THE ESSENCE PROJECT

Residential care home

Case studies

Read the full case study for 'Person-centred support for people living with dementia in care homes: economic evidence' here (PDF)
Michela Tinelli, Renee Romeo, Martin Knapp, Danielle Guy 2019

KEY POINTS

  • Almost all (95%) of the average cost of care home residence (£792 per week) is accounted for by room and board charges. Hospital contacts contribute the largest proportion of the additional healthcare costs. The absence of an association between cost and needs emphasizes the importance of a more needs-based service system which could result in clinical and economic advantages.
  • Person-centred, integrated, and in-reach care home services responding to the needs of individual residents may improve health outcomes and quality of life at reasonable costs.
  • Interventions providing good value for money, similar to the Wellbeing and Health for People with Dementia or Enhanced Care Home Outcomes interventions are good value for money.

Evidence

A comparative cost and outcome analysis with residential care
Baumker T Journal of Service Science and Management, 40, 523-539. 2011

Extra care housing is a housing model that has considerable potential to support older people in leading active, independent lives.

Autism Spectrum Disorder in Adults: Diagnosis and Management [CG142]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2016

This guideline covers diagnosing and managing suspected or confirmed autism spectrum disorder (autism, Asperger’s syndrome and atypical autism) in people aged 18 and over. It aims to improve access and engagement with interventions and services, and the experience of care, for people with autism.

In August 2016, 2 research recommendations were removed from this guideline.

Recommendations
This guideline includes recommendations on:

identification and assessment
interventions for autism
interventions for challenging behaviour
interventions for coexisting mental disorders
assessment and interventions for families, partners and carers
organising and delivering care
Who is it for?
Health and social care professionals (including those in the independent sector)
Commissioners and providers
Adults with autism and their families, partners and carers

Related NICE guideline:
APPENDIX 18:HEALTH ECONOMIC EVIDENCE – EVIDENCE TABLES OF PUBLISHED STUDIES Authors not listed

Cost-effectiveness of an Integrated Care Home Support Service in Oxfordshire, England.
Tsiachristas A, et al International Journal of Integrated Care, 17, 1-8. 2017

Background: Multi-morbidity is an increasing threat to population health and healthcare systems. A high proportion of people living in care homes have dementia, mental illness and/or physical frailty. Thus, this population has high and complex care needs, which require substantial healthcare expenditure.

Intervention: An Integrated Care Home Support Service (CHSS) in Oxfordshire, England, combined two evidence based approaches to deliver a stepped care and treatment to meet both physical and mental health needs, called the BRIghTER DAWN programme. These evidenced based approaches trained staff to deliver Dementia Assessment of Wellbeing and Needs (DAWN) and/or a personalised intervention focusing on Building Relationships and Individually Tailored Evaluation and Responses (BRIghTER).

Methods: Different data sources and methods were combined in this observational study to perform an economic evaluation of the CHSS. Individual patient data (IPD) on two-year community care utilisation and time alive since admission to a care home were used to calculate community care costs and Life Years (LYs) per patient. Mahalanobis one-to-one propensity score matching (PSM) was used to match 443 residents who received DAWN and/or BrighTER with residents from a control cohort of 5,339 residents with respect to community care costs at baseline, date admitted to a care home, date of birth, mental health cluster codes, gender, and care home. Multiple imputation by predictive mean matching was used to impute missing observations in community care cost at baseline. To reduce remaining confounding, 5,000 bootstrapped samples were generated from the paired dataset and for each one, Generalised Linear Models were specified to estimate incremental community care costs and incremental Lys adjusting for confounders. Difference-in-differences analysis supplemented with inverse probability weighting for propensity score matching was performed to estimate incremental non-elective hospital costs based. A decision model was built to combine the incremental costs and effects from the two different analyses to estimate costs per LY gained and to perform probabilistic sensitivity analysis. Uncertainty was displayed in cost-effectiveness acceptability curves.

Results: The CHSS resulted to £575 higher costs and 0.04 more Lys than usual care resulting to an ICER of £13,886, which is considered to be cost-effective under conventional NICE thresholds (i.e. £20,000-£30,000). Looking at the interventions separately, DAWN was even more cost-effective (ICER=£2,081), while DAWN was less cost-effective (ICER=14,837) but still under NICE’s threshold. The probability of the interventions to be cost-effective at £20.000 ceiling ration was more than 80%.

