Provision and perceived quality of mental health services for older care home residents

in England: A national survey

Running head: CMHTsOP outreach services to care home residents

Key words: care homes; older people; mental health; community mental health teams for older people; outreach

Key points:Care home residents are likely to have increasing levels of morbidity and having adequate services in place has the potential to make a significant contribution to quality of care. CMHTsOP were questioned about mental health provision and perceived quality of the support they provided.

Regular reviews of both the mental health of residents, including regular contact with a GP and anti-psychotic drug use, were associated with a better perceived quality of service by CMHTsOP managers.

Further research for mental health support to care home residents should focus on the use of specialist services, for example, dedicated specialist care home liaison teams and dementia specific services.

Authors:Karen Stewart, Research Fellow, Personal Social Services Research Unit, University of Manchester.

Claire Hargreaves, Research Associate, Personal Social Services Research Unit, University of Manchester.

Rowan Jasper, Research Assistant, Personal Social Services Research Unit, University of Manchester.

David Challis, Professor of Community Care Research, Personal Social Services Research Unit, University of Manchester.

Sue Tucker, Research Fellow, Personal Social Services Research Unit, University of Manchester.

Mark Wilberforce, Research Fellow, Personal Social Services Research Unit, University of Manchester.

David Challis1, Professor of Community Care Research, Personal Social Services Research Unit, University of Manchester. Telephone: 0161 275 5222. Email: david.j.challis@manchester.ac.uk

1 Corresponding author

1

Acknowledgements (including sponsor and grant number):

This paper outlines independent research commissioned by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research (grant number: RP-PG-0606-1109). The views expressed in this paper are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

We are very grateful to the CMHTsOP staff who participated in this research. This study was an anonymous service audit and did not require ethical permissions at the time it was undertaken.

Word count: 2770

Structured abstract

Objective

This study examined the nature, extent and perceived quality of the support provided by community mental health teams for older people (CMHTsOP) to care home residents.

Methods

A postal survey was sent to all CMHTsOP in England. Information was collected about teams’ staffing and their involvement in case finding, assessment, medication reviews, care planning and training as well as team managers’ rating of the perceived quality of the service they provided for care home residents. Data were analysed using chi-square tests of association and ordinal regression.

Results

Responses were received from 225 (54%) CMHTsOP. Only 18 per cent of these teams contained staff with allocated time for care home work. Services for care home residents varied considerably between teams. Two-fifths of teams provided formal training to care home staff. Team managers were more likely to perceive the quality of their service to care homes as good if they had a systematic process in place for reviewing antipsychotic drugs or routine mental health reviews, including contact with a GP.

Conclusion

The findings suggested that more evidence is needed on the best approach for supporting care home residents with mental health needs. Areas to consider are the potential benefits of training to care home staff and regular mental health reviews, utilising links between GPs and CMHTsOP.

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Introduction

Care home residents commonly have a mix of comorbidities affecting both physical and

mental health, with international evidence indicating growing dependency over time

(Chenoweth et al., 2009; Ballard et al., 2011; Gordon et al., 2014). Resident mental health is

a rising concern, with high levels of both dementia and depression reported (British Geriatric

Society, 2013). It has been estimated that dementia and/or significant cognitive impairment

is present in around three-quarters of UK care home residents (Macdonald et al., 2002), with

an estimated total of 322,000 people with dementia living in care homes (Alzheimer’s

Society, 2013). Clinically significant levels of depression affect between 30 and 45 per cent

of residents (Purandare et al., 2004; Dening and Milne, 2009; Milne 2016). Furthermore,

care home staff have found depression hard to detect in residents (Bagley et al., 2000).

Concern has been expressed about the extent and quality of specialist mental health support

provided to care home residents, with input from mental health services mainly occurring on

an ad-hoc basis and referrals to specialist services usually made at a time of crisis

(Department of Health, 2009). In one study, only half of care home managers reported the

frequency of visits by old age psychiatrists as adequate and a high proportion (80%) reported

a need for mental health education and training for staff (Purandare et al., 2004). Such

concerns are also evident in the Netherlands and United States (Seitz et al., 2010; Asch et al.,

2013). Furthermore, concern has been expressed regarding the overuse of antipsychotic

medication to manage the associated behavioural and psychological symptoms of dementia

(Alzheimer’s Society, 2007). There is evidence that these drugs are prescribed freely, not

always reviewed appropriately and not withdrawn as soon as they could be (Banerjee, 2009).

