Isolating residents including wandering residents in care and group homes: Medical ethics and English law in the context of Covid-19.

This article investigates the lawfulness of isolating residents of care and group homes during the COVID-19 pandemic. Many residents are mobile, and their freedom to move is a central ethical tenet and human right. It is not however an absolute right and trade-offs between autonomy, liberty and health need to be made since COVID-19 is highly infectious and poses serious risks of critical illness and death. People living in care and group homes may be particularly vulnerable because recommended hygiene practices are difficult for them and many residents are elderly, and/or have co-morbidities. In some circumstances, the trade-offs can be made easily with the agreement of the resident and for short periods of time. However challenging cases arise, in particular for residents and occupants with dementia who 'wander', meaning they have a strong need to walk, sometimes due to agitation, as may also be the case for some people with developmental disability (e.g. autism), or as a consequence of mental illness. This article addresses three central questions: (1) in what circumstances is it lawful to isolate residents of social care homes to prevent transmission of COVID-19, in particular where the resident has a strong compulsion to walk and will not, or cannot, remain still and isolated? (2) what types of strategies are lawful to curtail walking and achieve isolation and social distancing? (3) is law reform required to ensure any action to restrict freedoms is lawful and not excessive? These questions emerged during the first wave of the COVID-19 pandemic and are still relevant. Although focussed on COVID-19, the results are also relevant to other future outbreaks of infectious diseases in care and group homes. Likewise, while we concentrate on the law in England and Wales, the analysis and implications have international significance.

Evidence-based practice in group care: the effects of policy, research, and organizational practices.

This article describes the effect of a province-wide vision of evidence-based and outcome-based services for children and youth and the challenges of implementing evidence-based practice (EBP) and evidence-based treatment (EBT) approaches within group care settings. The paper is based on the results of a survey of group care settings in the province of Ontario, Canada, which was designed to understand the factors affecting the use of EBP and EBT. The critical roles of policy, access to research, and organizational structure as they affect the frontline workforce were explored. The results identified key differences between programs who implemented an evidence-based approach and those who are struggling to do so. Differences in case management practices as well as organizational factors affect the program's ability to use an evidence-based approach.

Prospects of future measures for persons with dementia in Japan.

In May 2008, the Japanese government launched the 'Emergency Project for Improvement of Medical Care and Quality of Life for People with Dementia' under the idea that it is necessary to build a society, without delay, where people can live life safely without anxiety even after being affected by dementia, where they can be supported by appropriate and integrated services of medical care, long-term care and community care. We would like to introduce our future dementia policy standing on the outcome of this project, which was published as a report on 10 July 2008. The measures for people with dementia in Japan have gradually achieved good results. For example, public understanding and awareness of dementia has increased through renaming the term for dementia in Japanese from 'Chiho' to 'Ninchi-sho' in 2004, and the comprehensive care system was founded focusing on the importance of providing community based long-term care while maintaining the person's familiar human relationships and residential circumstances. However, case reports show that there are yet some cases that fail to deliver appropriate treatment or long-term care service as a result of a lack of timely definite diagnosis in an early stage or a lack of coordination between medical care and long-term care. Therefore, the future dementia policy should be designed by envisaging the flow of the measures that would support the life of the person and his/her family, and improve their quality of life; starting with measures that link early notice of the patient, his/her family or neighbor to early diagnosis, and then measures to develop well-designed comprehensive care planning that provides appropriate medical and long-term care services through good coordination, while promoting research and development of diagnosis/treatment technology. In addition, in regard to early-onset dementia, comprehensive self-support measures including employment assistance should be promoted.

Living 'a life like ours': support workers' accounts of substitute decision-making in residential care homes for adults with intellectual disabilities.