Discussion: This study demonstrated a series of methods to be used by health economists when dealing with Murphy’s law in the economic evaluation of complex interventions.

Conclusion: The Integrated Care Home Support Service implemented in Oxfordshire was very likely to be cost-effective.

Lessons learned: Evidence-based, integrated, and in-reach care home services improve health outcomes at reasonable costs. These value-for-money interventions can improve efficiency in elderly care and meet the complex needs of an rapidly increasing part of the population.

Limitations: The impact of the CHSS on quality of life is not included in the economic evaluation.

Suggestions for future research: Investigate whether the cost-effectiveness results are sustainable in time and replicable in other settings.

Exercise for depression in care home residents: a randomised controlled trial with cost-effectiveness analysis (OPERA)
Underwood M, Lamb SE, Eldridge S, et al Health Technology Assessment, 17, 1-281. 2013

Headline

Study finds no evidence to support the use of a whole-home physical activity and moderate-intensity exercise programme to reduce depression in elderly care home residents.
Abstract
Background:

Many older people living in care homes (long term residential care or nursing homes) are depressed. Exercise is a promising non-drug intervention for preventing and treating depression in this population.
Objective:

To evaluate the impact of a ‘whole-home’ intervention, consisting of training for residential and nursing home staff backed up with a twice-weekly, physiotherapist-led exercise class on depressive symptoms in care home residents.
Design:

A cluster randomised controlled trial with a cost-effectiveness analysis to compare (1) the prevalence of depression in intervention homes with that in control homes in all residents contributing data 12 months after homes were randomised (cross-sectional analysis); (2) the number of depressive symptoms at 6 months between intervention and control homes in residents who were depressed at pre-randomisation baseline assessment (depressed cohort comparison); and (3) the number of depressive symptoms at 12 months between intervention and control homes in all residents who were present at pre-randomisation baseline assessment (cohort comparison).
Setting:

Seventy-eight care homes in Coventry and Warwickshire and north-east London.
Participants:

Care home residents aged ≥ 65 years.
Interventions:

Control intervention: Depression awareness training programme for care home staff. Active intervention: A ‘whole-home’ exercise intervention, consisting of training for care home staff backed up with a twice-weekly, physiotherapist-led exercise group.
Main outcome measures:

Geriatric Depression Scale-15, proxy European Quality of Life-5 Dimensions (EQ-5D), cost-effectiveness from an National Health Service perspective, peripheral fractures and death.
Results:

We recruited a total of 1054 participants. Cross-sectional analysis: We obtained 595 Geriatric Depression Scale-15 scores and 724 proxy EQ-5D scores. For the cohort analyses we obtained 765 baseline Geriatric Depression Scale-15 scores and 776 proxy EQ-5D scores. Of the 781 who we assessed prior to randomisation, 765 provided a Geriatric Depression Scale-15 score. Of these 374 (49%) were depressed and constitute our depressed cohort. Resource-use and quality-adjusted life-year data, based on proxy EQ-5D, were available for 798 residents recruited prior to randomisation. We delivered 3191 group exercise sessions with 31,705 person attendances and an average group size of 10 (5.3 study participants and 4.6 non-study participants). On average, our participants attended around half of the possible sessions. No serious adverse events occurred during the group exercise sessions. In the cross-sectional analysis the odds for being depressed were 0.76 [95% confidence interval (CI) 0.53 to 1.09] lower in the intervention group at 12 months. The point estimates for benefit for both the cohort analysis (0.13, 95% CI −0.33 to 0.60) and depressed cohort (0.22, 95% CI −0.52 to 0.95) favoured the control intervention. There was no evidence of differences in fracture rates or mortality (odds ratio 1.07, 95% CI 0.79 to 1.48) between the two groups. There was no evidence of differences in the other outcomes between the two groups. Economic analysis: The additional National Health Service cost of the OPERA intervention was £374 per participant (95% CI −£655 to £1404); the mean difference in quality-adjusted life-year was −0.0014 (95% CI −0.0728 to 0.0699). The active intervention was thus dominated by the control intervention, which was more effective and less costly.
Conclusion:

The results do not support the use of a whole-home physical activity and moderate-intensity exercise programme to reduce depression in care home residents.
Trial registration:

Current Controlled Trials ISRCTN43769277.
Funding:

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 17, No. 18. See the Health Technology Assessment programme website for further project information.