Furthermore, there is some evidence of their use in managing challenging behaviours in order

to reduce staff stress and burden (Szczepura et al., 2016).

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As part of England’s National Dementia Strategy (Department of Health, 2009),

recommendations for improving quality of care relevant for residents with dementia include

commissioning specialist in-reach services from community mental health teams to support

reduced reliance on antipsychotic medication for people with dementia and to improve

quality of care. Whilst primary care services are available to care home residents, specialist

mental health provision for older people, including care home residents, is provided in

England by community mental health teams for older people (CMHTsOP). These are

multidisciplinary teams within local mental health NHS Trusts and include old age

psychiatrists as core members (Tucker et al., 2014).

A recent literature review included multiple surveys exploring the support care homes receive

to address residents’ physical health care needs. However, less attention has been paid to the

services in place to support their mental health needs (Illiffe et al, 2015). This paper aims to

add evidence to the debate on the nature, extent and perceived quality of the provision of

specialist mental health outreach services provided by CMHTsOP to care home residents.

The main aim is to identify the factors that are associated with better quality of care for this

client group. The results explore an overview of support provided, service profiles and

factors associated with team managers’ perceived quality of support they provide to care

homes.

Method

Data

A national cross sectional survey of all CMHTsOP in England was undertaken in 2011/12 to

provide an overview of the nature and extent of the mental health support provided to care

homes. A database of CMHTsOP was compiled by updating records obtained through an

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earlier study (see Wilberforce et al, 2011). Following a pilot of the questionnaire to three

teams and its subsequent revision, a postal questionnaire was sent to the team managers of the

421 CMHTsOP identified in England in July 2011. A second mail out to non-respondents

was conducted in August, followed by telephone reminders. Data collection concluded in

January 2012.

Data were collected from team managers on four areas. First, CMHTsOP staff support

detailing numbers of staff and their involvement in care homes, including allocated staff time

and the provision of training. Second, support activities provided by CMHTsOP staff,

including case finding and screening, assessment of residents' mental health and medication

review, and involvement in care planning. Third, professional involvement of external

groups e.g. GPs or pharmacists in the support activities provided by CMHTsOP detailed

above. Fourth, CMHTsOP managers’ views of mental health provision provided to care

homes; respondents were asked to evaluate the statement: ‘the quality of the specialist mental

health support provided to care homes in our area is good’ by indicating the strength of their

(dis)agreement on a 4-point Likert scale (completely agree, tend to agree, tend to disagree

and completely disagree).

Statistical Analysis

Data were coded and entered into SPSS (version 19; SPSS Inc, Chicago, USA). Chi-square

tests were used to explore associations between the binary independent factors listed in Table

2 and perceived quality of support to care homes. The dependent variable was originally a 4-

point quality in care home preference variable, however, as so few respondents (n = 3)

selected ‘completely disagree’, it was combined with ‘tend to disagree’.

5

To investigate the relationships further a proportional odds ordinal logistic regression

analysis was conducted. This analysis allowed for the ordinal structure of the dependent

variable, the three point quality in care home preference variable. One of the assumptions of

the statistical technique was that the proportional odds i.e. the relationship between each pair

of outcome groups (completely agree, tend to agree and disagree) was the same. Through

running three separate binomial logistic regressions, one for each pair, the model was found

to meet the proportional odds assumption. In addition, the test assumes that there is little or

no multicollinearity (highly correlated predictor variables) in the data. Correlations between

the independent variables confirmed the absence of multicollinearity.

Results

Overview

Questionnaires were returned by 231 CMHTsOP, six were excluded as they were specialist

care home liaison teams, giving a final sample of 225 questionnaires (a 54% response rate).

Responses were received from 56 NHS Mental Health Trusts in England with between one

and 11 teams returning questionnaires in each Trust.

Table 1 provides an overview of the teams and staff numbers by nine geographical regions.

