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In this chapter the methodology (research design, hypotheses, data collection and analysis) is linked to the research aims and questions. This is a cross-sectional study of a defined population which focuses on major changes that occurred between 1990 and 2006 in two residential care homes run by the Helping Hand organisation. As discussed in Chapter 5, the ‘Standardised Care Need Assessment Mechanism’ (SCNAM) for the targeting of publically supported institutional care of older people was implemented from November 2000 with the primary intention of better allocating resources to those in greatest need. The research intention was to compare and contrast the dependency characteristics of the residents in the two care institutions before and after the introduction of this ‘gatekeeping’ policy, studying their physical health, functional abilities, cognitive status, and levels of frailty. Initially, a modified version of the Clifton Assessment Procedures for the Elderly (CAPE) instrument had been adopted by a staff team of the Helping Hand in a 1990 study. The same measuring instrument was used by this research in 2006. The fundamental question was to see how the ‘gatekeeping’ policy, the Standardised Care Need Assessment Mechanism (SCNAM), had achieved in the context of these two care homes its objective of better targeting of long-term care for older people as claimed by the government of Hong Kong. A range of data about the characteristics of the residents of the homes, the staff and the care routines was collected and T-tests and Pearson correlations were used to test the direction and strength of relationships between the variables, and to inform analysis of the findings.

For decades a variety of scales have been used to measure levels of dependency in studies of older people. Functional assessments usually involve three main dimensions, conventionally named, ‘activities of daily living’ (ADLS), ‘instrumental activities of daily living’ (IADLs), and mobility (Spector, 1990; Kane and Kane, 2000). These measures seek to be ‘the systematic process of identifying or assessing the capabilities and deficiencies of persons at risk as arisen from aging and ill health’ (Bernstein, 1992), and have been widely used among frail old people in care homes and those living in the community with chronic health problems (Zimmer, Rothenberg and Andresen, 1997). Measures such as the Clifton Assessment Procedures for the Elderly (CAPE) (Pattie and Gilleard, 1979), the modified Crichton Royal Behavioural Rating Scales (Wilkin and Jolley, 1979) are often used. The Nursing Home Disabilities Instrument (NHDI) has also been identified as a valid and efficient multidimensional instrument for assessing the ability levels of the nursing home residents (Valk et al., 2001).

In the current research, the Clifton Assessment Procedures for the Elderly (CAPE) devised by Pattie and Gilleard (1979), two distinguished clinical psychologists at the Clifton Hospital, is used. The CAPE instrument consists of two main parts: the Cognitive Assessment Scale (CAS) and the Behaviour Rating Scale (BRS), which can be used together or independently depending on the specific purposes. Using this instrument, the cognitive and behavioural abilities of older people can be quickly assessed within a brief period of time. The CAS provides an assessment of mental functioning, and has been shown to be applicable to elderly patients (Pattie and Gilleard, 1975). The BRS is a shortened version of the Stockton

Geriatric Rating Scale used to assess behavioural abilities and disabilities. The CAPE is widely recognised as ‘a short, brief, easily administered assessment of deficits’ (Mulgrave, 1985, p.180). It can be used for basic screening and deciding ‘the most appropriate living arrangements or the degree of support and services necessary for an elderly client’. McPherson and others (1985, p.83) show that the short survey version of the CAPE (Pattie, 1981) is useful in distinguishing older people with different dependency and impairment levels for screening or research purposes, albeit with uncertain ‘clinical value with individual patients’. Gibson, Moyes and Kendrick (1980, p.556) suggest the CAPE is most appropriately used ‘when an assessment of dependency needs is required, and when management decisions must be taken’. Due to its long and extensive use, the CAPE instrument provides a well-tested benchmark for use with older people in, or being considered for, residential care.

The research design

This study is built on a pioneer project conducted by a staff team in the five residential care homes run by the Helping Hand organisation in Hong Kong: at the Chak On, Lai Yiu, Lok Fu, Kwai Shing, and Tai Wo Hau Care Homes in 1990. Its main objective was to assess the dependency levels and characteristics of residents after admission to these care homes. It enabled continuous assessment of the residents as well as the quality of care provided to them. Using the modified version of CAPE, it had been conducted three times in January, March and July of 1990.

completed by a nurse, and another by a member of the care staff. Every respondent was interviewed by a nurse and Personal Care Worker (PCW) who conducted interviews separately with the same residents in the three points under study in 1990. Eventually a total of 229 residents from the five care homes were interviewed. The total number of completed questionnaires was 1375. All these data files contain valuable information on the elderly residents, including their physical condition, self-care abilities, cognitive abilities, behavioural problems, sociabilities, relationships with other residents, staff as well as relatives.

