Birmingham Mind
Quantitative Evaluation of
Older Adults Outreach
Service
Final Evaluation Report
January 2015
Acknowledgements
The evaluation team would like to thank everyone who participated in the research over the
past 3 years, without the involvement of clients and their carers this report would not have
been possible.
We'd also like to thank all the Mind Older Adults Outreach Service workers for their help
and support gathering data, introducing us to clients and carers, taking part in one to one
interviews, focus groups and for completing the online survey.
Particular thanks go to Becky Smith, Pat Motzheim which in the early days of the evaluation
were instrumental in helping the evaluation understand the work of the service.
Merida would also like to thank John Bristow and Melanie Moxon for their patience,
excellent partnership working with all the evaluation team and unfailing good humour in
the face of many questions and requests for information.
Commissioned by Birmingham Mind
Written by Polly Goodwin, Angus McCabe, Karen Garry and Dr Ruth Wilson
January 2015
[email protected]
www.merida.co.uk
© Birmingham Mind 2015
Contents
1. Introduction
1
2. Context for the Mind Older Adults Outreach Service
1
2.1 Prevalence
1
2.2 Policy themes and initiatives
4
2.3 Dementia services in Birmingham
9
3. Evaluation approach and methodology
11
3.1 The Evaluation Framework
11
3.2 Evaluation tools
16
4. Findings
20
4.1 Profile of clients
20
4.2 Client Outcomes Data Analysis
21
4.3 Carer Outcomes Data Analysis
23
4.4 Risk Data Analysis
25
4.5 Clients and carers experience
28
4.6 Referral agencies experience
30
4.7 Staff reflections
31
4.8 Case studies
35
5. Conclusions
52
6. Recommendations
54
Appendices
1.
Introduction
Birmingham Mind commissioned Merida Associates in January 2012 to undertake a 3-year
evaluation of the Mind Older Adults Outreach Service. This report presents final data
findings along with a refreshed overview of the policy and strategic landscape within which
the service is operating. The conclusions and recommendations are based on a review of
learning across the 3 years of the evaluation.
Funded by the Stone Family Foundation from 2011 to 2014, the Mind Older Adults Outreach
Service (OAOS) aimed to support, over the 3 years, 90 older adults living in their own homes
and experiencing dementia or functional mental health difficulties. The service is delivered
by skilled staff who, following an initial assessment, develop a range of bespoke
interventions designed to encourage independence, support people to live safely in their
own home and reduce social isolation.
Where the client lived with, or was significantly supported by, an informal carer (spouse,
son, daughter etc) the service provided respite for the carer and informal support to prevent
a breakdown in the caring relationship. This aimed to enable the client to continue to live in
their own home for as long as possible.
OAOS was developed from previous work undertaken by Mind in two areas of Birmingham.
In the North of the city Mind worked in partnership with Age Concern, Alzheimer's Society
and Crossroads to deliver a Collaborative Home Based Respite Service, and in the South
Mind delivered a similar service as the sole delivery agency.
2.
Context of the Mind Older Adults Outreach Service
This section outlines the context in which the Mind Older Adults Outreach Service has
evolved in terms of

The prevalence of dementia both nationally and locally and estimated future trends

