies that restrict access to available services. \200\231 This key standard was widely welcomed and has proved useful in audits with the aim of remov ing explicit (written policy) ageism in, eg, access to diagnostic services or treatments. I mplicit ageism is harder to tackle. 2 Person-centered care \200\230NHS and social services treat older people as individuals a nd enable them to make choices about their own care. \200\231 This incorporated the introduction of the Single Assessment Process as well as some ideas a bout shared commissioning of care and equipment between different government agencies. Many of the goal \200\231s planned reforms in this standard have had, at best, patchy implement ation. 3 Intermediate care \200\230Older people will have access to a new range of intermediate c are services at home or in designated care settings to promote their independence pre vent unnecessary hospital admission and effective rehabilitation services to enable early d ischarge and prevent premature or unnecessary admission to long-term residential care . \200\231 This standard was accompanied by earmarked funding to develop services and run 5000 new int ermediate care beds. It was the most controversial of the standards with many geriatricians arguing that the result of such services would be reduced access to acute hospital care \200\224 indeed one target relates to a reduction in the rate of rise of older persons \200 \231 admissions. 4 General hospital care \200\230 appropriate specialist care by hospital staff who h ave the right set of skills to meet their needs. \200\231 All hospitals should have a specialist multidisciplinary team for older people with appropriate training. 5 Stroke \200\230 action to prevent strokes access to diagnostic services and treated appropriately by a specialist stroke service program of secondary prevention and rehabilitation. \200\231 This standard has helped drive the development of stroke units (required in all hospitals b y 2004 although not fully achieved) and TIA clinics. THE NATIONAL SERVICE FRAMEWORK FOR OLDER PEOPLE 29 6 Falls \200\230 action to prevent falls and reduce resultant fractures or other inj uries. Older people who have fallen receive effective treatment and advice on prevent ion through a specialist falls service. \200\231 The development of falls services has lagged well behind the suggested timeframe. 7 Mental health in older people \200\230 access to integrated mental health services To ensure effective diag- nosis, treatment and support \200\231 Promotes integrated depression and dementia services. 8 The promotion of health and active life in older age \200\230 through a co-ordinat ed program of action led by the NHS with support from councils. \200\231 Targets related to \202 u vaccination, smoking cessation and blood pressure treatment etc are largely implemented in general practice where they are reinforced by the new GP contra ct (Box 2.2 ). Medicines and older people An additional document on medicine and older people stated that older people should: \200\230 gain the maximum bene \201 t from medication and not suffer unnecess arily from illness caused by excessive, inappropriate or inadequate consumption of medicine s. \200\231 It included a drugstore-led \200\230medicines review \200\231 for at-risk elderly people. As with many other NSFs, translating policy into change has been only partially successful but there is no doubt that the older people \200\231s health and social services today have been in \202 uenced by this important document. None of the other NSFs exclusively address the health of older people but more recent docum ents, eg the NSF for long-term conditions (2005), the NSF for chronic obstructive pulmonary disease (COPD) (2009), have much of relevance to older people. There have been a series of UK government regulation and inspection bodies which use NSFs and other legal and quality standards as guides: \200 Commission fo r Health Improvement (CHI): 2001 \200\2232004 \200 Commission for Health Care Audit and I nspection (CHAI): 2004 \200\2232009 \200 Care Quality Commission: 2009 to date Further reading National Service Framework online : M www.dh.gov.uk . Evans JG , Tallis , R C . ( 2001 ). A new beginning for care for elderly people? \200\224 and related correspondence . BMJ 322 : 807 \200\223 808 . Healthcare Commission online : M www.healthcarecommission.org.uk . 