The same measuring instrument, the modified version of CAPE, was adopted and replicated in this cross-sectional study in 2006. The objective is to make comparisons of the changes in the local residential homes across the period 1990-2006. Minor modifications were made in the light of known deficiencies of the measuring instrument. Among the five homes in the 1990 survey, two were selected for the current study: the Chak On Care Home and the Lai Yiu Bradbury Care Home. This was mainly due to the constraints of time, person resource, and administrative concerns. Regarding the location of the five care and attention homes, two are situated on the West Kowloon side of Hong Kong, while the other three belong to the western part of the New Territorities. In order to acquire representativeness, this study chose one home from each of the two different regions in Hong Kong for the study in 2006, comprising a total of 152 respondents. The findings are then used to compare with those in the July 1990 survey, which is the ‘only’ one that contains records of the residents’ ages. A total of 122 older respondents (60 from the Chak On Care Home and 62 from the Lai Yiu Bradbury Care Home) were interviewed during

the July 1990 study.

In this quantitative study, the structured questionnaire (Appendix 1) includes an assessment of the older residents’ functional abilities, mobility levels, cognitive status, relationships with other residents and staff. Under the Cognitive Assessment Scale, nine questions (Q.15 to Q.22) are asked of the older persons about understandings of their own names, age, present place of residence and time. Aside from that, the elderly respondents were asked to answer Question 23: ‘Will you count up from 1 to 10 - as quickly as you can?’ to test their cognitive ability. The Behaviour Rating Scale covers four sub-scales of important aspects of behavioural disability amongst older people. Firstly, physical disability includes levels of mobility, incontinence, ability to feed, dress, bathe themselves (Q.6 to Q.9 and Q.24 to Q.32). The second set is about communication ability, which includes expressiveness, comprehension, vision, and hearing (Q.10 to Q.14). The third sub-scale assesses social behaviours such as wandering, accusing others of doing bodily harm or stealing possessions, sleeping patterns (Q.33 to Q.37). The fourth aspect relates to levels of involvement within the residential home, such as engaging in the home’s activities, willingness to help others, talking with staff and other residents (Q.38 to Q.46). In addition, information about personal particulars was collected. In order to fulfill the research objectives, six questions (Q.49 to Q.54) were added to this evaluative study. These sought information about the respondents’ marital status, educational level, financial situation, prior living arrangements, and date of home admission. Summing up, the dependency levels of the respondents were measured in a comprehensive way through the use of this modified CAPE

instrument.

Inter-rater reliability

Previous studies have tested the reliability and validity of the CAPE instrument. As Pattie and Gilleard (1979) show, long-term test-retest reliability is likely for ‘more static populations’ in residential facilities, as their cognitive status tends to ‘provide a more stable index of level of functioning’ (p.20). Despite its simple and brief procedures, the Cognitive Assessment Scale (CAS) has been found to be ‘a more sensitive predictor of outcome in the elderly psychiatric patient population’ (p.24), compared with, for example, the detailed Wechsler Adult Intelligent Scale (WAIS).

As far as the reliability of the Behaviour Rating Scale (BRS) is affected by use by different observers Pattie and Gilleard (1979) show that the test takes account of a level of agreement between raters, during the same period of observation.

In the previous 1990 study, briefing sessions were held with all the staff involved so as to reduce inconsistencies and to ensure all interviewers used the same yardstick for measurement. For each question, there is a set of criteria with which interviewers were required to be acquainted with prior to conducting interviews. Each elderly respondent was interviewed separately by a nurse and a Personal Care Worker three times in 1990. This produces some variations in the results as indicated in the Pearson Correlation. For variables like ‘wanders within the Home without specific purpose’ and ‘shows willingness to help others’, the Pearson correlation coefficients are 0.307 and 0.325 respectively which indicate insignificance (Table

6.1). Nevertheless all items under the Cognitive Assessment Scale, as well as the Behaviour Rating Scale in the questionnaire, are found to be statistically very significant, except for the two variables on ‘accusing’ and ‘sleep pattern’. The level of significance of all other items, including mobility level, communication difficulty, orientation ability, and social disturbance, is p = 0.000. In view of this pattern reliability and validity, the modified version of the CAPE instrument was used in this study, and administered in a way as similar as possible to the early studies. Unlike the previous 1990 survey, all the interviews were solely conducted by the researcher in 2006. Information was collected from a proxy if the older person was too frail to respond to the questionnaire. Proxies included nurses, social workers, and personal care workers.

