“We don’t have the infrastructure to support them at home”: How health system inadequacies impact on long-term care admissions of people with dementia
Introduction
The aging population across Europe has the potential to create considerable strain on long-term care service provision in the coming decades, particularly for people with dementia. In light of this, there is great interest in identifying the factors which predict transition of people with dementia to long-term care (LTC) services. Gerontological researchers have conventionally focused on the characteristics of the older person that influence the transition from community to LTC use [1], [2], [3], [4]. These largely emanate from what has been termed the ‘geriatric giants’ of ageing [5]. They include immobility, falls, incontinence as well as dementia [5], [6], [7]. However, meta-analyses in the area have acknowledged that this research contains a considerable degree of unexplained variance in the prediction of LTC admissions (ranging from 50 to 60%) [6], [8], [9].
The psychological health effects on family carers responding to a care recipient’s needs have also been recognised. Such work has led to the belief that, as family carers are critical to homecare, if the level of stress carer’s experience as a consequence of providing care becomes too great, the homecare arrangement may break down [10], [11], [12]. Indeed, a recent study of factors associated with long-term institutional care of people with dementia across Europe concluded that ‘“caregiver burden appeared the most consistent factor associated with institutionalisation” ([13] p.9).
However, a recent systematic review and meta-analysis indicates that family carer stress does not have as strong an effect on LTC admissions as was previously believed. Although a significant association was found, the effect size was negligible (SMD = 0.05, 95% CI 0.04–0.07) ([14] p.12). The results of this review suggest the need to look wider than the needs of the care recipient or the carer that mitigate against the continuation of homecare.
Despite the provision of homecare taking place within the context of the wider healthcare system, comparatively little attention has been concentrated specifically on healthcare system factors that influence the transition to LTC [15], [16]. As Muramatsu et al. acknowledge “the most understudied factors of nursing home admission are those related to the healthcare system” (16 p.S170). Where studies have examined healthcare system factors, they have identified the importance of community care services for people with dementia, options for service reconfiguration and potential costs savings [16], [17], [18], [19], [20], [21]. However, they have not addressed the implications of the interconnection between community and acute hospital care together in the transition to LTC [16], [19], [22]. Therefore, this study aimed to develop an in-depth understanding of how community and acute hospital care, along with the interconnection between the sectors, impact admissions of people with dementia to LTC. To the best of our knowledge, this present study is the first to examine this.
This issue has been examined in this study in the context of the Irish healthcare system. The national health service agency, the Health Service Executive (HSE), provides the majority of public acute hospital and community care services in Ireland. Acute hospitals provide services for medical and surgical treatment. These services include inpatient scheduled care, emergency care, maternity care and outpatient care and diagnostic services [23], [24]. The main state-funded community support services for older people are homecare package schemes which include community health nursing, home-help for domestic tasks or personal care assistants for intimate personal care. Respite may also be provided, depending on the person’s needs and where they live. Other HSE services for older people in the community include Physiotherapy, Occupational Therapy, Speech and Language Therapy and Social Work. The Nursing Home Support Scheme provides access to LTC facilities (known as nursing homes, residential care homes, assisted living facilities and care homes in different countries) [17]. The scheme provides financial assistance towards the cost of long term care services. It is administered by the HSE through the ‘Fair Deal’ scheme [25]. This scheme means that, depending on income or resources, applicants contribute towards the cost of LTC and the State pays the balance.
Following the economic crisis in Ireland in 2008 and the subsequent government programme of austerity, there have been continuous cuts to HSE staff numbers and budgets [26], [27]. For example, HSE funding has fallen by 22% from 2009 to 2013 [28]. Consequently, community care services have been reduced since the crisis. Data on home help hours are one of few measures of healthcare system activity in the community [29]. Home-help hours have decreased by 18% between 2008 and 2012 [28]. However, it should be noted that community care services were fragmented and under-funded prior to the economic crisis [30]. In terms of LTC, the number of LTC beds decreased from 25,209 in 2008 to 23,026 in 2013, despite the population aged over 85 increasing by 21.6% between the Census 2006 and 2011 [31]. This ageing population in Ireland is expected to result in an increased demand for LTC, assuming levels of community care supports remain consistent and age-standard disability rates continue to fall [32].
Section snippets
Study design
This study aimed to develop an in-depth understanding of the role of healthcare system factors in LTC admissions of people with dementia, thus a qualitative approach was adopted. This allowed for the nuances and complexities within the healthcare system to be analysed. We obtained ethical approval for the study from the Research Ethics Committee (REC) of the Royal College of Surgeons in Ireland (RCSI) (Ethics Reference number: REC1057b).
Sample
Participants included healthcare professionals and family
Profile of respondents
All family carers interviewed were providing care to a person with dementia. Thirteen women and three men participated. Nine participants were providing care to a spouse, while seven were providing care to a parent. Family carers were on average 60 years of age and were providing care to a loved-one who was on average 78 years of age.
A total of twenty-two healthcare professionals (HCPs) were interviewed, eighteen of whom were female. The largest group of professionals (n = 13) worked in nursing
Constrained community services impact on acute hospitals
The second major study finding indicates that constraints in community services were reported to impact on acute hospitals in two main ways, each of which are described below.
Pivotal influence of acute hospital admissions
The third major study finding suggests that there are multiple paths to LTC, presented in Fig. 2. The first is what could be referred to as the ‘ideal scenario’. That is, the person with dementia transitions from the community to LTC. This scenario is what is most often assumed when researchers analyse the care recipient factors that influence LTC admissions. However, healthcare professionals and carers reported that admission to LTC rarely happens this way. Rather, an admission to acute
Summary of findings
LTC admissions of people with dementia appear to be affected by inadequacies in the healthcare system. This was shown in participants’ experiences of limitations in community care services. How such limitations in community care were seen to increase acute hospital admissions and how admission of people with dementia to an acute hospital may accelerate the journey towards LTC for people with dementia.
The insufficiency and inequitability of community care services was seen in how constrained
Conclusions
Overall the findings suggest that the healthcare system is critical in the journey to LTC for people with dementia. This has implications for health policy makers and health services researchers. Firstly, in term of health policy, the apparent fragmentation and under-resourcing of community care services conflicts with Government Policy to support older people to remain at home for as long as possible and has a substantial impact on acute hospital admissions and LTC admissions of people with
Conflict of interest
The authors declare that there is no conflict of interest.
Funding
This work was funded by the Health Research Board (HRB) in Ireland under Grant No. PHD/2007/16. The funder had no role in the study design, data collection, analysis, interpretation, write-up of the data or the decision to submit the article for publication.
Acknowledgements
The authors are grateful to all the individuals who participated in the study as well as those who assisted with recruitment, particularly the Institute of Community Health Nursing, Care Alliance Ireland and Family Carers Ireland.
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