30 CHAPTER 2 Organizing geriatric services Community hospitals Community hospitals (CHs) vary in size, clinical focus, and facilities. In some areas, they represent a substantial inpatient resource, with older patients predom inating both as inpatients and outpatients. Their origins were commonly either as small \200\230cottage \200\231 hospitals or workhouses, pro- viding very limited services from da ted buildings. They are now undergoing substantial change and reinvention as a less central ized focus of non-acute, in- and outpatient, medical and rehabilitation services. Prompts t o recent change have included the GP contract (2004), the NSF (2001) (eg for falls services ) and additional funding for intermediate care. Locality-based serv- ices are also promoted as part of the NHS Plan (2001). Often there is substantial community support, both emotional and tangible (volunteers, gift s), for local hospitals. This makes service changes politically sensitive, slow, and dif \201 cult. In some cases, CH facilities are in desperate need of recon \201 guration to re \202 ect current service priorities. Facilities may include: Inpatient beds for between 10 and 60 patients \200 Physiotherapy and OT services (in- and outpatient) \200 DH \200 Of \201 ce/professional base for community-based care, rehab ilitation, and social services Outpatient medical facilities \200\224 easier access for frail elderly \200 Psychogeriat ric services, outpatient and/or inpatient \200 Local health (eg primary care trust (PCT)) management base \200 GP out-of-hours service base \200 Minor injuries unit \200\224 o ften staffed by nurse specialists \200 Maternity services \200\224 midwife of \201 ce b ase maternity beds \200 Often a GP practice is based on site or close by, with mutual bene \201 ts \200 Limited diagnostic testing, eg blood tests, plain radiography. More co mplex tests, eg CT and ultrasound, usually require transportation to another hospital Medical cover is usually by GPs. In \200\230cottage hospitals \200\231 they admit patients on their own practice list. In other \200\230community \200\231 hospitals a GP may be emp loyed as a clinical assistant. In some hospitals both patterns co-exist. Visits should be b oth regular \200\224 identifying potential problems and planning prospectively \200\224 a nd responsive to acute problems identi \201 ed by nursing staff. Specialist medical input may be available, including a visiting community geriatrician and psychogeriatrician. Other specialists, eg surgeons may hold outpatient clinics on site. Nurses and therapists are often very experienced in the care of older people, and are able and willing to work more independently from doctors. Nursing staff often lead the discharge planning process including multidisciplinary team (MDT) meetings. Staff turnover is often low, with a high proportion of committed, long-term staff. COMMUNITY HOSPITALS 31 Community hospitals admissions Groups of patients being admitted include the following: Rehabilitation and discharge planning Often transferred from acute hospitals following surg ery (elective or emergency) or acute medical problems. Timing of transfer must be appro- pr iate \200\224 is the patient medically stable, have relevant investigations been completed ? Palliative care Where the nature of illness is clear, and cure is not possible, CHs can pro vide high-quality nursing care and symptom control when things can no longer be managed in the patient s home. Preferable to admission to acute hospitals. Hospice beds are often very limited, and hospice care focuses on patients in whom symptom control is especially dif \201 cult. Respite care Usually now performed out of hospital, in care homes. Some especially complex, or emergency/unplanned respite care may occur. Acute illness or functional decline \200 In general, this should be discouraged because i llness in older people is often occult and atypical. Diagnosis is easier and more precise i n an acute general hospital with easy access to investigations and specialist opinions. Aft er accurate diagnosis and completion of invasive (eg intravenous) treatments, transfer to a CH becomes appropriate \200 Admission to CH may be justi \201 ed in cases of strong inf ormed patient opinion, where the diagnosis is clear, where invasive treatments and advanced monitoring are highly unlikely to be required, or when logistics dictate (eg very long dis tances) Admission may also be appropriate after specialist assessment in a Rapid Access Clinic or at a domiciliary visit \200\230Social \200\231 admissions Where staff perceive that the precipitant to admission has been a change in social supports (eg death or illness of a carer), not the condition of the patient. Beware occult acute illness on admission, or later \200\224 these patients a re often very frail. High death rates in such admissions have been reported. Effectiveness/cost effectiveness As with other forms of intermediate care, there is little evidence that CHs provide improved outcomes or cheaper care than alternative systems. 32 CHAPTER 2 Organizing geriatric services Domiciliary (home) visits A medical assessment in the home, usually by an experienced geria trician. This involves visiting the home of the ill person, sometimes alone, but perhaps wi th a GP or carer. On occasion, a therapist or care manager may also attend. Distinguish thi s \200\230medical \200\231 home visit from the home assess- ment visit performed by an OT to determine functional capacity and the needs for aids/adaptations prior to discharge from hospital. Historically, domiciliary visits (DVs) were widely used to prioritize patients on the waiti ng list for admission to hospital, but with the disappearance of such lists for acute medic al problems this is now rarely done. There are advantages and disadvantages to medical