extra care: a sustainable solution to the care crisis?

Extra Care – A Sustainable Solution to the Care Crisis?

Tuesday 13 September 2011

www.ilcuk.org.uk

The International Longevity Centre-UK is an independent, non-partisan think-tank

dedicated to addressing issues of longevity, ageing and population change.

Baroness Sally Greengross

ILC-UK

Extra Care



Dylan Kneale

ILC-UK

Extra Care



Establishing the extra in Extra Care: Perspectives from three Extra Care Housing Providers

Dylan Kneale

International Longevity Centre, September 13th 2011



• Housing:

• Lived in same house for 40+ years (17% 1993/4; 24% 2007/8)

• Rising levels of under occupancy?

• Rising levels of housing wealth?.....Rising inequality? (Older people

still biggest consumers of social housing)

• Less retirement housing being constructed

• Health care:

• Compression of morbidity? (Zaninotto et al 2010)

• Non communicable diseases (stroke, dementia)

• Social Care:

• Rising cost; Unequal provision; Who pays?

• Rates of receipt of domiciliary care at home declining…

Health, social care and housing among the ageing population



What is it? Little consensus….

Wide spectrum of self-designated extra care housing

Some common principles of extra care housing:

Ergonomically designed

Flexible and continually adapting care packages delivered onsite

Communal facilities

Group activities

Independent homes within small-medium sized retirement communities

Usually age specific

Leasehold tenure as well as rental tenure

Community balance of care needs

Extra care housing



Extra care housing

What do we know about extra care housing?



Research Questions 1. What is the social profile of extra care housing

residents and how does this compare with residents in the

community setting?

2. Can extra care housing be considered a home for life

for older people?

3. Does residence in extra care housing facilitate healthier

and more independent life?

4. What impact does residence in extra care housing

have on the uptake of overnight hospital beds?

5. What inferences can be made about the costs and

benefits of extra care housing?



Data and Methods Data: Longitudinal data from 3 partners on almost 4,000 residents of extra

care housing since 1995;

British Household Panel Survey; English Longitudinal Survey of Ageing;

Survey of English Housing (descriptive)

Limitations/Challenges

1. Characteristics of residents Descriptive analysis

2. Extra care housing as a home for life

Event history analysis (Lognormal and Competing Risks); Propensity Score Matching

3. Extra care housing as a healthy home for life

Event history analysis (Competing Risks); Propensity Score Matching

4. Extra care housing and hospital beds?

Zero inflated negative binomial regression; Propensity Score Matching

5.N Inferences on the costs and benefits of extra care housing?

Descriptive analysis



Gender

Age

Living arrangements

Additional care needs

Health shocks that may predict entry to extra care housing:

Stroke

Dementia

Parkinson’s disease

Characteristics of residents



Extra care as a home for life I Length of time until exit (all exits)

First quartile (25%) Median (50%)

All residents 3.1 6.5

GenderMale 2.6 6.0

Female 3.4 6.7

0.0

00.2

50.5

00.7

51.0

0P

rop

ort

ion s

till

resid

ent

0 5 10 15analysis time (years)

No additional care needs on arrival Very low care needs on arrival

Low - Moderate care needs Moderate to High care needs

High care needs on arrival Very high care needs on arrival

Proportion of extra care residents remaining



Extra care as a home for life II: Competing Risks Framework

Risk 1: moving to

an institutionRisk 2: death

All residents 8.2% (6.7-9.9) 25.0% (22.4-27.5)

GenderMale 6.4% (4.3-9.1) 30.6% (26.0-35.3)

Female 9.1% (7.2-11.3) 22.0% (19.2-25.1)

Health Status/Care Needs

on Arrival

No additional support

package5.5% (4.0-7.3) 16.8% (14.2-19.6)

Level 1 (very low package

needs)12.8% (6.8-20.8) 29.6% (20.0-39.7)

Level 2 (low support

package)17.5% (11.7-24.4) 39.8% (31.6-47.6)

Level 3 (moderate support

package)11.9% (5.2-21.5) 41.0% (28.3-53,1)

Level 4 & 5 (high or very

high support package)9.9% (4.9-17.1) 56.9% (46.1-66.3)

Age Group

50-64 6.8% (2.8-10.9) 10.2% (5.8-16.3)

65-69 6.2% (3.1-11.0) 13.0% (8.2-19.1)

70-74 6.0% (3.4-9.8) 18.2% (13.3-23.7)

75-79 9.0% (5.8-13.0) 24.6% (19.4-30.2)

80-84 8.0% (4.8-12.3) 27.2% (21.3-33.5)