Learning Disabilities and Behaviour That Challenges: Service Design and Delivery [NG93]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2018

This guideline covers services for children, young people and adults with a learning disability (or autism and a learning disability) and behaviour that challenges. It aims to promote a lifelong approach to supporting people and their families and carers, focusing on prevention and early intervention and minimising inpatient admissions.

This guideline should be read alongside the NICE guideline on challenging behaviour and learning disabilities: prevention and interventions.

We have produced an EasyRead version and video to explain this guidance, which are available from information for the public.

Recommendations
This guideline includes recommendations on:

strategic planning and infrastructure
enabling person-centred care and support
early intervention and support for families and carers
services in the community
housing and related support
services for children and young people
carers’ breaks services
making the right use of inpatient services
staff skills and values
Who is it for?
Commissioners and providers of health and social care services for children, young people and adults with a learning disability and behaviour that challenges
Health and social care practitioners working with children, young people and adults with a learning disability and behaviour that challenges
Providers of related services, including housing, education, employment and criminal justice services
Practitioners working with children, young people and adults with a learning disability and behaviour that challenges in other services or settings, including education, housing, voluntary and community services, employment and criminal justice services
Children, young people and adults with a learning disability and behaviour that challenges and their families and carers, including people who pay for their own care

Related NICE guideline:
Service models guidance: individuals with intellectual disabilities and behaviour that challenges Trachtenberg M and Knapp M

Older People with Social Care Needs and Multiple Long-term Conditions [NG22]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2015

This guideline covers planning and delivering social care and support for older people who have multiple long-term conditions. It promotes an integrated and person-centred approach to delivering effective health and social care services.

Recommendations
The guideline includes recommendations on:

identifying and assessing social care needs
care planning, including the role of the named care coordinator
supporting carers
integrating health and social care planning
delivering care
preventing social isolation
training health and social care practitioners

Who is it for?
Health and social care practitioners
Providers of care and support in health and social care services
Older people with social care needs and multiple long-term conditions (including both physical and mental health conditions), and their carers.
Commissioners should ensure any service specifications take into account the recommendations in this guideline.

Related NICE guideline:
Appendix C3: Cost-consequence and cost-utility analysis of an outpatient geriatric multidisciplinary assessment and case management intervention: the ‘GRACE’ model of care Trachtenberg M and Fernandez JL

Safeguarding Adults in Care Homes [GID-NG10107]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. Due to complete 2020

In development

Related NICE guideline:
In development In development

The Economic Value of the Adult Social Care sector -England
Kearney J and White A Skills for Care, Leeds. 2018

Key findings

Sector characteristics

An estimated 45,000 sites were involved in providing adult social care in the UK in 2016. Most of these sites provided residential care. A further 72,000 individuals receive direct payments and employ Personal Assistants (PAs);
There were an estimated 1.6 million jobs in the adult social care sector in the UK in 2016. Most of these jobs were involved in providing domiciliary care. There were a further 151,300 jobs due to individuals employing PAs, meaning there were a total of 1.8 million jobs in the adult social care sector in 2016;
There were an estimated 1.2 million Full-Time Equivalents (FTEs) in the adult social care sector in the UK, and a further 69,500 FTEs employed as PAs;
Most of the adult social care workforce providing regulated services were employed at sites run by private sector providers (845,200);
The level of employment in the adult social care sector represents 6% of total employment in the UK; and
The average earnings in the adult social care sector in the UK was estimated to be £17,300.

Economic value of the sector

It was estimated that in 2016, adult social care sector GVA was £23.6 billion (using the income approach). Most of this was estimated to be in domiciliary care (£7.0 billion, 30%);
This represents 1.4% of total GVA in the UK; and
It was estimated that the average level of productivity (GVA generated per FTE) in the adult social care sector was £19,200.