assessments in the home. The disadvantage s, and an appreciation of how much elderly people bene \201 t from selective use of modern , acute hospital facilities have led to a substantial reduction in the number of visits per formed. In many areas, they now serve a function predominantly in those who refuse to atten d hospital and who appear seriously or terminally ill. They have also been used by some as a method of routine, post-discharge follow-up. Although expensive, the latter may be effect ive, and overlaps with emerging systems of chronic disease management. They may also be use d to assess suitability for admission to non-acute settings, eg CHs. Disadvantages \200 Lack of equipment and other hospital facilities, eg diagnostic \200 Lack of nursing support (chaperone, lifting/handling during clinical examination) An inability to perform other than very basic tests \200 An inef \201 cient use of time \200\224 as well as traveling time, patients and family often expect longer discussions and they effectively control the duration of the con sultation Advantages \200 Provision of a second opinion for the primary care team, which may be str uggling to diagnose or treat, or need reassurance that it is doing all that is possible Function may be rapidly and effectively assessed, eg is there evidence of incontinence, is the larder stocked, is the dwelling acceptably clean, what degree of mobility is achieved ( through, eg \200\230furniture walking \200\231). Are there appropriate aids and adaptation s? Assessment of mental state may be more accurate in the patient s home (confusion worsened in hospital setting) Assessment of drug compliance (see b \200\230HOW TO Improve concordance \200\231, p.132) Patients appear more frail and vulnerable in a hospital setting \200 No travel for the pa tient \200 Some patients adamantly refuse assessment in hospital. The experience of the visit itself may persuade a reluctant patient to be admitted DOMICILIARY (HOME) VISITS 33 HOW TO Do a domiciliary visit When? \200 Combine with other trips if possible \200 Not too early or late in the day ( patient may rise late and settle early) Will you and your property be safe? \200 Danger from patient, relatives/carers, neighbors ? \200 Tell someone where you are going, and when you should be back What do you need to know before you go? \200 Name, address, directions (especially in rural areas) \200 Do you have a referral letter? \200 Review and take any previous medical notes \200 Can th e patient \200\231s family or carer attend? (One or two is useful \200\224 discourage excessive numbers of family members) Will the patient be in? Telephone them in advance and consider ringing again just before you are about to set off What to take? \200 Blood pressure (BP) cuff, stethoscope, tendon hammer, auroscope, ophth almoscope, \200\230PR tray \200\231 (jelly, gloves, wipes), urinalysis sticks \200 Scori ng charts (abbreviated mental test score (AMTS), Mini Mental State Examination (MMSE), Bart hel, Geriatric Depression Scale (GDS)) Paper and pen, dictation machine and cassette What will you do? \200 History, examination \200 Functional assessment \200 Environmental inspection \200 Medication (check the drug cabinet or top drawer for over-the-counter and prescription drugs) Accepting a cup of tea will inform in several areas \200 Discuss your \201 ndings and p lan with patient and family What to do afterwards \200 Telephone or fax GP to report \201 ndings and discuss plans \200 Dictate letter, copy to GP and hospital notes \200 C laim fee if applicable 34 CHAPTER 2 Organizing geriatric services Care homes This area of geriatric care is evolving rapidly with changes driven by \200 Ex pansion of elderly population \200 Reduced availability of informal carers (eg working wo men, smaller families living further apart) Closure of many council-owned homes (previously known as Part III homes) Closure of many privately owned homes (uneconomic at levels of current state funding, especially in view of recent legislation) Care home legislation \200 Shortage of staff \200\224 both nurses and untrained carers U ntil recently there was a clear division between residential homes (providing hotel-style s ervices and some basic personal care such as help washing/dressing to mobile patients) and nursing homes (providing full nursing to very dependent, often bed-bound patients). This di stinction was always arbitrary and as patients \200\231 care needs \202 uctuated or stead ily increased with time, they found themselves inappropriately housed. There is now a move towards establishments under the wider term \200\230care homes \200\231, which provide ser vices for the full range of dependencies. Staf \201 ng Most of the care provided in care homes is by unskilled staff (or those with basic NVQ training), who nonetheless may have extensive experi- ence. The quality of care i s a key issue for clients and their relative in selecting a home but it is very variable an d dif \201 cult to judge from the outside. In homes providing nursing care there has to be a trained nurse available on site at all times. Care home