These nine regions comprise all local authority areas in England and provide a representation

of spread across the country. A larger proportion of questionnaires were received from the

North West (18.2%) and South East (17.3%) and fewer returned from North Eastern (6.2%),

East Midlands and Greater London regions (both 7.1%). Overall, the average number of staff

was 19 per team and ranged from two to 61. Staff numbers varied by geographical region,

with the largest teams evident in North Eastern (22.6%) and the smallest in the East Midlands

(15.8%). Overall, two-thirds of staff were professionally qualified. Differences were evident

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across areas, with North Eastern having the highest average of professionally qualified staff

(16.7%) and the East Midlands having the lowest (10.9%).

Service profiles

Mental health support provided to care homes varied across the 225 CMHTsOP (Table 2). In

terms of staff support, two-fifths of teams provided formal training to care home staff and

fewer than a fifth ensured all members had allocated care home time. Furthermore, fewer

than a sixth of managers agreed care home staff had the skills they needed to care for

residents with mental health problems.

Of the support activities provided by CMHTsOP approximately two-thirds provided regular

assessments involving multiple sources, e.g. liaising with other professionals (both GP and

care home staff), family consultations and records reviewing. Additionally, a systematic

process for reviewing antipsychotic drugs and routine mental health reviews of residents

occurred in two-thirds of teams. Around half provided regular mental health reviews, again

involving multiple sources to complete these. CMHTsOP undertook regular care planning

advice in a variety of ways, e.g. in a regular/as required home visit, an open clinic or

telephone support. Two-fifths provided a regular systematic process for reviewing

antipsychotic drugs involving multiple sources and a quarter initiated screening in care

homes.

For the professional involvement of external groups almost four-fifths of CMHTsOP

provided regular assessments of care home residents involving contact with a GP. Around

two-thirds provided a routine mental health review with a GP and had a regular systematic

process for reviewing antipsychotic drugs, which involved a medical contact.

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Chi-square analysis

CMHTsOP providing formal training to care home staff and services providing routine

mental health reviews with a GP were significantly associated (p<0.05) with managers’

perceived quality of the specialist mental health support provided to care homes in their area

(Table 2). Over 90 per cent of managers of services providing either of the above agreed

(tend to agree, completely agree) that the quality of specialist mental health support provided

to care homes in their area was good. Whilst managers of services that provided neither of

these were twice as likely to disagree.

A further five factors were found to be more weakly associated with perceived quality of

specialist care home support (p<0.10). These included four support activity factors:

systematic process for antipsychotic drugs, routine mental health reviews of residents, regular

reviews involving multiple sources, and regular care planning advice involving multiple

approaches; and one professional involvement factor: regular systematic process for

antipsychotic drugs involving a GP or pharmacist.

Ordinal regression

Table 3 displays the results of the proportional odds logistic regression investigating the

association between managers’ perceived quality of the specialist mental health support

provided to care homes and service provision. One staff support factor and two professional

involvement factors were found to be significantly associated with managers’ perceived

support quality: routine mental health review of residents; regular systematic process for

antipsychotic drugs involving medical contacts; and routine mental health review including

contact with a GP. Whilst formal training was found to be highly associated in the chi-square

analysis it was not significant when all variables were taken into account.

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Managers of services offering routine mental health reviews of residents were almost twice as

likely to agree that the specialist mental health support provided to care homes in their area

was good. Equally, managers’ perceived quality of support increased twofold when their

service included a regular systematic process for review of antipsychotic drugs or routine

mental health reviews, including contact with a GP.

Discussion

This paper adds evidence on the nature, extent and perceived quality of the provision of

specialist mental health outreach services, provided by CMHTsOP, for care home staff and

residents. It identifies key factors associated with better quality of care for this client group.

The study found variation across the country in team composition and the support activities

they provided. Methodological considerations and implications for practice are considered

below.

Methodological considerations

The focus of this study was the support provided to residents in care homes by CMHTsOP

and the survey achieved a relatively high response rate of 54 per cent leading to confidence in

the results. The following limitations can be identified in this study. First, responses from

six specialist care home liaison teams were omitted as there were too few responses to

analyse. However, the questionnaire was not sent to specialist teams and these were not the

focus of the study. Second, the medication focus for this study was only on anti-psychotics

and CMHTsOP may also review psychotropic medications alongside these. A broader

medication question should be considered in future. Third, the quality of the support

provided, the dependent variable in the regression, was a personal judgement made by team

managers. Whilst this self-reported quality measure was subject to bias, the distribution of

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the responses provided confidence in this variable. A further paper will assess the quality of

mental health support received from the perspective of care home managers. Finally, it is

important to acknowledge that this study was undertaken before the full effects of public

sector cutbacks had taken place (and which are ongoing). Since fieldwork completed, reports

suggested that implementation of the National Dementia Strategy (Department of Health,

2009) was hindered by financial constraints (All-Party Parliamentary Group, 2014).

