Community Rehabilitation

Research Aim: To examine how, and with what impact, workforce substitution and specialisation is influenced by workforce change policies in the context of older peoples community and intermediate care services. Type and location:The setting for this research is older peoples community and intermediate care services, which will include health and social services across England. Specifically, the research will examine non-acute, time limited services that are designed increase the independence of older people. The research uses macro and micro level analysis to provide both a national perspective on the breadth and scope of older peoples services, staffing and skill mix, as well as a series of case studies of different models of older peoples care. Methods of working: The research will involve three key stages; (1.) Cross sectional analyses of existing data to enable macro level analysis of older peoples services, costs and outcomes; (2.) Application of a questionnaire (the Workforce dynamics questionnaire (WDQ) which examines a range of domains around workforce change; and (3.) A prospective longitudinal follow-up of a series of case study sites to examine, in depth specific hypotheses relating to workforce variations on service costs including, (a.) The relationship between workforce change and staff, service and user outcomes (b.) The relationship between different approaches to organization and management and staff, service and user outcomes (c.) The relationship between different approaches to service organization and management and workforce structures, and (d.) The impact of specialization on the team and service users. This cross sectional analysis will verify the theoretical background around the variations in service types, skill mix and outcomes for older people. Measures of outcome:The research will examine the relationships between the following variables: - Workforce configuration, including skill mix; substitution, specialisation, delegation; training and role overlap- Service organisation and management, including team structures, the setting of care, supervision / accountability- Staff outcomes, including worker satisfaction, autonomy, recruitment and retention - Service user outcomes, patient and carer satisfaction, change in health related quality of life (HRQoL) and level of independence- Service outcomes: costs and the acceptability of different services to users

Purpose: Psychiatric halfway housing is important for community re-entry in individuals with mental illness. However, the benefits of psychiatric halfway housing have yet to be established. This review provided an overview of the literature pertinent to development of psychiatric halfway house in Taiwan. Methods: The review covered articles published up to May 2014 as retrieved from the Airiti Library, Chinese Electronic Periodical Services (CEPS), Chinese Electronic Theses and Dissertations Service (CETD), and Networked Digital Library of Theses and Dissertations (NDLTD). The key words were halfway house, community rehabilitation, psychiatric disorder, psychiatric rehabilitation, and residential institutions for psychiatric rehabilitation. Issues of review interest include the distribution and environmental characteristics of psychiatric halfway house, the service pattern and significance of psychiatric halfway house, the specialists of psychiatric halfway house, and the effects of psychiatric halfway house. Results: Nineteen reports were eligible for inclusion. The review indicated that the distribution of psychiatric halfway house was insufficient and distributed unevenly. In addition, the service pattern of psychiatric halfway house may not be adequate for assisting patients with mental illness to return home or the community. Specialists may not have been adequately allocated to implement sufficient service. Moreover, the results showed a trend for better life quality in psychiatric halfway house residents than in inpatients. There were no consistent reports of the intervention effects on life quality after community rehabilitation center service, outreach care program, and psychiatric halfway house care. Research is needed to validate the potential benefits of these programs and their differential effects. Conclusion: This literature review suggests that the number and arrangement of each specialist should take the quality of rehabilitation into consideration. Local studies of psychiatric halfway house were lacking, and the indicators of intervention effects were still unclear. Future research is needed to study the intervention effectiveness of each specialist and the cost-effectiveness of psychiatric halfway house.

Background and design:
This research was based on a reanalysis of a merged data set from two intermediate care (IC) projects in order to identify patient characteristics associated with outcomes [Nancarrow SA, Enderby PM, Moran AM, Dixon S, Parker SG, Bradburn MJ, et al. The Relationship Between Workforce Flexibility and the Costs and Outcomes of Older Peoples’ Services (COOP). Southampton: National Institute for Health Research (NIHR) Service Delivery and Organisation (SDO); 2010 and Nancarrow SA, Enderby PM, Ariss SM, Smith T, Booth A, Campbell MJ, et al. The Impact of Enhancing the Effectiveness of Interdisciplinary Working (EEICC). Southampton: NIHR SDO; 2012]. Additionally, the impact of different team and staffing structures on patient outcomes and service costs was examined, when possible given the data sets, to enable identification of the most cost-effective service configurations and change over time with service provision. This secondary analysis was placed within updated literature reviews focused on the separate questions.

Research objectives:
(1) To identify those patients most likely to benefit from IC and those who would be best placed to receive care elsewhere; (2) to examine the effectiveness of different models of IC; (3) to explore the differences between IC service configurations and how they have changed over time; and (4) to use the findings above to develop accessible evidence to guide service commissioning and monitoring.

Setting:
Community-based services for older people are described in many different ways, among which are IC services and community rehabilitation. For the purposes of this report we call the services IC services and include all community-based provision for supporting older people who would otherwise be admitted to hospital or who would require increased length of stay in hospital (e.g. hospital at home schemes, post-acute care, step-up and step-down services).

Participants:
The combined data set contained data on 8070 patient admissions from 32 IC teams across England and included details of the service context, costs, staffing/skill mix (800 staff), patient health status and outcomes.

Interventions:
The interventions associated with the study cover the range of services and therapies available in IC settings. These are provided by a wide range of professionals and care staff, including nursing, allied health and social care.

Outcome measures:
(1) Service data – each team provided information relating to the size, nature, staffing and resourcing of the services. Data were collected on a service pro forma. (2) Team data – all staff members of the teams participating in both studies provided individual information using the Workforce Dynamics Questionnaire. (3) Patient data – patient data were collected on admission and discharge using a client record pack. The client record pack recorded a range of data utilising a number of validated tools, such as demographic data, level of care (LoC) data, therapy outcome measure (TOM) scale, European Quality of Life-5 Dimensions (EQ-5D) questionnaire and patient satisfaction survey.

Results:
(1) The provision of IC across England is highly variable with different referral routes, team structures, skill mix and cost-effectiveness; (2) in more recent years, patients referred to IC have more complex needs associated with more severe impairments; (3) patients most likely to improve were those requiring rehabilitation as determined by levels 3, 4 and 5 on the LoC (> 40% for impairment, activity and participation, and > 30% for well-being as determined on the TOM scale); (4) half of all patients with outcome data improved on at least one of the domains of the TOM scale; (5) for every 10-year increase in age there was a 6% decrease in the odds of returning home. The chance of remaining or returning home was greater for females than males; (6) a high percentage of patients referred to IC do not require the service; and (7) teams including clinical support staff and domiciliary staff were associated with a small relative improvement in TOM impairment scores when compared with other teams.

Conclusions:
This study provides additional evidence that interdisciplinary teamworking in IC may be associated with better outcomes for patients, but care should be taken with overinterpretation. The measures that were used within the studies were found to be reliable, valid and practical and could be used for benchmarking. This study highlights the need for funding high-quality studies that attempt to examine what specific team-level factors are associated with better outcomes for patients. It is therefore important that studies in the future attempt empirically to examine what process-level team variables are associated with these outcomes.

This article discusses the advantages of arts-based research specifically for high-context, culturally diverse, power-infused, and chaotic or diffuse research settings as often found in international aid. It points to the ability of arts to concretize abstract concepts and to situate them within specific socio-cultural locations, enabling powerless groups to self-define and to adjust resilience-enhancing interventions to their own perceptions. The arts-based method as an indirect form of communication is shown to be effective in changing stands of power holders and experts, enabling a dialogue that creates culturally sustainable aid. The model used in this article is demonstrated and discussed.