In England and Wales, the Mental Capacity Act 2005 (MCA) provides a new legal framework to regulate substitute decision-making relating to the welfare of adults who lack the capacity to make one or more autonomous decisions about their care and support. Any substitute decision made on behalf of an adult lacking capacity must be in his/her 'best interests'. However, the value of adopting established principles and procedures for substitute decision-making in practice is uncertain, and little is known about the legal or ethical dynamics of social care support, including the day-to-day residential support provided to adults with intellectual disabilities (ID). Methods This paper reports a qualitative, grounded theory analysis of 21 interviews with support workers working in residential care homes for adults with ID, and observations of care practices. Results In contrast to the narrow legal responsibilities placed upon them, it is argued that support workers interpret substitute decision-making within a broad moral account of their care role, orientating their support towards helping residents to live 'a life like ours'. In so doing, support workers describe how they draw on their own values and life experiences to shape the substitute decisions that they make on behalf of residents. Conclusions Support workers' accounts reveal clear discrepancies between the legal regulation of substitute decision-making and the ways that these support workers make sense of their work. Such discrepancies have implications both for the implementation of the MCA, and for the role of support workers' values in the conceptualisation and delivery of 'good' care.

Prevalence of mental disorders and associated service variables among Ontario children who are permanent wards.

OBJECTIVE: To identify the prevalence rate of mental disorders among Ontario children who are permanent wards and also the key practice and descriptive variables associated with their diagnostic status. METHOD: I reviewed case files from a stratified random sample of 429 Ontario children who were permanent wards with no access to biological parents on December 31, 2003. Data abstracted from files included information on descriptive variables (such as age, sex, and type of permanent ward), all disorders (that is, mental and other current medical diagnoses and disabilities), family history, maltreatment experiences, service history (such as age at admission to care and current residential placement type), and permanency plans. RESULTS: The prevalence of mental disorders was 31.7%. A significantly higher proportion of children with mental disorders experienced maltreatment. Children with mental disorders were almost 3 times more likely than those without mental disorders to be placed by Children's Aid Societies in privately operated resources, such as group homes, and almost 10 times less likely to be living in a probationary adoption home. Although children with mental disorders were less likely to have a permanency plan of adoption than were children without mental disorders, regression analysis found that only 2 variables--age on becoming a permanent ward and age at the time of the study--were predictive of children's adoption plans. CONCLUSIONS: The findings support the need for improved monitoring of the aggregate mental health needs of children who are permanent wards. Numerous implications for service delivery and future research are discussed.

Comparison of reports by relatives and staff on living conditions of adults with intellectual disabilities.

Proxies typically serve as information providers in studies of persons with intellectual disabilities. However, little is known about the concordance between different proxy categories and how proxy characteristics influence the information provided. We compared 89 pairs of relative and staff reports on the living conditions of persons with intellectual disabilities, using percentage agreement and Cohen's kappa statistics. Results demonstrate differences between relative and staff reports for most of the domains investigated, with moderate agreement for objective items and fair agreement for subjective items. Relative and staff proxies contributed different information related to diverse viewpoints and varying types of information. Thus, we suggest that information provided by proxies should not be treated as being interchangeable but, rather, as complementary.

[Managing self determination and sexual violence in homes for young adults with mental handicap--report from an ongoing German model project]. / Umgang mit sexueller Selbstbestimmung und sexueller Gewalt in Wohneinrichtungen für junge Menschen mit geistiger Behinderung--Bericht aus einem laufenden Bundesmodellprojekt.

This report is based upon a model project financially assisted by a grant from the German Federal Ministry for Families, Senior Citizens, Women and Youth, starting in 1999 and ending at the end of 2003. In cooperation with two disability care residential institutions, a conceptual approach and method to the questions of sexual self-determination and sexualized violence is being developed. Through qualitative methods of research e.g. focus groups, professional helpers of all hierarchies of the institution, including management, and the residents themselves, all had the chance to contribute their own opinions and experiences to the research topic. Specifically, to ensure their voice was heard, the people with mental retardation had an important impact on the questionnaire themselves. All aspects of sexuality were discussed--with notable difficulty arising in particular over the subject of sexual violence. It turned out that nonverbal communication and the interaction between the group members in the residents group were most indicative of their concerns. The staff at the nursing and living areas discussed the following topics: distance and closeness in the interaction between staff and residents, standards, reflections of their own professional attitudes, questions of legality as well as the tense topic of individual needs and tasks of the group. How those questioned described their solutions and ways of coping, and the impressions of the researchers forms the starting point for the compiled work. The initial ideas for the topics and the design of the concept are now laid out.