85+ 12.7% (8.5-17.7) 49.0% (41.8-55.8)

N 1,189 1,189



Extra care as a home for life III All community match sample Domiciliary care match sample

Age 65+

Model 1

Age 75+

Model 2

Age 80+

Model 3

Age 65+

Model 4

Age 75+

Model 5

Age 80+

Model 6

Models adjusted for

Age, Sex, Living

Arrangements, Year

Sub-hazard

ratio of

moving to an

institution

Sub-hazard

ratio of

moving to an

institution

Sub-hazard

ratio of

moving to an

institution

Sub-hazard

ratio of

moving to an

institution

Sub-hazard

ratio of

moving to an

institution

Sub-hazard

ratio of

moving to an

institution

Extra care housing

1.776 1.216 0.905 0.694 0.532* 0.316**

(0.659) (0.471) (0.463) (0.207) (0.167) (0.121)

N 1714 1034 624 1630 1028 634



Diminution in loss of functional ability?

Extra care as a healthy home for life0.0

00.2

50.5

00.7

51.0

0

0 2 4 6 8 10analysis time

No additional care needs on arrival Very low care needs

Low-moderate care needs Moderate-High care needs

High to very high care need on arival

Time to increase in care package



Conceptualising ‘risk’ of health improvement

Extra care as a healthy home for life

Risk: improvement in

health (decrease in care

needs)

All residents 24.0% (20.6-27.5)

GenderMale 25.7% (19.5-32.3)

Female 23.8% (19.3-27.5)

Health Status/Care Needs on Arrival

No additional support package 30.8% (24.7-37.1)

Level 1 (very low package needs) 16.3% (9.4-24.8)

Level 2 (low support package) 26.0% (19.1-33.5)

Level 3 (moderate support

package)15.3% (7.5-25.6)

Level 4 & 5 (high or very high

support package)14.9% (7.9-24.0)

Village or Court developmentCourt 9.2% (5.8-13.7)

Village 32.1% (27.4-36.8)

N 603



Falls (fractures), stroke and heart disease account for the main

financial burden of older people’s health care

Within extra care setting, most accidents represent falls (“loss of

balance”, “got up too quick”, “turned around”)

Ergonomic adaptations? Group exercise classes?

Compare rates for small sample size with sample from ELSA

Matching indicative of a lower rate in extra care (49% vs 31%)

Sample size – caution – indicative evidence

Men susceptible to falls in extra care setting?

Falls in extra care



Extra care and overnight hospitalisation I Number of available beds for geriatric medicine declined by 61%

(1987-2008); Bed blocking an issue

Comparison group

Inverse care law – evidence in BHPS (or other effect?)

Incidence rate is higher than in overall community sample BUT

reflects length of stay

Number of episodes of admission consistently lower in extra care

sample i.e. less people go to hospital in the extra care sample, but

those that do stay longer

Closely matched comparison group overall incidence lower in extra

care sample

Mechanism?



Extra care and overnight hospitalisation II



Extra care and inferences on costs

Social care costs (median community care package and extra care)



Extra care and inferences on costs II

Initial social care costs of extra care housing may be higher

than if remaining in the community

But, because of higher probability of transition to institutional

accommodation , long-term costs lower

– Planning for retirement

Cost of lower rate of hospitalisation

Cost of reduction in package



Extra care housing:

1. Supports some of the most vulnerable in society

2. Appears to be a home for life for the vast majority

• Compared to those with similar characteristics appears to be

lower rate of transition to institution; plausible mechanism (age,

living arrangements, gender, in receipt of care at home)

3. Associated with fewer inpatient stays

4. Associated with fewer falls

5. Is a healthy home for life

Conclusions



Policy Recommendations I1. Policy-makers need a co-ordinated response to providing housing,

health care and social care for our ageing population.

2. Policy-makers should make specific pledges to increase the level of

provision of extra care housing.

3. The proposed National Planning Policy Framework should champion far

more robustly the housing needs of older people.

4. Policy-makers should recognise and encourage private sector

development of extra care housing.

5. The findings in this report suggest that policy-makers drafting the Health

White Paper should explicitly consider and make specific pledges to

increase the role of housing with care.



Policy Recommendations II6. Policy-makers should enhance and sustain programmes of education and information

for those who are retired and newly retired to plan their housing and financial futures.

Furthermore, consumers need reassurance that policy changes will not negatively

impact their retirement decisions.

7. Any National or Local Falls Prevention Strategy should include housing as a key

component of preventing further falls.

