Caring for Older People: Community services: healthBMJ 1996; 313 doi: http://dx.doi.org/10.1136/bmj.313.7060.805 (Published 28 September 1996) Cite this as: BMJ 1996;313:805
Many frail or disabled elderly people are now being maintained in the community, partially at least as a consequence of the Community Care Act 1993. This paper details the work of the major health professionals who are involved in caring for older people in the community and describes how to access nursing, palliative care, continence, mental health, Hospital at Home, physiotherapy, occupational therapy, equipment, and optical, dental, and dietetic services. In many areas, services are evolving to meet needs and some examples of innovative practice are included.
The provision of health care to elderly people in the community is an important aim of the health service, perhaps particularly since the introduction of the Community Care Act 1993. About 8.5 million people over 65 years old are living in their own homes.1Older people comprise 70% of the 6.2 million people with disability, and 92% of elderly disabled people live in their own homes. The general practitioner plays a pivotal role in the delivery and coordination of such patients' health care. This article describes the role of other health professionals in caring for older people at home.
After inpatient medical care, rehabilitation and convalescence is often continued and completed in the community. District and liaison nurses provide continuity of care after discharge from hospital.
Liaison nurses are usually employed by hospitals and provide a professional link between hospital and community health services. They can improve the quality of transfer for patients from hospital to the community; liaise with social service departments and help to assess patients' needs; identify and respond to problems occurring at the point of discharge; and improve communication between services.
District nurses provide nursing treatment and support to patients and their caregivers within a variety of community settings—patients' own homes, health centres, and residential homes. They are key people in the community, the vast range of their work includes practical work such as dressing ulcers and pressure sores, maintaining bowel and bladder care and giving injections, as well as supportive components—for example, in palliative care. Referrals for continued nursing care are through general practitioners or through hospital based doctors or nurses. This service has usually been available in the daytime only, but some areas now have a night nursing service.
Specialist nurses provide specific services such as palliative care, continence management, and psychiatric services (see specific subsections below).
Palliative care services
Palliative care is the active total care of patients whose disease no longer responds to curative treatment and for whom the goal must be the best quality of life for them and their families. Most palliative care is for patients with cancer, and well over half the number of patients with advanced cancer are cared for at home by hospice and palliative home care services, which work closely with the patient's general practitioner and primary health care team.
In some areas, Hospice at Home schemes enable patients to stay at home. A comprehensive service, including practical nursing and night sitting, is provided by a multiprofessional team that has access to consultant advice and may be supported by experienced volunteers. The care at home is usually based on Macmillan nurses or the Marie Curie service.
Macmillan nurses were set up by Cancer Relief Macmillan Fund, which itself exists due to Douglas Macmillan who, shocked by the distressing death of his father, set up the charity in 1911 to improve awareness of cancer. The nurses are specialist trained to give supportive care and advice and are employed by the NHS. They provide information about illness and treatment and give advice on pain and symptom control and on financial entitlements, such as attendance allowance for caregivers. They offer time to talk through problems and anxieties, provide aids and equipment to assist in care, and provide support to caregivers.
Marie Curie service—The Marie Curie Memorial Foundation was established in 1948 and the name Marie Curie was chosen as a tribute to the scientist who discovered radium. The Marie Curie nurses, of whom there are 5000, provide free “hands on” nursing care for cancer patients in their own homes throughout the day and night; thus they also provide support and respite to informal caregivers. The service usually runs in conjunction with district nursing services, with access through the district nurses or the Marie Curie nurse manager.
Urinary incontinence affects 10-20% of elderly women and 7-10% of elderly men living in their own homes, and rates are much higher in elderly people in residential and nursing homes. The consequences of urinary incontinence are both medical and social, with higher rates of depression and social isolation among people who are incontinent. A thorough assessment of all people with incontinence is essential so that appropriate management may be planned. In many places this is provided by a continence service, which aims to promote continence and better management of incontinence and to increase public understanding of incontinence and its management.
The service is usually delivered by a district nurse, who assesses the individual's need. A specialist nurse continence adviser is also usually available, and there may be access to a continence clinic run by a physician, gynaecologist, or urologist with a special interest in the condition. In general the service includes
* Social and environmental assessment to maintain continence—for example by attention to
Mobility (walking aids, correct chair height)
Clothing adaptations (Velcro fasteners, etc)
Toilet facilities (grab rails, raised toilet seat)
* Advice on fluid intake and diet (encourage adequate fluid intake, reduction of caffeine and alcohol)
* Prevention of constipation
* Bladder retraining
* Pelvic floor muscle exercises
* Help with catheterisation: instruction in self catheterisation and on emptying catheter bags and dealing with blocked catheters
* Counselling for patients and caregivers
* Advice on appropriate aids to deal with incontinence:
Absorbent products such as pads, pants, and bed protection
Commodes and hand held urinals
In addition, urodynamic studies can be carried out to clarify the mechanism of incontinence. This is especially useful when empirical treatment has failed or when surgery would be clinically appropriate if a correctable condition was found.