medicine Medical care is usually provided by one or more GPs from a local practic e (clients are rarely able to keep their own GP). Some community geriatricians routinely vi sit care homes in their area to provide support and education. Attention should be paid to try to minimize sedative medication, maximize preventive interventions (eg \200\230 \202 u jabs, osteoporosis prophylaxis) and where possible to involve patients in advance care pl anning (eg decisions about future hospitalization, living wills). Care homes for patients with dementia Elderly mentally in \201 rm (EMI) homes are register ed to take patients with signi \201 cant dementia who may have behavior problems such as a ggres- sion, anti-social behavior or wandering. These homes are in particularly short suppl y. Eligibility for such homes may need to be determined by a psychogeriatrician. They have specially trained staff and often have secure entrances. Some ordinary homes are not regist ered to take patients with a diagnosis of dementia and decline to do so although many patie nts in ordinary homes will have a degree of cognitive impairment. CARE HOMES 35 HOW TO Advise a patient about residential care This task is of grave importance; ther e are implications for the patient \200\231s independence, quality of life and \201 nance s and it tends to be a one-way move. Ensure that the patient has had a full assessment (ide ally a spe- cialized, geriatric, multidisciplinary one (see b \200\230Comprehensive geri- atric assessment \200\231, p.70) at a point of maximized health and functioning (ie not dur ing an intercurrent illness or emergency). It is unwise to make recommendations based on on ly your own impression or those of the family \200\224 an OT or social worker can be very helpful. Ensure that the patient has had an adequate trial of rehabilitation. Consider the prog- nosis of underlying conditions \200\224 you would be more likely to recom- mend resi dential care with deteriorating health. Some patients (often with normal cognition, living alone) may choose to go into care and ar e grateful for help with arrangements. They often describe loneliness/isolation or fear. If they are functionally independent ensure that sheltered housing or day center attendance h ave been considered \200\224 the majority of care home residents are cognitively impaired clients who may not provide the company they seek. Most patients do not want to go into car e because of: \200 Negative \200\230workhouse \200\231 preconceptions of what care homes are like \200 Emotional attachment to their spouses, homes, pets, neighbors \200 A fea r of loss of independence and dignity \200 Anxiety over costs and loss of inheritance for family \200 Stigmatization and perception that they have failed Patients with dementia m ay lack insight into their care needs (see b \200\230HOW TO Manage a patient insisti ng on returning home against advice \200\231, p.663). Many of the principles of breaking ba d news apply, eg \200\230warning shots \200\231 will prepare the patient. Explain what fac tors make it advisable to consider residential care and why other options are not feasible \200\224 use factual examples (eg you need help during the night and we cannot provide thi s at home). Clarify the contribution that other professionals have made to this assessment. The following positive points can be persuasive: \200 By actively choosing a care home t hey are more likely to get one they like. Leaving it until an emergency may remove any choi ce \200 Placements are often on a trial basis initially with review at a month \200 Emp hasize the positive \200\224 company, hot meals, less anxiety for family \200 Where plac ement is from home and is not urgent then a trial stay/ respite period of a week or two can sometimes be arranged \200 Reassure there will be hel p with \201 nancial/logistical arrangements \200 Some care homes allow well-behaved pet s A privately owned house does not always have to be sold, eg if a family member continues to live there Further reading Challis D , Clarkson P , Williamson J , et al . ( 2004 ). The value of spec ialist clinical assessment of older people prior to entry to care homes . Age and Ageing 33 : 25 \200\223 34 . 36 CHAPTER 2 Organizing geriatric services Funding of care homes Funding \200 The cost of residential care in 2011 ranges from aroun d 400 to 1100 a week depending on client dependency, local costs (eg house prices, staf f availability) and the quality and variety of facilities provided \200 While in Scotland the state pays for all nursing and personal care, in England and Wales fees are means-test ed and calculated on a sliding scale. In 2011 people with savings of more than 23,500 (in cluding the value of their home) have to pay the full cost Regardless of income, a small sum for certain kinds of nursing care is provided by the state. Patients needing nursing care have an assessment carried out by spec ially trained nurses in order to be categorized into one of three bands which entitle then to some state funding (the Registered Nursing Care Contribution \200\224 RNCC) Funding issues are