Le strutture residenziali: problemi e prospettive

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Residential Care Geoff Shepherd Director of
Partnerships Service Development (visiting
Professor, Health Services Research Unit,
Institute of Psychiatry, University of
London) FEARP, Madrid, November 2005
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Changing models of residential care in the
community

• From small, institutions in the community to
  integrated, mainstream community housing
• From segregated, special housing, with staff on
  site (group homes, hostels, etc.) to ordinary
  housing, with flexible support, delivered as
  required
• From specialist clinical providers (i.e.
  hospitals) to specialist housing providers
• From an emphasis on selection and throughput
  to an emphasis on choice and security

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Graded systems or flexible support?

• A graded system (ladder model) with each unit
  having different levels of support (24hr.cover,
  day staff, visiting staff, etc.)
• OR
• Flexible levels of support, from specialist
  community teams, delivered according to
  individuals changing needs
• Advantage of a graded system - easier to cope
  with different levels of need disadvantage -
  difficult to ensure levels of support match
  levels of need (especially over time)
• Advantages of flexible support - more cost
  effective, also generally preferred by patients
  disadvantage - may not cover most disabled
• Hence, perhaps a combination is best? (24hr.cover
  for only those who need it flexible support for
  the rest?)

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What does the evidence tell us about the
different models? (Shepherd Murray, 2001)

• Generally, community is preferred to hospital
• However, there are few consistent differences
  between different types of sheltered and
  supported community housing
• Most users want their own front door, but
  loneliness can be a problem
• Conversely, the stress (and stigma) of living
  with others with active mental health
  difficulties can also be a problem.
• Hence, no one, universal solution
• Placement in the community does enhance social
  integration - increasing the number of
  non-patients and friends in social networks - but
  there are considerable individual differences
  (and it takes time)

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How can we estimate needs? (after
Thornicroft Strathdee, 1992)

• Type of housing Range
• (per 250,000)
• High staffed hostel 40-150 95
• Day staffed hostel 30-120 75
• Group homes 48-80 64
• Respite 0-5 3
• Acute beds 50-150 95
  

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So, estimating numbers is very difficult because.

• Need to take into account social deprivation
  (Johnson et al., 1996)
• Local differences due to demography, transport,
  history, etc.
• Profound influence of substitution effects -
  need to take a whole system perspective (i.e.
  range of housing alternatives, range and
  effectiveness of community teams, etc.)
• Hence ..
• Better to survey existing facilities and
  populations served (casemix, dependency levels,
  etc.)
• Examine bed occupancy, throughput, costs, etc.
• Include those not resident in local provisions
  (homeless, police custody, families?)
• Try to identify obvious deficits in provision
  (e.g. high dependency, dual diagnosis, women,
  BME, etc.)

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National Standards for Residential Care
(Department of Health, 2003)

• 6 areas
• Support plan - What is the type and amount of
  support received? Is it appropriate to need?
• Needs and risk assessment - How does service
  assess needs and involve the resident?
• Health, safety and security - Do residents feel
  safe and secure?
• Protection from abuse
• Fair access, diversity and inclusion - How is
  information provided? Are residents asked for
  their views?
• Complaints - Do residents know how to give
  feedback and make complaints?

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Restrictiveness, choice and privacy (Leff,
1997 Shepherd et al., 1996)

• Range of similar measures - Hospital Hostel
  Practices Index (HPPI) Wykes, 1982
  Environmental Index (EI) ODriscoll Leff,
  1993)
• Strong relationship between resident satisfaction
  and low levels of restrictiveness (absence of
  unnecessary rules and restrictions) higher
  levels of choice and privacy.
• Mean EI scores (restrictiveness) halved between
  community and hospital settings 26 gt 10 (Leff,
  1997) hence, general preferences for own front
  door and non-shared accommodation
• Stronger in younger people?

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Staff-resident interactions

• Strong relationship between high levels of (high
  quality) staff-resident interaction and resident
  satisfaction (Shepherd et al., 1996)
• What constitutes high quality staff-resident
  interactions? Concept of Lo EE staff (Ball,
  Moore Kuipers, 1992).
• Strong relationship between good leadership and
  perceived autonomy and high levels of interaction
  (King, Raynes Tizard, 1972)
• Hence (a) select and train good staff (b)
  develop and support good leaders

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Assessing user preferences

• How to assess? Semi-structured interviews
  conducted by user researchers (Dean et al.,
  2004)
• Minimise sampling bias
• Attempt to create informed judgements (CUES
  methodology)

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Costs

• Comparative costs very useful
• Most costs taken up by staffing
• Fixed staffing (shared housing) always more
  expensive than floating support
• Need to look at costs v. levels of dependency
• Need to look at costs and benefits

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In conclusion an evidence-based checklist for
developing new facilities

• Identify necessary capital and revenue
• Select local provider
• Find suitable site
• Deal with local concerns
• Select residents (pay attention to casemix and
  natural social groupings)
• Select and train staff (relevance of EE models)
• Plan access to day activities and community
  support
• Ensure access to care for physical and mental
  health needs
• Ensure maintained contact with families and local
  community
• Ensure ongoing external support (to prevent
  growth of institutional practices)
• GOOD LUCK!

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For further information contact Professor
Geoff Shepherd (Director of Partnerships
Service Development) tel. [phone]
398542 mobile [phone] email
geoff.shepherd_at_cambsmh.nhs.uk