Indirect and induced value of the sector

The indirect effect of the adult social care sector (resulting from the purchase of intermediate goods and services by the adult social care sector in delivering its services) was estimated to contribute a further 603,500 jobs (424,800 FTEs) and £10.8 billion of GVA to the UK economy;
The induced effect of the adult social care sector (resulting from purchases made by those directly and indirectly employed in the adult social care sector) was estimated to contribute a further 251,300 jobs (176,100 FTEs) and £11.1 billion of GVA to the UK economy
The total direct, indirect and induced value of the adult social care sector in the UK was estimated to be 2.6 million jobs (1.8 million FTEs) and £46.2 billion.

The Economic Value of the Adult Social Care sector -UK
Kearney J and White A Skills for Care, Leeds. 2018

Key FindingsSector characteristics■An estimated 45,000sites were involved in providing adult social care in the UKin 2016. Most of these sitesprovided residentialcare. A further 72,000 individuals receive direct payments and employ Personal Assistants (PAs);■There were an estimated 1.6 millionjobs in the adult social care sector in the UKin 2016. Most of these jobs were involved in providing domiciliarycare. There were a further 151,300jobs due to individuals employing PAs, meaning there were a total of 1.8 millionjobs in the adult social care sector in 2016;■There were an estimated 1.2 millionFull-Time Equivalents (FTEs) in the adult social care sector in the UK, and a further 69,500FTEs employed as PAs;■Most of the adult social care workforce providing regulated services were employed at sites run by private sector providers (846,600);■The level of employment in the adult social care sector represents 6% of total employment in the UK; and■The average earnings in the adult social care sector in the UK was estimated to be £17,300.Economic value of the sector(using the income approach)■It was estimated that in 2016, adult social care sector GVA was £24.3billion. Most of this was estimated to be in domiciliarycare (£7.6billion, 31%);■This represents 1.4% of total GVA in the UK;and■It was estimated that the average level of productivity (GVA generated per FTE) in the adult social care sector was £19,700.Indirect and induced value of the sector(using the income approach)■The indirect effect of the adult social care sector (resulting from the purchase of intermediate goods and services by the adult social care sector in delivering its services) was estimated to contribute a further 603,500 jobs (424,800FTEs) and £10.8billion of GVA to the UKeconomy;■The induced effect of the adult social care sector (resulting from purchases made by those directly and indirectly employed in the adult social care sector) was estimated to contribute a further 251,300jobs (176,100FTEs) and £11.1billion of GVA to the UKeconomy; and■The total direct, indirect and induced value of the adult social care sector in the UKwas estimated to be 2.6million jobs (1.8 millionFTEs) and £46.2billion in 2016.

The Economic Value of the Adult Social Care sector -Wales
Kearney J and White A Skills for Care, Leeds. 2018

Key FindingsSector characteristics■An estimated 2,070sites were involved in providing adult social care in Walesin 2016.Most of these sites were provided nursing care.A further 1,700 individuals receive direct payments and employ Personal Assistants (PAs);■There were an estimated 79,800jobs in the adult social care sector in Walesin 2016.Most of these jobs were involved in providing residential care.There were afurther 3,600 jobs due to individuals employing PAs,meaning there were a total of 83,400 jobs in the adult social care sector in 2016;■There were an estimated 60,000 Full-Time Equivalents (FTEs) in the adult social care sector in Wales,and a further 1,600 FTEs employed as PAs;■Most of the adult social care workforce providing regulated services wereemployed at sites run by private sector providers (44,500);■The level of employment in the adult social care sector represents 6% of total employment in Wales; and■The average earnings in the adult social care sector in Wales was estimated to be £16,900.Economic value of the sector(using the income approach)■It was estimated that in 2016, adult social care sector GVA was £1.2billion. Most of this was estimated to be in residential care (£328 million, 28%);■This represents 1.9% of total GVA in Wales;■It was estimated that the average level of productivity (GVA generated per FTE) in the adult social care sector was £18,700; and■The estimated GVA in the adult social care sector in Wales is estimated to be higher than the Agriculture, forestry andfishing, Arts, entertainment andrecreationand Water supply; sewerage andwaste managementsectors.Indirect and induced value of the sector(using the income approach)■The indirect effect of the adult social care sector (resulting from the purchase of intermediate goods and services by the adult social care sector in delivering its services) wasestimated to contribute a further 31,200 jobs (23,000 FTEs) and £554million of GVA to the Welsh economy;■The induced effect of the adult social care sector (resulting from purchases made by those directly and indirectly employed in the adult social care sector) wasestimated to contribute a further 12,200 jobs (9,000 FTEs) and £543 million of GVA to the Welsh economy;and■The total direct, indirect and induced value of the adult social care sector inWales was estimated to be 126,800 jobs (93,600 FTEs) and £2.2 billion in 2016.