addressed by a care manager (usually a social worker, see b \200\230Soc ial work and care management \200\231, p.98) using a complex questionnaire To complicate this system further a small number of highly dependent patients (who would pr eviously have been provided for in long-stay NHS wards) are eligible for NHS continuing car e . Examples of such patients include those who require terminal care and those with ongoin g complex medical or psychiatric needs who require frequent specialist medical or nursing i ntervention. Patients eligible for continuing care have 100 % of their funding provided by the state regardless of their own \201 nancial status. The provision of continuing care h as been very inconsistent between health authorities and the health service ombudsman has a dmitted that tens of thousands of residents have been denied the free care they are entitle d to. The assessment systems are still regionally developed and administered. A review of f unding is planned by the current (2011) UK government (see M www.direct.gov.uk for updates) . The national care home standards ( M www.dh.gov.uk ) These were published following the C are Standards Act in 2000 and de \201 ne minimum standards. There is guidance about all as pects of care, eg care planning, documentation and complaints procedures as well as spe- ci \201 c requirements about facilities (eg all doors 80cm wide, ratio 1 assisted bath/8 res idents) and minimum staf \201 ng ratios. While these regulations have improved some facili ties they have also forced many smaller homes out of business. DELAYED DISCHARGE 37 Delayed discharge While some patients are admitted directly from their home to a care home in a planned move, the majority are admitted following an acute illness. This often occurs via a hospital setting, eg a patient who has a stroke and does not regain suf \201 cient f unction to return home after reha- bilitation. Where patients are held in National Health S ervice (NHS) hos- pitals after they no longer require hospital treatment while awaiting car e home beds they are sometimes called \200\230bed blockers \200\231. Whilst most geri- atr icians dislike this stigmatizing term (delayed discharge is better) there is no doubt that such patients cost the NHS millions of pounds a year and reduce the availability of hospita l beds for patients that would bene \201 t more. Delays in placement are due to one or mor e of the following: \200 Shortage in care home places, especially for EMI homes. Availabi lity varies according to region but stems from \201 nancial and staf \201 ng shortfall Overworked social workers may prioritize urgent cases from the community over hospital cases (who are perceived as being in a \200\230place of safety \200\231), which can lead to delays in assessment and processing \200 Social services tha t are short of cash may \200\230ration \200\231 the number of new care home places they fu nd to try to limit costs. Some NHS trusts charge social services for such delayed discharge s \200\224 this system (called reimbursement or cross-charging) was designed to improve di scharge rates but creates more paperwork and has had a patchy impact Patients/relatives may oppose discharge because they are unwilling to accept that there is no further capacity to recover and return home \200 Patients/relatives may be reluctant t o move from free NHS care to means-tested care because of \201 nancial implications Role of doctors caring for delayed discharge patients \200 Ensure that it is clear to eve ryone (including the patient and relatives) that the patient is no longer requiring acute h ospital care. Record \200\230medically \201 t for discharge \200\231 in the notes and do cument follow-up arrangements for outstanding problems Continue medical monitoring \200\224 Switch to \200\230care home medicine \200\231 priorities but remember that these frail patients are prone to new or recurrent illnesses a nd are at risk from hospital-acquired infections \200 Actively drive discharge \200\224 communication is key, eg case conferences and MDT meetings Consider interim options \200\224 the patient may be able to wait in an intermediate care facility such as community hospital or \200\230transitional \200\231 bed in a private care home arranged by social services 38 CHAPTER 2 Organizing geriatric services Home care In most countries the majority of people needing personal care remain at home rat her than moving into an institution (eg care home). Their needs are provided by (a) carer(s ) who may be a spouse or other family member, informal carers or professional carers (self- employed, or employed by a private care agency or public body). In the UK, the care needs o f a patient are usually speci \201 ed by a care manager (social services) and then deliv- ered by private and/or state care agencies. Community care assessment ( \200\230needs assessment \200\231) This is the process whereby a care manager determines the needs of a dis- abled person and how they can be met. Assessi ng need requires informa- tion from the patient and others, often including relatives, OT, physio, and