I’d prefer to stay at home

A recent study by the Irish Association of Social Workers and others, entitled “I’d prefer to stay at home” has found that the strong preference of older people is to remain living at home for as long as possible, receiving care when it is needed.

The collaborative research project was undertaken by the Irish Association of Social Workers (IASW), Age Action, the Alzheimer Society of Ireland (ASI) and the School of Social Policy, Social Work and Social Justice, University College Dublin. The research gathered information on the experiences and views of social workers working across the country with older people, including people living with dementia.  The purpose of the study was to investigate how the health and social care system is responding to the care needs, required supports and preferences of older people.

The findings of the study echo previous Irish research studies, which show the preferences of older people are to remain living at home for as long as possible, receiving care when it is needed in this setting. Despite this, one of the striking findings was the lack of consistency across geographic areas and professional disciplines in both the provision of services and in how older people are involved in decision-making about their care.  A difficulty, due to the reliance of the Irish system on family members to provide care, is balancing the older person’s preferences and those of family carers.

Entitlement and Accessibility

Lack of transparency existed in relation to older people’s entitlement to services with differing practices highlighted across HSE areas. For example, in some areas older people had to be in receipt of a medical card in order to access formal community-based support services while in other areas they did not. Findings also showed that there are large disparities between services that are available in different areas. In general, demand far outstrips what is available and participants reported discrepancies between the number of hours an older person had been assessed as needing, the level of home care hours requested, and the number of hours of home care which were actually approved. This situation regularly meant that older people did not receive the level of service that their care needs’ assessment indicated. An unfortunate consequence of this was unnecessary or premature admission to long-term residential care.

In the past, previous studies have highlighted the need for home and community care services to be established on an equitable basis underpinned by legislation and appropriate funding and also highlighted the lack of eligibility criteria for service that was underpinned by legislation.

Findings showed that there was no formal or standardised prioritisation process in place. At times, individuals were prioritised based on their age, whether they lived alone, their perceived Vulnerability and whether they were assessed as a hospital delayed discharge. Different approaches operated in an informal way in each area.  In some areas dementia was a ‘red flag’ for prioritisation, resulting in ‘people with dementia getting services more quickly’.  However, this was not the case in every area, and many participants reported that there were no exceptions for people with dementia.

One of the most common themes to emerge from the qualitative data was that our health and social care system is focused largely on physical care needs. In all areas, priority in the allocation of services was given to older people with personal physical care requirements while older people with social needs, related to loneliness, for example, were reported to be ‘lower down the list’.

This theme was also identified in how the older person’s care needs was determined. For example ‘where family are available, people are less likely to get a service’ especially: “If there is an adult child living in the house the expectation would be that they should provide care.

Provision of Home Care Services

The survey shows that nearly 30% of social work cases in acute hospitals in June 2015 were medically ready for discharge but were awaiting supports to be put in place. As illustrated in Figure 4, delays in discharge were most (48% of cases) likely to be due to inability to access home supports rather than LTC.

For older people in hospital and at home, accessing timely home care in the community was found to be more difficult than accessing long-term residential care. Waiting times for home care package approval/ implementation varied from one month to six months, with applications made through hospitals receiving quicker responses. The area in which a client lived was also a differentiating factor. For other supports, like home help, an older person living in the community could wait up to a year for the service.

Medical social workers indicated that of the total number of older people receiving home care,  a high percentage (40%) did not receive the number of hours they had been assessed as needing.  The allocation of HCP hours to an area was not based on demographics, but set budgets.  Therefore, in areas with a high proportion of older people, hours are ‘spread more thinly’. Demand for HCP hours frequently outstrips supply, with over half of the participants reporting a difference between the HCP hours the older person was assessed as needing, the amount applied for and the hours granted.

The report makes a number of recommendations related to the provision of budgets, the standardisation of needs assessments and the provision of services, as well as making available a full compliment of health and social care professionals.

The full report can be downloaded here.

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