Dementia policy in England 1 and Birmingham and Solihull

Local services within the city
2.1
Prevalence
“Dementia is one of the biggest challenges we face today – and it is one that we as a society
simply cannot afford to ignore any longer…Our research knowledge on dementia lags behind
other major diseases such as cancer or heart disease. People with dementia and their carers
1
There are separate dementia strategies in the devolved administrations of Scotland, Wales and Northern
Ireland
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
1
still face a lack of understanding from public services, businesses and society as a whole. And
as many as half of all dementia sufferers in this country are unaware that they have the
condition, meaning that they cannot get the help that they and their families need.”
(Prime Minister: David Cameron’s Dementia Challenge: March 2012) 2
With an increase in ageing populations across the world, dementia has acquired particular
policy urgency to the extent that it was a focus for discussion at the G8 Dementia Summit in
London in December 2013.
It is estimated that, globally there will be more than 75 million people living with dementia
by 2030 and that the number of people living with dementia worldwide will treble by 2050.
Alzheimer's Disease International says 44 million people live with the disease now, but that
figure will increase to 135 million by 2050 3. The G8 summit committed to developing a cure
or treatment for dementia by 2025. The UK has already said it aims to double its annual
research funding to £132m by 2025.
Estimates of prevalence in the UK vary, in part because of assumed rates of undiagnosed
(estimated at 42% by the Alzheimer’s Society 4) or late diagnosis of dementia. In 2009 the
Department of Health 5 indicated that there were 570,000 people living with the condition in
England. By 2013, this estimate had risen to 800,000 with an indication that dementia
remained undiagnosed in approximately 45% of cases. More recent estimates suggest that,
by 2015, this number will be closer to 850,000 with increases, in particular, within lower age
groups (60-65). Given current population trends it is suggested that dementia rates within
the UK will increase to over one million by 2025 and 2 million by 2051. 6
Other sources suggest that, in the next 30 years, the number of people with dementia in the
UK will double to 1.4 million. The cost of dementia to health and social care services is
estimated at £17 billion, with a further £6 billion equivalent in unpaid care and support, and
rising by 2040 to £50 billion 7. 670,000 people (family and friends) are estimated to be
providing primary care for those with dementia 8.
2
Department of Health (2012) The Prime Minister’s challenge on dementia; delivering major improvements in
dementia care and research by 2015. DoH, London
3
http://www.alz.co.uk/research/statistics
4
Alzheimer’s Society (2012) Mapping the Dementia Gap 2011, Alzheimer’s Society, London
5
Department of Health (2009) Living well with dementia; A National Dementia Strategy. DoH, London
6
Prince, M, Knapp, M, Guerchet, M, McCrone, P, Prina, M,Comas-Herrera, A, Wittenberg, R, Adelaja, B, Hu, B,
King, D, Rehill, A and Salimkumar, D. (2014) Dementia UK: Second Edition. Alzheimer’s Society, London
7
Data source: Department of Health (2009) Living well with dementia: A National Dementia Strategy and The
Prime Minister’s Challenge on Dementia: delivering major improvements in dementia care and research by
2015. Annual report of progress (2013) DoH, London
8
Source; Carers Trust (2013) http://www.carers.org/help-directory/alzheimers-and-dementia
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
2
A summary of the prevalence of dementia cases in the UK by age and gender is provided in
Table 1.
Table 1: Prevalence of Dementia cases in the UK by Age and Gender 9
Age
Male
Female
60-64
1.58%
0.47%
65-69
2.17%
1.10%
70-74
4.16%
3.86%
75-79
5.04%
6.67%
80-84
12.12%
23.50%
85-89
18.45%
22.76%
90-94
32.10%
32.25%
Percentage of total population
The 2011 census shows that the number of people who are 85 and over has increased in
Birmingham (as part of an overall local population increase of 9.8 per cent) since 2001. This
means that people aged 85 plus now make up 1.8 per cent of Birmingham’s population –
around 19,000 people – and 2.7% in Solihull (5,501 people). It is estimated that numbers will
grow by around 18 per cent, in other words, by around 1,800 people in Birmingham by 2021
and 900 in Solihull. 10. These demographic changes would mean a rise in health and social
care costs in the two Authorities to £350 million and £120 million respectively. 11
According to other sources, there are an estimated 13,819 people with dementia in
Birmingham and this figure will grow as people live longer, rising to 16,300 by 2021 12.
Within the Birmingham context there are also concerns that, within an overall younger Black
and Minority Ethnic population, dementia rates will rise further – with currently around
6.1% of younger people in these communities with early onset dementia – compared to
2.2% in the population as a whole. 13
9
Source: Alzheimer’s Society (2013) http://www.alzheimersresearchuk.org/dementia-statistics/
Census 2011 ONS
11
Birmingham City Council, Solihull Metropolitan Council, NHS: Give me something to believe in: Birmingham
and Solihull Dementia Strategy 2014/2017
12
Estimated number of dementia cases based on national prevalence rates reported in Dementia UK:
Alzheimer’s Society, 2007. Sources: Dementia UK: Alzheimer’s Society, 2007. ONS population projections
interim 2011-based
13
Moriarty, J., Sharif, N, and and Robinson, J (2011) Black and minority ethnic people with dementia and their
access to support and services . Available at http://www.scie.org.uk/publications/briefings/files/briefing35.pdf
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
10
3
2.2
Policy themes and initiatives
Current dementia commissioning policy and practice is guided by two key documents: the
National Dementia Strategy (2009), developed under the New Labour administration, and
the updated Coalition paper: The Prime Minister’s Challenge on Dementia: Delivering major
improvements in dementia care and research by 2015 (2012).Whilst there are key
differences between these governmental statements, there is a consistency in terms of their
central themes:
 Early diagnosis

