DAVID CHALLIS, ROBIN DARTON, LYNNE JOHNSON, MALCOLM STONE, KAREN TRASKE
Summary This paper provides the main findings of an evaluation of a service to provide alternative care at home for patients receiving long-stay hospital care. Elderly people receiving the service were compared with a group of similar patients in an adjacent health district. The paper presents data on length of time at home and in hospital, changes in quality of life and care of elderly people, and effects upon informal carers for the two groups. Elderly people receiving community-based care had a higher quality of life, and there was no evidence of greater stress upon their carers. The community-based service, although it involved extra costs to the social services department, had lower costs for the health service and society as a whole than long-stay hospital provision. It is concluded that the model of care can effectively integrate the new approach of case management into an existing geriatric multidisciplinary team.
The Darlington Project, described in an earlier paper [1], was designed to provide alternative care at home for frail elderly patients in longstay hospital care. The service was based upon multi-purpose carers deployed by case managers. A fuller description of the Darlington Project is presented in Challis et al. [2]. Here we present key findings from the evaluation.
Method The study compared individual cases receiving services from the project with a group of similar patients identified in long-stay wards of an adjacent health district, which was seen as providing a reasonably similar style of geriatric service [3]. This 'quasiexperimental' approach [4] was used in place of random allocation, since the funding for the service was earmarked for long-stay patients in a specific
hospital. Because of these funding arrangements and the associated objective of closing wards, the evaluation was focused upon a particular service model as part of a local system of care. Thus, although the unit of analysis was the individual patient, to allocate patients randomly within the single service would neither have been acceptable nor practicable and would have risked contamination effects. This approach has been employed in other studies of alternatives to institutional care in the United Kingdom [5, 6]. The advantages and disadvantages of different experimental designs for the evaluation of services are discussed in more detail elsewhere [7]. Both groups of elderly people were seen in hospital and followed up after 6 months. Their informal carers were also interviewed, focusing on the experience of care and degree of burden. Since the Darlington Project was principally concerned with improving the experience and environment of elderly people requiring long-term care by providing a community-based alternative to hospital care, the Age and Ageing 1991 ;20:245-254
Downloaded from http://ageing.oxfordjournals.org/ at University of California, San Diego on December 29, 2014
An Evaluation of an Alternative to Long-stay Hospital Care for Frail Elderly Patients: II Costs and Effectiveness
D. CHALLIS ET AL.
246
Results Characteristics of clients receiving the service:
During the pilot project phase, 101 elderly clients were discharged to the project, 36 of whom were men and 65 women. Table I
provides a summary of the characteristics of the elderly people who received community care, using the Behaviour Rating Scale from the Clifton Assessment Procedures for the Elderly (CAPE BRS) [10]. The profile indicates that the Darlington clients were similar to patients on an acute medical ward. This is not surprising since, although the clients selected for the Darlington Project came from among patients who were identified as requiring long-stay care, many were on the acute geriatric wards, often awaiting transfer. Only 26 of the 101 clients were on long-stay wards prior to discharge. A change in the availability of additional housing between the planning and implementation stages of the project tended to focus the project upon those who still retained accommodation, since these were the people who could be most readily discharged. Patients sometimes retain their accommodation two and three years after admission [11], and it has been suggested that the definition of long-stay should be based on social and medical state rather than time spent in hospital, or ward of origin [12]. Thus the project developed more closely as an alternative to hospital care for patients recently admitted from home than had been initially envisaged. Table I also compares the Darlington group with the 113 cases in the control group, and it can be seen that the two were very similar, except on the social disturbance variable, on
Table I. Mean CAPE BRS subscale and total scores for all individuals who have received project service and for control patients Subscale Communication Physical Social disability Apathy difficulties disturbance
BRS total
No. of cases
0.8 0.9 0.8*
14.8 13.7 14.1
36 65 101
1.3 1.7
14.1 14.2 14.2
40 73 113
Project clients Men
6.5
Women 6.1 Both 6.3 Control patients Men
Women Both
5.9 5.9 5.9
7.1 6.4 6.6
0.6 0.4
6.5 6.3 6.4
0.5 0.3 0.4
0.5
* Analysis of variance: p
Summary This paper provides the main findings of an evaluation of a service to provide alternative care at home for patients receiving long-stay hospital care. Elderly people receiving the service were compared with a group of similar patients in an adjacent health district. The paper presents data on length of time at home and in hospital, changes in quality of life and care of elderly people, and effects upon informal carers for the two groups. Elderly people receiving community-based care had a higher quality of life, and there was no evidence of greater stress upon their carers. The community-based service, although it involved extra costs to the social services department, had lower costs for the health service and society as a whole than long-stay hospital provision. It is concluded that the model of care can effectively integrate the new approach of case management into an existing geriatric multidisciplinary team.