The Economic Value of the Adult Social Care Sector in England
ICF GHK Skills for Care, Leeds. 2013

Skills for Care is part of the Sector SkillsCouncil, Skills for Care and Development. It is responsible for improving qualifications, training and development for alladult social care workers in England. Skills for Care had identified a need to establish the economic contribution of the activitiesprovided by the sector, measured as the economic value of the sector. However, the adult social care sector in England has historically been difficult to assess in terms of its economic value, as distinct from the children’s workforce and the wider UK workforce.Skills for Care has recently generated estimates of the number of employers, enterprises and employees in the sector, through its work on the National Minimum Dataset for Adult Social Care (NMDS-SC). ICF GHK was commissioned by Skills for Care to build on this work and to assess the economic significance of the adult social care sector in England to the wider economy.This study was commissioned in support of further policy development towards the sector including consideration of a broader case for investment in skills in the sector. The purpose of the study was to establish the economic contribution of adult social care servicesin England(defined in terms consistentwith the UK national accounts)and provide estimates of:■the annual GDP andGVAgenerated directly by the adult social care sector in England (including the public sector activities within the sector as well as the independent sector) (direct impact);■productivity -GVA per worker for the adult social care sector in England;■the supply chain multiplier for the adult social care sector in England (indirect impact);■the wage multiplier for the adult social care sector in England (induced impact)

Transition Between Inpatient Hospital Settings and Community or Care Home Settings for Adults with Social Care Needs [NG27]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2015

This guideline covers the transition between inpatient hospital settings and community or care homes for adults with social care needs. It aims to improve people’s experience of admission to, and discharge from, hospital by better coordination of health and social care services.

The Care Quality Commission uses NICE guidelines as evidence to inform the inspection process.

Recommendations
The guideline includes recommendations on:

person-centred care and communication and information sharing
before admission to hospital including developing a care plan and explaining what type of care the person might receive
admission to hospital including the establishment of a hospital-based multi-disciplinary team
during hospital stay including recording medicines and assessments and regularly reviewing and updating the person’s progress towards discharge
discharge from hospital including the role of the discharge coordinator
supporting infrastructure
training and development for people involved in the hospital discharge process.
Who is it for?
The guideline is for health and social care practitioners; health and social care providers; commissioners; service users and their carers (including people who purchase their own care).

Related NICE guideline:
Appendix C3 Bauer A and Fernandez JL

Transition Between Inpatient Mental Health Settings and Community or Care Home Settings [NG53]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2016

This guideline covers the period before, during and after a person is admitted to, and discharged from, a mental health hospital. It aims to help people who use mental health services, and their families and carers, to have a better experience of transition by improving the way it’s planned and carried out.

The Care Quality Commission uses NICE guidelines as evidence to inform the inspection process.

Recommendations
This guideline includes recommendations on:

overarching principles for good transition
planning for admission and discharge
out-of-area admissions
support for families and carers
Who is it for?
Providers of care and support in inpatient and community mental health and social care services
Front-line practitioners and managers in inpatient and community mental health and social care services
Commissioners of mental health services
People who use inpatient and community mental health services, their families and carers

Related NICE guideline:
Economics, economic modelling, appendix C3.2 Cost–utility analysis of a 2-year multi-staged psychological intervention for bipolar I patients with their first, second or third hospitalisation vs Generic outpatient treatment of bipolar affective disorders (active treatment as usual) Trachtenberg M and Knapp M

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