8. Receipt of Attendance Allowance opens a gateway for many older people to access

extra care housing, through helping to finance monthly care costs and to help access

other benefits. We would urge policy-makers to ensure that all who are eligible to claim

Attendance Allowance do so which could enable greater numbers of older people to

support a stay in extra care housing.

9. Further research is needed into the extra care housing sector.



Full report available:

www.ilcuk.org.uk

Further information:

Dr Dylan Kneale, International Longevity Centre

[email protected]

Thanks for your attention

http://www.ilcuk.org.uk/

mailto:[email protected]



Robin Darton

PSSRU

Extra Care

The PSSRU Evaluation of Extra Care Housing

Robin Darton

Extra Care ‒ A Sustainable Solution to the Care Crisis?, International Longevity Centre ‒ UK, 13

September 2011

Presentation

The PSSRU evaluation


Outcomes for residents

Costs and cost-effectiveness

Social well-being

Other issues

Summary and discussion28

PSSRU Project Team

Professor Ann Netten Robin Darton Theresia Bäumker Lisa Callaghan Jacquetta Holder Ann-Marie Towers Jane Dennett Lesley Cox 26 local researchers

The Extra Care Housing Fund: Aims

To develop innovative housing with care options

To stimulate effective local partnerships between the NHS, local housing authorities, social services authorities, care providers, housing associations and private sector and other developers of extra care housing in the interests of older people

(Department of Health, 2003)

PSSRU Evaluation: Aims

Evaluation of 19 new build schemes supported by the DH Extra Care Housing Fund (2004-2006)

Main evaluation: Short- & long-term outcomes for residents &

schemes

Comparative costs

Factors associated with costs & effectiveness

Role in overall balance of care

PSSRU Evaluation: Linked Studies

Extension to additional schemes: Wakefield

Birmingham & Plymouth (Thomas Pocklington Trust)

JRF-funded study of social well-being

JRF-funded study of Rowanberries, Bradford

EVOLVE: EPSRC-funded study of design evaluation (Sheffield/PSSRU)

PSSRU Evaluation: Extra Care Schemes

2004/052 retirement villages: 258 & 270 units7 newbuild: 344 units (38-75)2 newbuild/remodelled delayed: dropped

2005/061 retirement village: 242 units9 newbuild/remodelled: 372 units (35-

48)1 retirement village delayed: dropped

PSSRU Evaluation: Data Collection

Resident data Functioning, services, expectations & well-being

Moving in; 6, 12, 18 & 30 months later

Schemes Contextual information on opening

Social activities at 6 months

Costs and context a year after opening

Fieldworker questionnaire at end of data collection

PSSRU Evaluation:Response (November 2010)

No. No. resid

s

No. with data

No. with Res Q

No. with Ass Q

No. Ass Q + 6m

No. Ass Q + 18m

No. Ass Q + 30m

Smaller schemes

16 996 680 620 645 390 187 114

Villages

3 896 568 562 172 63 61 9

Total 19189

4124

8118

2817 453 248 123

Entrants to Extra Care (2006-10):

Require Help with IADLs

0

10

20

30

40

50

60

70

80

Perc

ent


Require Help with ADLs

0

10

20

30

40

50

60

Perc

ent

Entrants to Extra Care (2006-10) & Care Homes (2005): Barthel

Index of ADL

0

10

20

30

40

50

17-20 13-16 9-12 5-8 0-4

Perc

ent

Barthel score (grouped)

Extra care

Care homes

Entrants to Extra Care (2006-10) & Care Homes (2005): MDS CPS

0

10

20

30

40

50

60

70

0 1 2 3 4 5 6

Perc

ent

MDS CPS score

Extra care

Care homes


Change in Dependency by Follow-Up

Follow-up%

deteriorated

% improved

Barthel Index of ADL

0‒6 months

9 12

0‒30 months

22 8

MDS CPS0‒6

months8 6

0‒30 months

6 14


Location at End of StudyNumber %

Still in scheme 458 56.1

Moved 69 8.4

Nursing home 29 3.5

Care home 16 2.0

Elsewhere/not known

24 2.9

Died 161 19.7

Died in scheme 62 7.6

Died elsewhere 99 12.1

Lost to follow-up 129 15.8

Entrants to 11 Extra Care Schemes (2006-07): Mortality &

Survival

Number of individuals 374

Number of deaths 115

Mean time to death 20 months

% died by 30 months (≥65) 34%

Predicted median (50%) survival from model:

Extra care (≥65) 32 months

Care home (2005) 21 months

Nursing home (2005) 10 months

Cost Variations: Factors Associated with Higher Costs

Individual factors: Living alone Higher levels of physical and cognitive impairment Need for nursing care Long-standing illness Higher levels of well-being