A better quality of care at each stage of dementia: from early intervention, through to
care delivered in the home, residential and hospital settings and end of life care

Reducing the stigma attached to dementia through public awareness raising and the
promotion of dementia friendly communities

Improved research capacity
Underpinning both documents is a concern about the rising cost of dementia care in terms
of funding residential care and admissions (and re-admissions) to acute hospitals 14.
Table 2: National Dementia Objectives 2009 and 2012/13
National Dementia Objectives 2009
The Prime Minister’s Challenge on
Living Well With Dementia: A National
Dementia: Delivering major improvements
Dementia Strategy
in dementia care and research by 2015
(2012) and Progress Report (2013)
•
Improved public and professional
awareness and understanding of
dementia
•
•
•
•
Good quality early diagnosis and
intervention for all
•
•
•
Good quality information for those with
diagnosed dementia and their carers
Enable easy access to care, support and
advice following diagnosis
•
•
•
Dementia Friends programme training
volunteers to raise public awareness of
dementia (Alzheimer’s Society)
National dementia campaign to promote
early diagnosis
Dementia education programme in
schools
Improved rates of diagnosis
Pro-active diagnosis included in
Enhanced service agreements with GPs
Development of appropriate post
diagnosis support
Development of the Dementia Care and
Support Compact
14
Care Quality Commission (2013) The state of health care and adult social care in England:
an overview of key themes in care in 2011/12, Care Quality Commission, London
4
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
National Dementia Objectives 2009
Living Well With Dementia: A National
Dementia Strategy
The Prime Minister’s Challenge on
Dementia: Delivering major improvements
in dementia care and research by 2015
(2012) and Progress Report (2013)
•
Improved community personal support
services
•
•
Dementia Friendly communities initiative
Local Dementia Action Alliances
established to promote and co-ordinate
quality care
•
Implementing the Carers’ Strategy for
people with dementia
Improved quality of care for people
with dementia in general hospitals
•
Dementia friendly hospitals to provide
dementia risk assessments for
emergency admissions aged over 75
•
•
•
•
•
•
•
•
•
•
•
Improved intermediate care for people
with dementia
Improved end of life care for people
with dementia
People with dementia and their carers
receive the right housing support,
housing related services and telecare at
the right time
Living well with dementia in care homes
Improved registration and inspection of
care homes and other health and social
care services for people with dementia
and their carers
An informed and effective workforce for
people with dementia
Develop structured peer support and
learning networks
A joint commissioning strategy for
dementia
A clear picture of research evidence and •
needs
Effective national and regional support
for implementation of the Strategy
Improved research capacity
The 2012 ‘Prime Minister’s Challenge’ introduced a range of initiatives to promote
improvements in dementia care. These include:

An enhanced role for Public Health and the development of a ‘Dementia Support and
Care Compact’ and improved co-ordination of services via multi-stakeholder Dementia
Action Alliances.
5
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)

Embedding dementia risk assessment for those aged over 75 into hospital admission
procedures and incentivising improved dementia care and hospital environments
through Commission for Quality and Innovation (CQUIN) rewards.

Promoting dementia friendly communities through Dementia Friends, volunteer-led
community awareness programmes and piloting ‘dementia friendly communities’ – see
for example the Joseph Rowntree Foundation’s ‘Dementia without Walls’ initiative. 15

Enhanced and targeted investment in research through the Medical Research Council
and National Institute for Health Research.
These objectives remain in place until the current strategy expires in 2015. Whilst the All
Party Parliamentary Group on Dementia (2014), welcomed the role of the strategy and
global summit in the raised profile of dementia, it also expressed concern that:

Given predictions of rising prevalence, there was no long term strategy in place.

Difficulties remained in accessing early support interventions.

Health and social care services for people with Alzheimer’s remained poorly coordinated. 16
The National Institute for Health and Clinical Excellence (NICE) 17 issued commissioning
guidance (2007/2010) for memory assessment services that identified best practice goals in
services for people with dementia and their carers including:

Increase early diagnosis of dementia.