Table 6.1 Inter-rater reliability Variables Pearson correlation

coefficient Sig. level walking aid 0.900 0.000 mobility 0.802 0.000 urine incontinence 0.727 0.000 faeces incontinence 0.651 0.000 expressiveness 0.443 0.000 comprehension 0.395 0.000 vision 0.307 0.000 hearing 0.382 0.000 hearing aid 0.317 0.000 state ‘name’ 0.492 0.000 state ‘age’ 0.513 0.000

state ‘date of birth’ 0.598 0.000

state ‘living place’ 0.616 0.000

state ‘region’ 0.639 0.000 state ‘day’ 0.603 0.000 state ‘month’ 0.604 0.000 state ‘year’ 0.587 0.000 counting 0.544 0.000 toileting 0.814 0.000 dressing 0.752 0.000 feeding 0.455 0.000 washing 0.695 0.000 bathing 0.816 0.000 shopping 0.649 0.000 managing money 0.714 0.000 grooming 0.716 0.000 bed making 0.704 0.000 wandering 0.307 0.000 day disturbance 0.361 0.000 night disturbance 0.335 0.000 accusing 0.130 0.066 sleep pattern 0.151 0.033 helping others 0.380 0.000 constructive activities 0.317 0.000 willingness to help 0.325 0.000

talk with residents 0.397 0.000

conflict with

residents

0.251 0.000

sociability 0.461 0.000

talk with staff 0.393 0.000

conflicts with staff 0.211 0.000

The research aims

Though the Standardised Care Need Assessment Mechanism (SCNAM) for elderly service has been used since November 2000, little has been done to assess the policy outcomes so far. Various aspects of change that have been taken place in the two Care Homes in Hong Kong during the period 1990-2006 are the focus of the present research. These include the demography, daily life and dependency characteristics of the older residents, together with the staffing and financial condition of the two Care Homes. The aim is to compare the dependency and demographic characteristics of the residents at two points of time, particularly whether they are different or remain the same after the introduction of the formal ‘gatekeeping’ mechanism. Furthermore, this research examines whether service resources have been better allocated and targeted to those older people with the greatest need of care, and whether greater efficiency and effectiveness of long-term residential care are likely to have been achieved by this policy initiative.

Clearly, this study belongs to a form of ‘summative evaluative research’, as it involves collecting data about a programme intervention ‘either during or after its application with the aim of deciding whether it should be continued or repeated’ (Netten, 2002, p.176). This summative evaluative research is applied to help reach judgements about the degree of success of a government policy, particularly how far it improved the matching of resources, needs and outcomes of care (Davies et al., 1990), and whether this affects the outcomes of care in a positive manner or not.

Hypotheses

1. Under the Standardised Care Need Assessment Mechanism used since November 2000, only more seriously disabled older individuals will have been admitted to residential homes. In this way, the ‘gatekeeping’ mechanism is likely to have contributed to a more efficient provision of residential care in Hong Kong.

2. The admission of more disabled older people is likely to have affected the resident case mix in the two Care and Attention homes, and may have adversely impacted on the degree of social participation of older people.

3. With the change in the resident case mix, there may be evidence of an increase in the workload of caring staff in the two residential homes in 2006 when compared to that in 1990.

4. If additional staff numbers and skill have not been added to care for the increasing number of very frail residents in the two care homes, this may have had a negative impact on the outcomes or effectiveness of care.

Research questions

This study investigates the following questions:

1. With the inception of the Standardised Care Need Assessment Mechanism in late 2000, had the two residential homes of the Helping Hand undergone any changes by 2006 when compared with 1990, in terms of the demographic and dependency characteristics of the residents?