Furthermore, recent media reports raise concern that care homes may have been particularly

affected (Ruddick, 2017), which is tentatively supported by early evidence linking local

authority funding cuts with reduced care home quality in some instances (Burns et al., 2016).

Implications for practice

In recent years there has been some increase in dedicated specialist care home support

services, and there is evidence that these services can improve quality of care for residents

and reduce anti-psychotic drug use (Hirst and Oldknow, 2009; Lawrence and Banerjee, 2010;

Tucker et al., 2014). Such specialist services may be increasingly beneficial given the rising

concern with residents’ mental health needs (British Geriatrics Society, 2013). This is

enhanced by evidence that teams provided more intensive support to older people living at

home compared with care home residents, where the focus was on supporting care home staff

(Challis et al., 2014). There was also evidence of low numbers of team staff having allocated

care home time, although this may be a function of how commissioners specify time use

rather than how time is allocated within a team. An area for future research may be to

investigate the use of dedicated care home services.

Training may be an important component of a quality service as it has been shown to help

staff in care homes in their work with vulnerable residents (Hughes et al., 2008; Spector et

al., 2016). This could be in terms of formal training sessions or informal advice on

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individual residents. Different levels of training provision have been shown in previous

studies, for example, one found 47 per cent of old age psychiatry services provided formal

training sessions (Challis et al., 2002), and another reported 51 per cent of teams provided

training to care home staff (Tucker et al., 2007). A later study found a lower number

provided education to staff (43%) (Tucker et al., 2014). The current study only found 41 per

cent provided formal training sessions to care home staff. However, it is important not to

discount the informal learning that the engagement of team staff in a care home can provide

and further research may be valuable in this area. Indeed, the impact of both formal training

and informal learning may be manifested through better engagement of staff in case-finding,

assessing and reviewing of care home residents undertaken as part of the involvement of

CMHTsOP.

In England antipsychotic management is largely managed by GPs and in this study regular

involvement of GPs with CMHTsOP staff was associated with a better perceived quality of

service. However, as found in this study and elsewhere, regular reviews are not always

undertaken (Banerjee et al., 2009; British Geriatrics Society, 2011; Szczepura et al., 2016).

Whilst it has been suggested that prescribing rates of anti-psychotic medication and length of

treatment have not changed since the National Dementia Strategy was implemented in 2009

(Szczepura et al., 2016), account should be taken of the rising numbers of residents with

dementia in care homes and that these findings should be seen in this context. Furthermore,

there is evidence of continuation of anti-psychotic treatment to reduce care home staff

difficulties and distress (Zuidema et al., 2011). Hence, it is not clear from the available

literature whether or not there has been an improvement in anti-psychotic drug use in recent

years following the recommendations of the National Dementia Strategy (Department of

Health, 2009).

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Conclusion

This postal survey of CMHTsOP provides evidence on the nature, extent and perceived

quality of specialist mental health support provided to care home residents. Key issues to

consider for the future include: the importance of training provided by team members to care

home staff to improve their skills and enhance capacity; working with GPs to a greater extent

leading to a better quality service; and undertaking regular mental health reviews, including

antipsychotic drugs. Further research should be undertaken on the key issues examined in

this study as well as the use of specialist services, for example dedicated specialist care home

liaison teams and dementia specific services.

Key points box:

Care home residents are likely to have increasing levels of morbidity and having

adequate services in place has the potential to make a significant contribution to

quality of care.

CMHTsOP were questioned about mental health provision and perceived quality

of the support they provided.

Regular reviews of both the mental health of residents, including regular contact

with a GP and anti-psychotic drug use, were associated with a better perceived

quality of service by CMHTsOP managers.

Further research for mental health support to care home residents should focus

on the use of specialist services, for example dedicated specialist care home

liaison teams and dementia specific services.