Reduce expenditure on residential care by delaying the time to nursing home
admissions.

Reduce stigma.

Enhance the quality of life for those with dementia by supporting independent living.

Reduce inequalities in provision and improve access to treatment.

Increase patient choice.

Respite and short break support for carers.

Achieve better value for money.
15
Two dementia friendly community pilot initiatives, supported by the Joseph Rowntree Foundation in
Bradford and York and about to be evaluated.
16
All Party Parliamentary Group on Dementia (2014) Dementia does not discriminate: The experiences of
black, Asian and minority ethnic communities. APPG, House of Commons, London
17
National Institute for Health and Clinical Excellence (2007 – updated 2010) Memory assessment service for
the early identification and care of people with dementia: Commissioning Guidelines. NICE, London
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
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The shift in emphasis within the policy context towards home-based and community care as
a means of sustaining the quality of life for those with dementia and their carers has been
welcomed by campaigners although concerns were expressed about the £150 million
allocated to implement the 2012 strategy over its first two years. 18
There is also growing recognition of the importance of carers in what is known as the
‘Triangle of Care’ 19 around people with dementia – patients, professionals and carers – and
recent guidance sets standards for carer engagement and support, which the Older Adult
Outreach Service models.
The local response to national dementia policy is presented in the joint Birmingham and
Solihull Local Authority and Care Commissioning Groups strategy for 2014-17 20. This
identifies five stages in the dementia pathway:

Health Promotion and Prevention.

Recognition and identification.

Assessment, diagnosis and planning for the future.

Living well with dementia.

Increasing care including End of Life care.
The strategic objectives place emphasis on early intervention:

By providing support earlier to people that have a higher risk of dementia we can
potentially delay the onset of the disease.

By providing the community support and community services that people with dementia
want and need, we can improve their quality of life while reducing emergency hospital
admissions and premature admission to care homes, i.e. deliver better services in a more
cost-effective way.

By supporting the families and carers of people with dementia we can help people to
remain independent for longer. (pages 17/19)
The combined strategy goes on to note that ‘early targeted support can result in a 23 per
cent reduction in the need for institutional care’ (page 22).
18
For a local response raising these concerns see
http://www.dementiaaction.org.uk/members_and_action_plans/461sandwell_and_west_birmingham_nhs_tr
ust
19
http://www.rcn.org.uk/__data/assets/pdf_file/0009/549063/Triangle_of_Care__Carers_Included_Sept_2013.pdf
20
Birmingham City Council, Solihull Metropolitan Council, NHS Give me something to believe in: Birmingham
and Solihull Dementia Strategy 2014/2017
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
7
The Birmingham Mind OAOS delivers against the ‘Living Well with Dementia’ element of the
strategy which aims to provide the community support and community services that people
with dementia want and need.
OAOS’s strategic positioning is strong in that it contributes to 8 of the strategy’s key
objectives: – wellbeing, early support, personalised/tailored services, feeling valued, living
normally, enhanced quality of life, staying safe and secure at home and support in
community. In this context it is important to recognise that OAOS is not a sitting service.
Whilst its role in respite for carers is important, its emphasis on keeping people active,
ideally outside the home, and strengthening social networks is related closely to the
evidence that such activities are particularly beneficial to the physical and mental wellbeing
of older people generally and those with dementia in particular. 21
“Successful models are characterised by relationship based delivery…..Aspects that are
particularly valued include an ability to share confidences, hopes, fears and anxieties (…) an
ability to interpret and understand people’s support needs on a personalised basis, based on
their knowledge of people’s histories and lives” 22
There is increasing recognition that as dementia becomes more pronounced and causes
changes in behaviour, people can lose touch with their friends and other social
connections 23 and social isolation is a key factor in referrals to the Mind OAOS.
With its focus on taking people out, where possible, the Mind service reflects emerging best
practice to enable people with dementia to engage in activity that is riskier than staying at
home but has benefits in terms of health and mental wellbeing 24.
The national Dementia Friends initiative operates in line with the Positive Risk-Taking
agenda, and through it people from all walks of life are receiving basic information about
the signs of dementia and how it might affect people when they are out in the
neighbourhood or community. Shopkeepers, council workers and the general public are
learning how to recognise someone who may have dementia and to respond with patience,
only offering supported if needed. The goal is to develop dementia-friendly communities
where people with dementia can be supported to continue with daily activities in a
supportive and safer environment. OAOS helps people with dementia to access community
facilities safely and contributes to ‘normalising’ dementia in the community.
21
For a comprehensive review of the literature see Harris, K. (2013) Age friendly societies in our time: A
literature review, Woodgreen Community Services, Toronto
http://www.birmingham.ac.uk/generic/tsrc/documents/tsrc/reports/external/age-friendly-societies.pdf
22
Bowers H (2013) Widening Choices for Older People with High Support Needs, Joseph Rowntree Foundation,
York (page 4)
23
http://www.dementiajourneys.com/wp/
24
Morgan, S. and Williamson, T. (2014) How Can ‘Positive Risk-Taking’ Help Build Dementia-Friendly
Communities, Joseph Rowntree Foundation, York
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2.3
Dementia services in Birmingham
It is important to place Birmingham MIND Older Adults Outreach Service within the context
of local home support and early intervention services in the city, particularly given recent
controversies in home care, and related, support provision such as the short duration of
home care visits and the increased use of zero hours contracts. 25
In relation to home care services locally, there is a mixed economy of provision by:

