Promoting older people's voices- the contribution of social work to inter-disciplinary research.

UK government policies over the last decade or more have focussed on giving older people more voice in the design, delivery and assessment of services. Mirroring these trends, there has been a shift towards increased involvement of older people in the research process. Drawing on three research studies, this paper examines the contribution of social work to an inter-disciplinary research agenda designed to promote increased involvement of older people in issues of service quality in primarily health settings. Challenges and opportunities are discussed. Each of the studies illustrates the importance of promoting research practice congruent with social work's commitment to partnership and empowering forms of practice. This, it is argued, requires the challenging of ageist assumptions, the use of a range of research methods and the valuing of different forms of knowledge.

Nurse-led implementation of the single assessment process in primary care: a descriptive feasibility study.

OBJECTIVE: to determine the resources required to carry out the single assessment process in primary care. DESIGN: prospective descriptive study. SETTING: one urban primary care practice, Southampton. PARTICIPANTS: nine hundred and forty-four people aged 70+ years, registered with the practice, not living in a residential/nursing home, or terminally ill. INTERVENTION: participants were sent the six-item Sherbrooke questionnaire (case-finding tool). Non-responders were re-mailed after 4 weeks. All those scoring 4, 5 or 6 and a randomly selected half of those scoring 2 or 3 were offered overview assessment and comprehensive assessment as indicated by the Minimum Data Set for Home Care protocol. The nurse assessor identified unmet needs and agreed an action plan with participants. Another researcher conducted semi-structured interviews with a purposive sample of 26 participants to elicit their views of the process. MAIN OUTCOME MEASURES: response rates/scores of Sherbrooke questionnaire; numbers/characteristics of people requiring overview and comprehensive assessments; nature of resulting recommendations/referrals and impact on other agencies; resources required; views of service users. RESULTS: eight hundred and sixty-three (91%) participants replied. Five hundred and seven (54%) scored 2+, triggering an overview assessment, which was offered to 307. One hundred and twenty-four participants (40%) accepted; 64 (52%) had unmet needs (median 8 each, range 2-18), resulting in 34 referrals within the practice including four case conferences, and 21 to community/secondary health services. Few participants with a Sherbrooke score of 2 required comprehensive assessment. Users perceived the process as acceptable and useful, but not always relevant to their current needs. CONCLUSION: targeting those scoring 3+ on the Sherbrooke questionnaire (28% of sample) may improve the identification of patients who would benefit from further assessment. A contact approach rather than a case-finding one may improve the relevance of this process to older people.

The effectiveness of implementing a care pathway for femoral neck fracture in older people: a prospective controlled before and after study.

OBJECTIVES: To investigate whether a care pathway for older hip fracture patients can reduce length of stay while maintaining the quality of clinical care. DESIGN: Prospective study of patients admitted 12 months before and after implementation of a care pathway for the management of femoral neck fracture. Audit data for corresponding time periods from nearby orthopaedic units was used to control for secular trends. SETTING: Teaching hospital. SUBJECTS: Patients aged 65 years and over with a femoral neck fracture. EXCLUSION CRITERIA: multiple fractures, fractures due to malignancy, re-fracture, total hip replacement, previously entered into the study, operation performed elsewhere. Three-hundred and ninety-five (99%) and 369 (97%) case records were available for full analysis. MAIN OUTCOME MEASURES: primary outcome: length of stay on the orthopaedic unit. SECONDARY OUTCOMES: ambulation at discharge, discharge destination, in-hospital complications, 30 day mortality, readmission within 30 days of discharge, post-operative days the patient first sat out of bed and walked. RESULTS: Mean length of stay increased by 6.5 days (95% confidence interval 3.5-9.5 days, P < 0.0005) in the second period with a significant improvement in ambulation on discharge (odds ratio 1.6, 95% confidence interval 1.0-2.6, P = 0.033) and a trend towards reduction in admission to long term care (odds ratio 0.6, 95% confidence interval 0.3-1.0, P = 0.058). CONCLUSIONS: This care pathway was associated with longer hospital stay and improved clinical outcomes. Care pathways for hip fracture patients can be a useful tool for raising care standards but may require additional resources.