Fair play on the housing front.

People with disabilities are treated unfairly in many community-based housing programs. Forcing a person to participate in a program simply because he or she is a tenant is discriminatory and many advocacy groups are questioning the legality of the practice. People with disabilities must be able to choose where they wish to live and the services they need.

Balancing restriction and freedom in the care of people with intellectual disability.

The case of a 50-year-old man with severe intellectual disability is described. After 20 years of institutional care, the subject was moved to a newly opened community group home. His physical and mental health deteriorated at this location after unproven allegations of sexual abuse which had taken place whilst he had been living in the institution. Although the subject's health continued to deteriorate, there was resistance to his readmission to the same hospital for assessment. He had always needed to be cajoled into eating, but this approach had not been followed by the home which had contributed towards his weight loss. The situation the subject, the carers and the health personnel found themselves in illustrates how problematic it is to find the right balance between restrictive practices and respect for an individual's choice.

Child and Adult Care Food Program: improved targeting of day care home reimbursements--Food and Consumer Service, USDA. Final rule.

This final rule amends the Child and Adult Care Food Program regulations governing reimbursement for meals served in family day care homes by incorporating changes resulting from the Department's review of comments received on a January 7, 1997, interim rule. These changes and clarifications involve: The appropriate use of school and census data for making tier I day care home determinations; documentation requirements for tier I classifications; tier II day care home options for reimbursement, including use of child care vouchers; calculating claiming percentages/blended rates using attendance and enrollment lists; and procedures for verifying household applications of children enrolled in day care homes. This final rule also amends the National School Lunch Program regulations to facilitate tier I day care home determinations by requiring school food authorities to provide elementary school attendance area information to sponsoring organizations. These revisions implement in final form the provisions of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 to target higher CACFP reimbursements to low-income children and providers.

A consumer satisfaction survey of people with mental retardation and mental illness.

This study investigated consumer satisfaction among 98 members of the Thomas S. class action lawsuit in North Carolina, in which the court ordered implementation of habilitative and residential service plans. Class members have mental retardation, and most also have a mental illness. Before the court order, 83 of the consumers were inappropriately placed in state psychiatric hospitals; one year after, 82 were living in community residences. A survey at baseline and one year later indicated that consumers' satisfaction had increased significantly. They were more satisfied with where they lived, the food, and the level of freedom. They also felt that staff were more helpful, and that more staff were "nice" rather than "mean."

Impact of regulation and financing on small board-and-care homes in Maryland.

States use forms of regulation in small board-and-care homes to control quality; however, quality varies in spite of these efforts. This study of 94 small facilities compared quality of care measures in homes regulated by a state-administered program with those in nonregulated homes. It also compared homes on those variables using average payment for services as the independent variable. Results indicate that higher payments for services had a greater impact on quality than did participation in a regulatory program. Adequate funding may be key to maintaining reasonable quality in these homes.

Court says insurer needn't pay for town's illegal discrimination.

AIDS: Reliance Insurance Company is not legally obligated to indemnify the town of Waterford, NY, under its errors and omissions policy. Waterford officials tried unsuccessfully to block the Support Ministries for Persons with AIDS from converting a structure into a 15-bed group home for people with AIDS. A Federal judge ruled that Waterford officials violated the Fair Housing Act. In 1990, village officials amended the zoning law to prohibit group homes, making it impossible for Support Ministries to pursue its plans. Support Ministries alleged that Waterford violated the Federal Fair Housing Act by discriminating against people with disabilities; a Federal judge found Waterford guilty. The village must pay more than $108,000 in legal bills and compensatory damages. The insurance policy states that village officials would not be indemnified for willful violation of the law.^ieng

Supported housing for the mentally ill elderly: implementation and consumer choice.

The development of innovative alternatives to nursing homes is critical, especially in the context of OBRA mandates and the growing geriatric population. This article examines the experience of one urban country in Washington State in providing supported housing for the OBRA-affected mentally ill elderly. The significance of this demonstration project is its "bold" new approach in applying this emerging model to the elderly. It illustrates the perspectives and experience of both consumers and caregivers in implementing the supported housing approach, and the tensions between consumer preferences and staff, organizational and funding constraints.