The Darlington Project, described in an earlier paper [1], was designed to provide alternative care at home for frail elderly patients in longstay hospital care. The service was based upon multi-purpose carers deployed by case managers. A fuller description of the Darlington Project is presented in Challis et al. [2]. Here we present key findings from the evaluation.
Method The study compared individual cases receiving services from the project with a group of similar patients identified in long-stay wards of an adjacent health district, which was seen as providing a reasonably similar style of geriatric service [3]. This 'quasiexperimental' approach [4] was used in place of random allocation, since the funding for the service was earmarked for long-stay patients in a specific
hospital. Because of these funding arrangements and the associated objective of closing wards, the evaluation was focused upon a particular service model as part of a local system of care. Thus, although the unit of analysis was the individual patient, to allocate patients randomly within the single service would neither have been acceptable nor practicable and would have risked contamination effects. This approach has been employed in other studies of alternatives to institutional care in the United Kingdom [5, 6]. The advantages and disadvantages of different experimental designs for the evaluation of services are discussed in more detail elsewhere [7]. Both groups of elderly people were seen in hospital and followed up after 6 months. Their informal carers were also interviewed, focusing on the experience of care and degree of burden. Since the Darlington Project was principally concerned with improving the experience and environment of elderly people requiring long-term care by providing a community-based alternative to hospital care, the Age and Ageing 1991 ;20:245-254
Downloaded from http://ageing.oxfordjournals.org/ at University of California, San Diego on December 29, 2014
An Evaluation of an Alternative to Long-stay Hospital Care for Frail Elderly Patients: II Costs and Effectiveness
D. CHALLIS ET AL.
246
Results Characteristics of clients receiving the service:
During the pilot project phase, 101 elderly clients were discharged to the project, 36 of whom were men and 65 women. Table I
provides a summary of the characteristics of the elderly people who received community care, using the Behaviour Rating Scale from the Clifton Assessment Procedures for the Elderly (CAPE BRS) [10]. The profile indicates that the Darlington clients were similar to patients on an acute medical ward. This is not surprising since, although the clients selected for the Darlington Project came from among patients who were identified as requiring long-stay care, many were on the acute geriatric wards, often awaiting transfer. Only 26 of the 101 clients were on long-stay wards prior to discharge. A change in the availability of additional housing between the planning and implementation stages of the project tended to focus the project upon those who still retained accommodation, since these were the people who could be most readily discharged. Patients sometimes retain their accommodation two and three years after admission [11], and it has been suggested that the definition of long-stay should be based on social and medical state rather than time spent in hospital, or ward of origin [12]. Thus the project developed more closely as an alternative to hospital care for patients recently admitted from home than had been initially envisaged. Table I also compares the Darlington group with the 113 cases in the control group, and it can be seen that the two were very similar, except on the social disturbance variable, on
Table I. Mean CAPE BRS subscale and total scores for all individuals who have received project service and for control patients Subscale Communication Physical Social disability Apathy difficulties disturbance
BRS total
No. of cases
0.8 0.9 0.8*
14.8 13.7 14.1
36 65 101
1.3 1.7
14.1 14.2 14.2
40 73 113
Project clients Men
6.5
Women 6.1 Both 6.3 Control patients Men
Women Both
5.9 5.9 5.9
7.1 6.4 6.6
0.6 0.4
6.5 6.3 6.4
0.5 0.3 0.4
0.5
* Analysis of variance: p