Appraising the evidence: reviewing disparate data systematically.

The authors describe a method of systematically reviewing research from different paradigms. They draw on the methods adapted, developed, and designed during a study concerned with the delivery of care across professional boundaries. Informed by the established method of systematic review, the authors undertook the review in distinct stages. They describe the methods developed for each stage and outline the difficulties encountered, the solutions devised, and the appraisal tools developed. Although many of the problems encountered were related to the critical assessment of qualitative research, the authors argue that the method of systematic review can be adapted for use with different data andacross disciplines.

Identifying 'value' in day care provision for older people.

Day care can play a prominent part in the overall development of high quality health and social care provision for older people. This paper describes an approach to evaluating day care services which brings together costs and service users' views as a means of establishing the overall 'value'. This strategy, it is argued, underlines the purpose of day care itself as a means of promoting the independence and autonomy of older people.

The communication of information about older people between health and social care practitioners.

AIM: to provide an evidence base for strategies, and effectiveness of the transfer of patient information between hospital and community for older people with physical illness. DESIGN: a systematic review of qualitative and quantitative literature. SEARCH STRATEGY: literature from medical, health-related and social science databases as well as work in progress from national databases, the Internet, British PhD theses and other grey literature and policy documents. SELECTION CRITERIA: literature relating to similar healthcare systems published between January 1994 and June 2000 on hospital discharge planning. Empirical studies from peer reviewed sources; theoretical papers from non-peer reviewed sources; research papers from non-peer reviewed sources and professional documents. DATA COLLECTION AND ANALYSIS: extracted data from empirical studies under the headings of location, sector, research questions and study design and duration. We made structured summaries of all other data sources and used them to supply context and background. We categorized literature and analysed it in terms of method and analysis, quality and strength of evidence and its relevance to the research questions. We synthesized the results and presented them in terms of answers to our research questions. RESULTS: a database of 373 potentially relevant studies and of these, 53 were accepted for further analysis. Thirty-one were empirical studies, most of which were qualitative or a combination of qualitative and quantitative in design. The most effective strategy for transferring information is the appointment of a 'key worker', who can provide a point of contact for workers from hospital and community. Nevertheless, problems have arisen because both settings are under pressure and pursuing different goals. Neither setting is fully aware of the needs, limitations and pressures of the other. CONCLUSION: raised awareness and the establishment of common goals are the first steps needed to bridge the divide between health and social care staff in hospital and the community.

Nutraceuticals: potential roles and potential risks for pain management.

Over the past 2 decades, the world health market has been flooded with over the counter herbal products, also known as nutraceuticals. Although many of these products are neither recommended nor prescribed by conventional medical practitioners, an increasing number of people are taking these products on a daily basis. A recent survey at Texas Tech University School of Medicine in Lubbock, Texas concluded that 32% of patients scheduled for elective surgery or pain procedures were taking one or more herbal supplements; however, 70% did not disclose these during a routine anesthetic assessment.(1) Pain physicians are also increasingly needed in the care of these patients. As many of these agents carry a potential to cause bleeding problems, we have reviewed here briefly, the basic mechanisms of coagulation and correlated the role of commonly used herbs known to possess side effects, which can cause excessive bleeding. In addition, we have reviewed a number of potential useful herbal derived agents for pain management.

Goal negotiation with older people in three day care settings.

Drawing on a wider study of effectiveness in three models of day care, this paper explores the process and outcome of goal negotiation with older people in a day hospital, an outreach service and a day centre. Using qualitative data from interviews with day care attenders and focus groups with service providers, differing perspectives on goal setting and achievement are presented. It concludes with a brief discussion of this approach in the wider context of promoting older people's participation in decision-making in day care settings, where the espoused emphasis is on maintaining and maximising personal autonomy and independent living.