Scheme-level factors: Separate housing management and care arrangements Higher staff turnover Larger housing providers London location

Cost-Effectiveness

Rowanberries study: higher cost/person associated with improved social care outcomes and quality of life

Comparisons of costs and outcomes with matched sample from 1995 care home survey: Lower costs: £374 vs £409 pw Slight improvement in physical functioning and cognitive

functioning stable for extra care Slight deterioration in functioning for care homes

Restricting comparisons to more dependent (2005 cases): Outcomes for extra care remain better Less evidence of cost savings

Social Well-Being Study

Role of communal facilities in friendship development: Smaller schemes: restaurants and shops – lunchtime Villages: indoor street and role of resident volunteers

Villages well-suited to more active people Poor health and receipt of care could hinder social

involvement – importance of staff support Links with local community valued – importance of

location Attitudes to other residents’ frailty and community

use of facilities

PSSRU Evaluation: Other Issues

Timescale of developments (resiting, redesign) Mixed tenure (demand) Future proofing (1-bed flats) Communal facilities and links with community Setting-up and participation in social activities Transport within and outside scheme Division of responsibilities for housing and care Expectations of partner organisations

PSSRU Evaluation: Summary

Average level of dependency lower than in care homes

Substantial need for help with IADLs & mobility Very few with severe cognitive impairment Cost-effectiveness analysis demonstrates potential

as alternative for proportion of care home residents Follow-ups demonstrate that can be home for life,

but support for cognitively impaired less certain Relationships between fit and frail, social groups

etc: importance of support and managing expectations, especially in villages

Discussion

Sustainability of extra care model: Pressure resulting from local authority nomination rights Maintenance of facilities (e.g. restaurants) Development of new schemes (provision relatively

limited) Public understanding/demand (downsizing) Local authority staff understanding and expectations Impact of policy developments (e.g. personal budgets)

Other issues: Management turnover and stability Relationships with local community

Is it expected to do too much?

Contacts

PSSRU publications on the evaluation: www.pssru.ac.uk/projects/echi.htm

Housing and Care for Older People Research Network: www.hcoprnet.org.uk/



Jeremy Porteus

Housing LIN

Extra Care

Extra Care – a sustainable solution to the care crisis?

Jeremy Porteus

13 September 2011

The economic case for independence at home?• A fall at home that leads to a hip fracture costs the state £28,665 on average – over 100 times the cost of installing hand and grab rails

• Where it is appropriate, postponing entry into residential care for one year saves an average of £28,080 per person • A hospital discharge service that enables older people to return to a safe and suitable home environment saves over £100 per day – the amount charged to local authorities when patients ‘block beds’

(source: Fit for Living Network Position Statement. hact, 2010)

The challenges facing health and social care

• 2.4million more older households by 2026 •Two thirds of older people with dementia live in their own homes, with one third in care homes•At least two thirds of people in care homes have dementia• There are approx 18,450 care homes in England• There are approx 4,897 home care agencies providing support to people living at home• People with dementia over 65 years of age are currently using up to one quarter of hospital beds at one time

Key policy developments and reports

•Dilnot Commission on Paying for Care & Support- the Commission hopes that more people will be able to consider extra care housing in the future, if they are more aware of this type of provision and can be more certain over their financial planning. - ..there is also an indication that they help people to avoid moving into more intensive residential care settings

•Age of Opportunity (CSJ) - .. We believe that as as country we have not yet realised the potential of extra care

Some questions when thinking about solutions for independent living for an ageing society

• How might accommodation and care for older people change over next 20-30 years to cater for ‘baby boomers’?• What impact will changing wealth and tenure on accommodation and services older people might want as opposed to might need • What will the implications of levels of equity held by older people, estimated to be £1trillion• How best to use the considerable asset of sheltered housing in the UK, estimated to be £40billion

And finally, why should our options for assisted living and lifestyle be limited as we get older? The market will demand a growing variety of independent living choices to meet the diverse of needs and aspirations of older people.

Thank You

Jeremy Porteus Housing LIN c/o EAC3rd Floor, 89 Albert EmbankmentLondon, SE1 7TPUK

email: [email protected] email: [email protected]: 07899 652626 tel: 020 7820 8077

website: www.housinglin.org.uk



http://www.housinglin.org.uk/

Extra Care – A Sustainable Solution to the Care Crisis?

Tuesday 13 September 2011

www.ilcuk.org.uk

extra care: a sustainable solution to the care crisis?

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