Thursday 22 May 2008

Staffing Care Homes

I wrote about care homes and how, sometimes, they're the best place for a person to be.

Recently our Trust has been sharing experiences with an area in the USA.

This coincidentally resonated with a comment Pem made about quality of provision of community care. In the USA the best quality of care in hospitals is arguably the best in the world. It's got problems with delivering great care for chunks of the population, but what hospital care does well, it does very well.

Through funding pressures, community services (especially in mental health) are generally much less well developed in the USA than in the UK.

Both health and social welfare provision isn't brilliant in the UK, but it can be pretty good. It struck me that a gentleman of 62 with Parkinson's Disease who's developed PD dementia or Lewy Body Dementia can get very good care in the UK. There are many specialist units to look at younger adults/folk of working age with cognitive impairement. Thus his assessment, diagnosis and care planning can be generated by a dedicated Consultant Psychiatrist and a capable, motivated, enthusiastic multidisciplinary team. Ongoing community support from the team can be frequent (several times a week) with care provided by Health services in centres outside hospital environments. Any medication can be prescribed by the NHS Consultant Psychiatrist, protocols are simply guidelines and the Consultant has clinical latitude to prescribe in their patient's best interests (unlike when care's privately funded and either the hospital or the insurance company can curtail clinical freedom, meaning certain drugs may not be available).

Care can be shared across boundaries more readily in the UK, so this chap with Parkinson's Disease and dementia will be seen by a specialist early onset dementia team but also by a specialist Parkinson's Disease nurse and neurologist.

A real difference is in care homes. Within half an hour of where I'm sitting there are over 60 registered care homes. There's plenty of choice. What if a care home can't undertake the care the man needs and deserves? They've not the staffing levels, or experience? Well, resources can be put in place so they can meet his needs. A community team from the Trust can reach in to the care home, supporting their staff with ongoing training and education as well as modeling practical dementia care (e.g. getting him up and out of bed on a morning then having breakfast) so the care staff can learn good practice. If they don't have staffing levels to continue to attend to this, Continuing Care funding can ensure they do have cash for extra staff to be employed on the shifts so the gentleman can get the time needed. It may be he needs one to one care, if so, we can get it funded and he can get one to one care.

With mental health services providing continuity of his dementia care through a specialist team (which includes a dedicated Consultant Psychiatrist), social services providing funding for a 24 hour specialist care home for him, joint Continuing Care funding for extra staff, a Parkinson's Disease team providing continuity of care of his PD and mental health services having ongoing training for the care homes, the gentleman can receive exceptionally good care.

A work of fiction? An idealistic aspiration? Why, no, not at all. The scenario above describing the NHS and social provision is exactly, exactly what one of my patients (and his care home) is currently receiving.

The NHS can coordinate and deliver community care well. Sometimes we forget that.


Socrates said...

I'm afraid that other people have a very different experience of NHS health and social care . It's not an easy read nor for the feint hearted. And it's not an isolated case.

Pem said...

My husband isn't to the point of needed supervision yet, so I'm only in the early stages of researching options. But I'm worried, because I don't want to give up my job as a college professor to care for him.

At present my husband sees mainly a family practitioner and a local neurologist. The neurologist sent him to a Parkinson's specialist 4 hours drive away who diagnosed the Lewy Body Dementia. My husband is going to a psychologist tomorrow for neuropsych testing. There has been no mention of seeing a psychiatrist, but he doesn't at this point have any symptoms of psychosis. My impression is that once various testing is done he will see the neurologist every two or three months. He will also go to a sleep specialist. His health insurance pays 80% or more of those.

The health insurance will pay for a few months of physical therapy, but in general neither health insurance nor Medicare once he is 65 will pay for home health care or a nursing home. We don't have long-term care insurance so we will have to pay the costs (in this area currently around $60,000 a year) ourselves. If we impoverish ourselves then Medicaid will pay, but many nursing homes will not accept Medicaid patients.

The local nursing homes do not have separate units for dementia patients. I'm worried that even those that do will be set up for Alzheimer's and not well prepared to deal with hallucinations and delusions. Except for Hospice, I don't know of any system that provides nursing homes with the kind of extra training and medical help you write of. That integrated system sounds wonderful.

Cat said...

I think it's really important to look at the positives that exist in the system as the negatives get a lot of attention but there is some very good work going on as you testify.

The Shrink said...

Indeed, all too often we bash what's irritating/wrong but don't reflect on what's going well.