12

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Table 1: CMHTsOP and staff descriptors by geographical region

Geographical region

Number of CMHTsOPn* (%)

Mean number of CMHTsOP staff (SD)

Mean number of professionally qualified CMHTsOP staff** (SD)

Eastern 24 (10.7) 16.57 (10.35) 11.83 (8.20)

East Midlands 16 (7.1) 15.81 (8.74) 10.94 (7.01)

Greater London 16 (7.1) 18.13 (4.98) 14.20 (4.21)

North Eastern 14 (6.2) 22.64 (12.44) 16.71 (10.38)

North West 41 (18.2) 19.13 (10.33) 13.28 (6.57)

South East 39 (17.3) 20.64 (9.16) 12.61 (6.10)

South West 32 (14.2) 20.03 (12.91) 13.91 (9.41)

West Midlands 18 (8.0) 18.76 (8.11) 13.41 (6.81)

Yorkshire and

Humberside25 (11.1) 17.91 (8.58) 12.00 (5.62)

*n=225**Not including administrative staff or support workers

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Table 2: Factors associated with the extent to which CMHTsOP managers agree with the statement ‘The quality of the specialist mental health support provided to care homes in our area is good’ (dependent variable).

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a All four sources: liaison with GP; discussion with care home staff; records review; and family consultation. b All four contacts: liaison with GP or pharmacist; discussion with care home staff; records review; and family consultation.

c At least three approaches: regular home visits; as required home visits; open clinics; and telephone support.

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Dependent variable

n (%)

Completely disagree or tend

to disagree%

Tend to agree%

Completely agree%

Chi-square p-value

Independent variableCMHTsOP staff supportAll staff have allocated care home time

Yes 39 (18.1) 7.7 43.6 48.7 4.0 .136No 177 (81.9) 13.0 54.8 32.2Staff provide formal training to care home staff

Yes 89 (40.5) 6.7 50.6 42.7 7.6 .022No 131 (59.5) 16.8 55.0 28.2Managers agree care home staff have the skills theyneed to care for residents with mental health problems

Yes 32 (14.5) 9.4 53.1 37.5 0.5 .795No 188 (85.5) 13.3 53.2 33.5

Support activities provided by CMHTsOPInitiated screening in care homes

Yes 55 (25.6) 7.3 47.3 45.5 4.6 .102No 160 (74.4) 13.8 55.6 30.6Regular assessments involving multiple sourcesa

Yes 136 (63.6) 10.3 56.6 33.1 1.8 .405No 78 (36.4) 14.1 47.4 38.5Systematic process for antipsychotic drugs

Yes 150 (69.1) 9.3 51.3 39.3 5.0 .082No 67 (30.9) 16.4 58.2 25.4Regular systematic process for antipsychotic drugsinvolving multiple contactsb

Yes 86 (40.2) 10.5 50.0 39.5 1.3 .529No 128 (59.8) 11.7 56.3 32.0Routine mental health reviews of residents

Yes 126 (58.6) 10.3 49.2 40.5 5.0 .083No 89 (41.4) 13.5 60.7 25.8Regular reviews involving multiple sourcesa

Yes 120 (56.1) 7.5 58.3 34.2 5.0 .084No 94 (43.9) 17.0 48.9 34.0Regular care planning advice involving multipleapproachesc

Yes 96 (44.9) 10.4 45.8 43.8 5.8 .055No 118 (55.1) 12.7 59.3 28.0

Professional involvementRegular assessments involving contact with GP

Yes 167 (78.0) 11.4 55.1 33.5 1.0 .598No 47 (22.0) 12.8 46.8 40.4Regular systematic process for antipsychotic drugsinvolving GP or pharmacist

Yes 131 (61.8) 8.4 51.1 40.5

Table 3: Predictors of CMHTsOP managers’ perceived quality of the specialist mental health support provided to care homes in their area

Variable p-valueStandard

error

CIOdds ratioLower Upper

Systematic process involving medical contactsNo (reference) - - - - -Yes 0.035 0.300 0.046 1.223 1.886

Undertakes routine mental health reviews of residentsNo (reference) - - - - -Yes 0.027 0.293 0.072 1.222 1.91

Mental health review includes contact with a GPNo (reference) - - - - -Yes 0.038 0.314 0.037 1.267 1.92

Model fit: -2 log likelihood = 57.766; X2 = 15.195; p = .002Proportional odds test X2(3) = 4.48, p = 0.214

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