Mental health services for elderly people
The elderly mental health services provide an integrated service to older people suffering from either functional or organic mental illness. The service aims to provide prompt assessment, treatment, and rehabilitation of elderly people with mental illness and to maintain them at home wherever possible. Access to the service is usually through general practitioners or other registered medical practitioners. The service is usually organised on a geographical basis. The team, headed by a consultant in old age psychiatry,2 may include community psychiatric nurses, psychologists, occupational therapists, and physiotherapists.
Community psychiatric nurses offer psychiatric nursing care and monitor the patient's mental state and the effects of psychoactive medication. They may also provide specific treatment such as anxiety management, relaxation techniques, and management of cognitive and behavioural problems.
Clinical psychologists provide psychological evaluation and assessment of cognition, behaviour, mood, and personality. They may contribute to the non-pharmacological management of psychiatric symptoms, such as anxiety or behavioural difficulties.
Occupational therapists and physiotherapists provide assessments and treatment to optimise independence in all activities of daily living.
Some areas have extended home respite schemes, which provide support to patients in their own home, thus reducing the strain on informal caregivers. These serve patients with mental illness, especially dementia.
Hospital at Home
Hospital at Home schemes are still being developed. Starting in 1978 in Peterborough, the first British scheme was based on the Bayonne “hospitalisation a domicile” programme in France. The aim is twofold: to provide a community based scheme which offers medical, nursing, and therapeutic care, support, and treatment to patients in their own homes, either after discharge from hospital or as an alterative to hospital admission; and to improve the quality of discharge from hospital for these patients and to help reduce the length of an inpatient stay.
Suitability for Hospital at Home schemes
Continued rehabilitation, such as stroke patients
Patients rendered temporarily dependent—for example, owing to fractures
Patients who had prolonged hospitalisation and who would benefit from specific rehabilitative programmes in their own homes, to rebuild confidence and restore skills in their own environment
The team implementing the scheme consists of nursing staff with a named team leader, usually trained in district nursing, who assumes responsibility for assigning health care support workers to the patients and for coordinating the service provision. The team also includes a physiotherapist and an occupational therapist. Patients are referred from hospital wards and from accident and emergency departments, from domiciliary visits by consultants, and from general practitioners and district nurses. Patients are assessed and accepted on to the scheme if their disability is likely to respond to the rehabilitation service of the team and can be managed safely at home.
Patients are usually supported for a finite period—often four to six weeks. Existing services such as district nursing, social services, day centres, and day hospitals continue to ensure continuity of care, and liaison with these services ensures that there is no duplication in care. The patient is evaluated regularly by the team leader and, when required, by the consultant geriatrician or general practitioner, but a formal review and interdisciplinary assessment of the patient's medical condition and ability to cope with functional activities of daily living is undertaken before discharge. Where appropriate there is handover to statutory services such as home care, meals on wheels, or community physiotherapy. The cost effectiveness of Hospital at Home teams is currently under assessment.
Community physiotherapists are based in health centres and provide advice, assessment, and short term intervention. They help with problems such as:
* Mobility after a fall, when confidence is reduced
* Mobility after hospitalisation for fractures, hip replacement, etc
* Strokes, giving advice on positioning, handling, and other aspect of rehabilitation
* Giving advice to carers and district nurses on safe handling and lifting
* Dealing with acute musculoskeletal problems
* Giving advice on exercises to prevent muscle wasting
Referrals are usually through general practitioners, district nurses, consultants, and physiotherapy staff based in hospitals.
Community occupational therapists are employed by social services and assess patients in their own homes. Though the main emphasis of their work is in providing equipment, they may be involved in organising extra services such as home help sessions. Occupational therapists may liaise with surveyors and planners regarding major adaptations and advise on the fitting of such items as stair rails, modified toileting and bathing facilities, and stair lifts. The implementation of the Community Care Act has increased demands on this service considerably.
The equipment service provides selected nursing aids and aids to daily living (see box). These are intended to aid recovery and rehabilitation after illness and to promote the independence of disabled people, to enable them to function in their own home environment.