nurse. Meeting those needs requires agreement between care manager and client ( patient, or next-of-kin/legal representative if the client is not competent) after consider ing the options, \201 nances etc. Delivery of care \200 The bulk of care is delivered by care assistants, who should have b asic training in delivering personal care, and lifting/handling In speci \201 c cases they may be trained further to deliver care that is usually the doma in of the district nursing team, eg bowel care The work is poorly paid (at or close to the minimum wage), but may be very satisfying. Long term friendships may develop, with a commitment to patient welfare that goes beyond the st rict con \201 nes of a contract \200 Carers perform important supervision of patients, a nd are often the \201 rst to note the possibility of illness Continuity of care is an important contributor to quality, and is highly desirable, but not always achievable. There is a risk of physical, emotional, or \201 nancial abuse by care rs (see b \200\230Elder abuse \200\231, p.674), although such cases are uncommon. In the UK, there is a national shortage of carers, worse in some geographical areas. This c an delay discharge or at worst prevent it. It also renders existing care packages vulnerabl e to unexpected carer absence, eg due to sickness. Care packages provided by combinations o f care agencies may therefore be more stable than those provided by only one. Tasks routinely performed by carers \200 Washing, bathing, dressing \200 Safe moving an d handling including hoists \200 Feeding, meal preparation, and housework \200 Supervis ion of self-medication from dosette box \200 Emptying of urinary catheter, \201 tting o f penile sheath catheter \200 Bowel care if trained Tasks not usually performed by carers \200 Dressings \200 Administration of medications from individual containers \200 In sulin injections \200 Percutaneous endoscopic gastrostomy (PEG) feeding HOME CARE 39 Home care costs \200 In the UK, state support for care fees is \200\230means tested \200 \231 \200\224 a \201 nancial assessment is performed by the care manager. Criteria vary locally, but in general only tho se with no signi \201 cant savings have the costs of care met by the state Purchasing personal care is expensive. In the UK care costs about 20 per hour. A care pac kage consisting of 2hr daily would therefore cost around 300 per week \200\224 less expe nsive than a care home, but still a major \201 nancial burden for those who meet the fees themselves Structuring the care package \200 Tailor to the individual . A package usually consists o f between one and four visits per day, by one or two carers. A common pattern is for two vi sits daily, one early (wash, dress, toilet, food preparation) and one late (evening meal, r eady for bed). Lunch may consist of a pre-prepared meal, frozen and simply reheated by the patient, removing the need for a midday visit. Two carers are needed for \200\230double-ha nded care \200\231, eg turning or transferring a dependent patient Night-time visits are rarely needed, and dif \201 cult to provide reliably. Roles may incl ude toileting, pressure care (turns) or administering medication, but there may be other so lutions (eg other continence management, changing medication regimens) Continuous ( \200\23024hr \200\231) care is sometimes requested by patients or family, but close to impossible to provide \200\224 suf \201 cient staff are dif \201 cult to \201 nd, and the care would be extremely expensive; a move into a care home would usually be ch eaper. Therefore these packages are usually privately funded. Live-in carers are sometimes employed long-term, but cannot be on hand the whole 24hr, need holidays, and may go sick un predictably Access to the home by carers can be dif \201 cult if the patient is immobile and cannot get to the door. Combination locks or a key safe (conventional key locked within small combination \200\224 or key-accessed safe) provide a secure solution Equipment may be necessary before a patient can be discharged and a care package initiated, eg, hoist, bed, chair, cushion. OTs usually assess need and provide Commonly reported problems with care packages \200 Timing \200\224 unpredictable, or too early or late (eg 6pm visit to prepare for bed) Carers \200\224 variable quality, lack of continuity \200 Cost \200\224 often a signi \201 cant issue. Costs discourage some patients from taking an adequate (or any) care packa ge, and may result in it being stopped after a period Visits \200\224 may be brief; carer and patient feels rushed The Care Quality Commission ( M www.cqc.org.uk ) inspects and deals with complaints about social care providers. Nationa l Minimum Standards must be met if a care agency is to gain and retain a license. 