‘gatekeeping’ policy? Are the two residential homes admitting older persons who are more genuinely in need for care? Are the homes operating in a more efficient manner in 2006 than in 1990, in terms of costs and staffing?

3. Has the selection policy impacted upon the workload of the care staff? In what ways does the resident case mix affect the staff workload in the two care homes under study?

4. Has the selection policy changed the lives of the residents? Are there changes relating to the social participation of the residents in the two care and attention homes across the 16-year time period? What is the interaction between the residents and the staff as well as among the residents themselves at the two points of time? What are the factors contributing to any changes?

5. Are there any positive or negative unintended consequences attributable to the implementation of this ‘gatekeeping’ policy?

Access to the two homes under study

This research took place in the two institutional settings run by the Helping Hand organisation: the Chak On Care Home and the Lai Yiu Bradbury Care Home. Both care homes admit older persons (aged 65 and above) who are in poor health or suffer from functional disabilities and require assistance in self-care such as toileting, dressing, feeding, bathing. People lacking appropriate care can apply for admission to these institutions. Unlike most of non-governmental organisations (NGOs), the Helping Hand has its own unique funding system. Apart from receiving donations from the Hong Kong Jockey Club Charities Trust, the Community Chest Allocation

and other charity groups, it organises a ‘Cookie Campaign’ annually and other fundraising events. It does not rely wholly on subvention from the government (namely, the Social Welfare Department) which purchases places under the Bought Place Scheme/Enhanced Bought Place Scheme. In the 1990s, the homes under study also accepted referrals from the Housing Department. Since 2003 all places in the Chak On Care Home became ‘bought places’ by the Social Welfare Department.

Chak On Care Home

The Chak On Care Home commenced its service operation in January 1989

with a total capacity of 87 older persons, including 28 males and 59 females. Owing

to the physical design, residents are allocated to live in three separate blocks within

the same housing estate, namely, Lai Chak House, Wing Chak House and Wah Chak

House. The General Office is located in the first block - Lai Chak House, where the

Superintendent, Nurse-in-charge, social workers, and clerical staff are stationed. The

older people are allocated to nine dormitory bedrooms, with each accommodating

four to five residents. As at mid-September 2006, the resident population was 43.

Next to the General Office is a common room for the residents to dine together,

watch television and participate in some activities. The second block, Wing Chak

House, consists of four rooms, each with an average capacity of around six persons.

is available for the use of older people. Wah Chak House (the third block) has the

lowest capacity, serving a total of 19 residents whose impairment levels appear to be

more severe. As there is only one kitchen situated at the first block (Lak Chak House)

to serve the needs of all the 87 residents, the staff have to walk around and assist in

distributing food among the three blocks during the three meal times every day. At

night time, there is only one Registered Nurse (RN) on shift duty. This nursing staff

member (usually female) has to tour around to oversee the well-being of all the frail

old residents scattered across the three separate blocks. This caused inconvenience

and sometimes even mess in times of emergency.

Lai Yiu Bradbury Care Home

The Lai Yiu Bradbury Care Home is built as an independent housing block with three storeys, and thereby faces less difficulties than the Chak On Care Home. It began operation from January 1988, providing care places for 76 older people (including 23 male and 53 female residents). The General Office for the Superintendent, Nurse-in-charge, and social worker is situated at the Ground Floor. Within this care and attention home, an elevator is available for the use of visitors, residents and staff. On the first floor, there are eight dormitory bedrooms for residents with higher levels of frailty. Each room accommodates six persons who have to share toilet and bathing facilities with other roommates. There are altogether 52 beds on this floor.

Handrails are installed along the corridor to help the frail old residents walk around independently on their own without staff assistance. At the one end of the first floor, there is a dining room and equipment for doing physiotherapy. On the wall, the date of each day is posted on to orient the residents and keep them aware of the here-and-now. Opposite this dining area is the Nurse Office, where the nursing staff gather for daily duty handover meetings and case discussions. Next to this office is the kitchen which serves meals for the staff and service-users.

A most distinctive feature of the Lai Yiu Bradbury Care Home is its colourful physical design as well as the ‘couple rooms’ that are not commonly found among other homes within the Helping Hand. Originally the twelve rooms situated at the Second Floor were designed to serve only elderly couples. Owing to some practical constraints, the utilisation of rooms by couples is low. With the adoption of