In many areas there is an arbitrary and illogical distinction between “nursing aids” (supplied by health services, usually free of charge) and “aids to daily living” (supplied by social services, sometimes free). Other agencies are also involved, such as the wheelchair service, which provides specialist seating and wheelchairs, and housing agencies, which provide ramps.
Patients can get useful advice from disabled living centres (which are run by independent charitable institutions3) on what is available4 5 and where to get it. After the patient has been assessed by an occupational therapist, any health care professional may request equipment from the service.
Skilled assessment is required, so that appropriate aids are safe and effective, and also aesthetically pleasing and acceptable to the patient. The equipment service provides instructions to patients on how to use the device as well as follow up visits to monitor patients' progress.
Equipment commonly available from the equipment service
For nursing needs:
Mattresses, including pressure relieving equipment
Walking sticks and frames
For daily living:
Raised toilet seats
Bath boards, seats and mats
Visual problems become more common with increasing age. Though opticians may now make a charge for an eye test, many people can obtain free NHS sight tests (see box).
People entitled to free tests may have their sight tested at home if they are unable to get to an optician; they are also entitled to NHS vouchers to help pay for glasses. In addition, war pensioners who require sight tests or glasses as a result of a condition for which they get their pension may be able to claim some or all of the cost from the Department of Social Security.
Many elderly people retain few natural teeth. It has been estimated that 50% of over 65 year olds in Britain have used a full denture and 30% partial dentures. People who are unable to received treatment from a general dental practitioner may be treated by the community dental services. Such patients are mainly those with disability or infirmity and also those with medical conditions which make dental treatment more difficult. People who are housebound may be able to get their treatment at home.
The maximum cost of dentistry through the NHS is 80% of most treatments, up to a maximum of £275 for one course of treatment.
Exemption from charges
NHS sight tests
Registered blind or partially sighted people
People diagnosed as having diabetes or glaucoma or in a family with glaucoma
People receiving income support (or whose partner receives income support)
People with certificate AG2 (qualifying for low income entitlement)
Patients of hospital ophthalmologists
NHS dental treatment
People receiving income support (or whose partner receives income support)
People with certificate AG2
Chiropodists restore and maintain foot function and comfort through treatment and health promotion. Four in five people aged 65 or more have at least one foot problem and about half of these need a chiropody service, but it is estimated that only half of these patients currently receive treatment. Chiropody may be provided in community clinics, but domiciliary chiropody is available for patients who are housebound or have poor mobility. Referrals may be made by patients themselves or by doctors and nurses. “At risk” groups, such as people with diabetes, peripheral vascular disease, or peripheral neuropathy, are treated as a priority.
Most foot problems fall into the following categories:
* Foot ulcers—these can be neuropathic or ischaemic. In addition to treating foot ulcers, chiropodists give advice on preventive measures such as nail cutting and footwear
* Rheumatoid foot—deformation of the foot can occur by subluxation or dislocation at the metatarsophalangeal joints, and ulceration can occur at sites of nodules and bursae. Chiropodists can advise on appropriate footwear and protective insoles
* Nail problems (ingrowing toenails; onychogryphosis)—elderly people commonly have problems cutting long toenails. This usually arises because of a combination of impaired manual dexterity and limited hip and knee flexion
* Corns—pressure or friction causes these areas of hyperkeratosis; a chiropodist can provide advice on footwear
Malnutrition: those at greatest risk
Age over 75
Suffering from dementia
* Biomechanical problems—chiropodists can manufacture and fit corrective orthoses for mechanical problems of foot structure and function.
Chiropody services face a high level of demand. In some areas chiropodists' assistants perform the less technically demanding work. Some older people choose private chiropody, which is usually provided in their home and may be obtained more frequently than chiropody through the NHS.
Nutrition and dietetic services
A medical practitioner can refer an elderly patient at risk of malnutrition (see box) to a dietitian. The role of dietitians has evolved over the past 20 years, and they now provide nutritional education and treatment in the community. Patients may be seen in day centres, community hospitals, health centres, and at home.
Dietitians may offer simple, practical information about food to allow people to make informed choices about healthy eating or they may offer specific advice to the those with particular dietary requirements, such as patients with diabetes or those advised to follow a low fat diet. They may also provide help to patients receiving nasogastric or gastrostomy feeding.
As well as running commercial outlets, pharmacists offer advice to patients on the appropriateness of over the counter medications and can advise on risks of adverse drug reactions. Pharmacists may supply drugs dispensed in daily dose reminders,6 and some will deliver drugs to patients' homes.