40 CHAPTER 2 Organizing geriatric services Informal carers This term describes anyone who provides regular and substantive care to a p erson on a non-professional basis, usually without \201 nancial reward. This is often a f amily member, but may also be a friend or neighbor. \200 1 in 10 adults in the UK will pr ovide informal care to another person \200 A total of 6 million people acted as carers in 2003, and this is projected to rise to 9 million by 2037 Carers main bene \201 t is worth (in 2004) 44 per week, for an average of 35hr caring \200\224 just 1.26/hr \200\224 saving the economy 57 billion per year 12 % of the > 65s act as a carer, a third for > 50hr a week \200 The health of carers the mselves is poor \200\224 44 % have poor health, compared with 30 % of non-carers. The more demanding the caregiver role, the more likely th e carer is to experience ill health This vital group of individuals maintain many elderly patients in the com- munity and are t he backbone of the care system. For many, having an informal carer is the only way of stayi ng at home. A patient with cogni- tive problems (especially if mobile) may require constant supervision to ensure safety \200\224 a level of care that can only be provided by an inf ormal live-in carer (often a spouse). This level of care will often exceed that which can b e provided in a care home, leading to dissatisfaction when patients are temporarily or perm anently admitted to institutional care. The importance of this group is recognized in the government \200\231s national strategy Ca ring about Carers (2009), which aims to improve information and support to carers and impro ve the care they themselves receive. This includes the right of a carer to a \200\230carer \200\231s assessment \200\231, carried out by social services, which addresses the followi ng points: \200 Is the carer getting enough sleep? \200 Is the carer in good health? \200 Does the carer have time for themselves? \200 Are relationships adversely affected by the care giving? \200 Are there concerns about work? \200 Is the carer collecting al l available bene \201 ts? \200 Is all available help being provided (services include em otional support, help with household and caring tasks, accessing bene \201 ts and local activities, arrangi ng respite care \200\224 see Box 2.1 ) Support for carers is essential \200\224 caring can be relentless, unrewarding and often d epressing. Elder abuse is a rare but possible consequence of this highly stressful situatio n (see b \200\230Elder abuse \200\231, p.674). As well as government resources, a number o f charity and self-help organizations also provide support and practical help. Carers UK: M www.carersuk.org Princess Royal Trust for Carers: M www.carers.org Crossroads: M www.cross roads.org.uk INFORMAL CARERS 41 Box 2.1 Respite care Acting as a carer can be exhausting (both physically and mentally) for the carer and often the patient who may \201 nd accepting so much help from a loved one dif \201 cult. Part of any successful care \200\230package \200\231 is sustain- ability, which includes ensuri ng that everyone has a break from time to time. Some of the charities listed in the text (e g Crossroads) will offer a carer support worker to take over the caring role for a few hour s at a time, but a longer break may well be needed. In such situations, respite care in a residential establishment may provide the solution. M any care homes, particularly those in the independent sector are able to provide extremely \202 exible respite care packages. These can range from a 2-week visit (eg to cover a hol iday), to day care or even an overnight stay. A regular arrangement can be made, where, eg, 1 week on every eight is spent in residential care. Most local authorities operate a discretionary policy in terms of paying for respite care i n care homes, and may fund several weeks a year of respite to help sustain a care arrangeme nt. This is means tested. NHS respite is rare these days, but does still exist. Patients with psychiatric needs will often have respite on psychogeriatric wards. Long-standing arrangements on community hospit al wards and long-stay wards (becoming increasingly rare) may persist. Terminal care patien ts will often be offered respite care in hospices or community hospital wards. These servic es are free to the patient. 42 CHAPTER 2 Organizing geriatric services Other services Day centers \200 Traditionally run by health and social services but now i ncreasingly run by voluntary organizations (eg British Red Cross, Age Concern) \200 Accessed via social s ervices, (who assess need) or by self-referral \200 Offer regular visits (eg once or twic e a week) with transportation if needed \200 There is a charge that varies with requireme nts (eg transportation, meals) \200 Vary enormously, but may include: Catering (eg coffee, tea and lunch) \200 Social support network \200 Personal care (eg bathing facilities, hairdressing etc.) \200 Respite for carers \200 Skills development (arts and crafts, adult learning classes) \200 Access to services (eg podiatry, district nurse) \200 Leisure activities (eg quizzes, reminiscence, music, gardening, keep \201 t, trips out) Enables monitoring of progressive conditions (eg dementia) and early referral for extra support to prevent crisis Rehabilitation and independent living skills (may occasionally have OT, physiotherapy and s peech and language therapy (or therapist) (SALT) input)