Implementar un horario para la alimentación en pollos broiler para “pollipavos”, que implique el suministro de alimento en horas donde las temperaturas

Chapter One

Introduction

1.1 Introduction

Older people constitute a significant portion of the overall population of people needing ongoing and specialised health and social care services. Others include those with physical or learning disabilities and those with mental health problems. While the proportion of those aged 65 years or older in the population is expected to change little over the next five years, the number of older people in the following twenty years (2006 – 2026) is estimated to increase by up to seventy-seven per cent with those over 80 expected to double.1_{As the number of older individuals increases, so too will the} need for these services. The challenge for health and social services is not just to meet these needs in a cost-efficient manner, but to deliver a quality of service that maximises the older person’s quality of life. Central to the concept of quality of life for many people with health or social care needs is the desire to remain in their own homes while enjoying the same access to care as those who cannot or choose not to remain in that environment. A recent Irish study of almost 1,000 community-dwelling older people confirmed the primacy of home as their location of choice to live in, even in the face of long-term care needs (Garavan et al, 2001). The most favoured long-term care option for these people was remaining at home with minimal health board care in the form of respite services.

The introduction of community and domiciliary-based services for older people has been slow. Because of the sometimes multi-faceted and varied health and social situations of older people, the current service delivery systems are often inadequate or inflexible in accommodating the needs of this group. For instance, services are too

compartmentalised and fragmented to cater for individual situations, with linkages across services in the face of transitions to or from home, hospital or other institutions being weak or non-existent. This can lead to inappropriate use of acute hospital care or long-term care institutions especially when home services are not easily available (Bergman et al, 1997). Access to appropriate and timely services may be difficult, especially when a situation demands the expertise and co-ordination of an array of professionals, voluntary organisations and informal carers to meet the needs of the

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individual. When the existing situation changes in some way, no one person or agency may recognise the need for reassessment or take responsibility for ongoing monitoring. Further, older people are often faced with a lack of real choice and control over the types and conditions of various services (Challis et al, 1995). In addition, informal carers are often left with little or no support.

One possible solution to the burgeoning problem of delivering community services in a harmonised way is the adoption of a Care and Case Management style of service delivery. In this report, the term Care Management is used to refer to the process of service co-ordination and planning at management level, and the term Case

Management is used to refer to the provision of individually tailored care plans delivered through a Case Manager or team. This type of care is marked by its ability to

individually tailor care plans in a system of consultation between the older persons themselves, their informal carers, general practitioners, and other health and social service professionals. Its structure allows the flexibility to rapidly respond to changes and maximise resources. Interdisciplinary and inter-agency communication is

encouraged to increase access to needed services. The focus of Care Management is more concerned with the quality of care than its cost-effectiveness, although the two are, of course, inter-connected (Malin, 1994; Challis et al, 1995). Care Management approaches have been developed for older people in a number of countries. These will be described in detail later.

Care Management at the management and organisational levels, and Case Management as a mode of service delivery should both be situated in the context of a larger

continuum of care. The World Health Organisation (Edwards, 2001) provide a useful framework to describe this continuum. It comprises three different dimensions: self care, where the individual is able to look after him- or herself without direct intervention but with the support of the health promotion and health information agencies and a low level of family/informal assistance; informally-assisted care, where the individual is able to look after him- or herself with the assistance of a family member or some other form of informal care; and Care Management (implemented via Case Management), where a Case Manager becomes more involved in organising and providing health and social services to enable that person to stay at home. Informal care is of key importance in enabling older people to maintain their autonomy and decision-making power throughout the continuum of care. It is important to emphasise that these three dimensions are not a strict progression; rather they represent different states of care that an individual can move in or out of according to his or her changing needs and circumstances. In addition Care Management should be used as a model of care only when it is appropriate to do so, and should be implemented according to an ethos of respect for individuals irrespective of their age. Not all health and social services need to be delivered via Case Management.

1.2 The Care And Case Management

For Older People Project

Although recommended by the National Council on Ageing and Older People in publications dating back to 1992 (Browne, 1992; Ruddle et al, 1997; O’Shea and O’Reilly, 1999), little has been formally done to date to promote and encourage the development of Care Management initiatives throughout Ireland. In this context, the NCAOP commissioned the present study to provide a first, systematic national review of health and social care delivery practices in the care of older people for the purpose of identifying models of best practice within a Care Management framework in the Republic of Ireland.

1.2.1 Specific Objectives Of The Study

To review and summarise the literature on Care Management models and their application via Case Management within a range of settings and target groups. To identify and document current care delivery practices which approximate to models of Care Management for older people among the health boards in Ireland. To develop one or more ‘best practice’ model(s) of Care Management (implemented via Case Managers) suitable to the Irish context.

To develop a system of evaluation which is appropriate and valid for ongoing quantitative and qualitative review of Care Management Projects.

1.2.2 The Report

This report presents the findings of the Care and Case Management for Older People study. Key literature pertaining to the development of Case Management as a service delivery strategy, and the different Care and Case Management models in use internationally, are outlined in Chapter Two. An outline of the methods used in two phases of data collection regarding the current Irish situation is presented in Chapter Three. Analysis and discussion of the findings from Phase One of the fieldwork and from two focus groups with older people is presented in Chapter Four. Chapter Five presents input from feedback received in Phase Two on possible ‘best practice models’ of Case Management. Chapter Six discusses approaches to evaluation in Care and Case Management. Finally, the best practice model developed, along with key recommendations as to what should be put in place in order to progress Care Management as a model of planning care and Case Management as the consequent service delivery model in Ireland, are outlined in Chapter Seven.