Private sector agencies (e.g. Sunrise Care and Helping Hands). The major investment in
dementia services currently is coming via the private and non-profit sectors with 5 extra
care homes currently being built or in the planning process.

Birmingham City Council Community Links Team, various signposting services for Local
Authority support in accessing help to remain at home and respite/day centre services.

Voluntary organisations of which the largest provider is the Alzheimer’s Society which
offers: information services for people with dementia and their carers, support services
and social/activity groups such as a network of Dementia Cafés and help with assistive
technologies. The Alzheimer’s Society also operates a signposting service for early
interventions and is an OAOS referral agency.
Within this context, OAOS offers a rather different model of intervention which supports
people in their home. Much of the home care and early intervention work, both nationally
and locally, is based on a medical model of provision: a service (which may be high quality)
but delivered for, rather than with, the person with dementia. This has been criticised by,
for instance, the Joseph Rowntree Foundation in their Reframing Dementia 26 campaign, as a
model that, however caring, disempowers people with dementia. The approach adopted by
the Older Adults Outreach Service has a social framework which is predicated not only on
respite for carers but on undertaking meaningful and practical activity with, and determined
by, clients.
This kind of social model, whilst being acknowledged as difficult to implement, 27 is
increasingly promoted as best practice in the field of dementia care as it

Focuses on abilities rather than loss.

Recognises that dementia is not an individualised ‘problem’ but that sufferers
experience wider discrimination and marginalisation.
25
Both of these controversies have prompted Ministerial Response – see
https://www.gov.uk/government/news/care-minister-announces-proposals-to-deal-with-rushedcare-visits
26
See http://www.jrf.org.uk/blog/2013/10/help-us-reframe-dementia
See Clarke, C. et al (2013: Healthbridge: The National Evaluation of Peer Support Networks and Dementia
Advisers in the Implementation of the National Dementia Strategy for England. Department of Health Policy
Research Programme, London
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
27
9

Starts with listening to personal experiences of dementia and those with the condition
can express their preferences for, and choice and control of, service interventions and
activities.

Recognises that the quality of the built environment, as well as services, is important in
determining quality of life for those with dementia and carers. 28
The Older Adults Outreach Service is, therefore, aligned with national policy drivers as
evidence shows that it makes a demonstrable contribution towards creating ‘dementia
friendly communities’ in Birmingham and it is delivering against the ‘Living Well with
Dementia’ element of the Birmingham and Solihull Dementia Strategy. It also has a focus on
supporting carers and adheres to the wellbeing of carers principle underpinning the new
Care Act 2014. 29
The All Party Parliamentary Group on Dementia (2014) notes:
'Services need to be strengthened with additional funding and must support people with
dementia and their carers to live independently in their own homes for as long as they are
able and wish to. Services such as dementia cafés, peer support groups, carers support and
befriending services are essential to reduce isolation and maintain wellbeing, but any
support must suit the needs and wishes of individuals, as well as of their carers who may
have their own health needs.’ 30
Whilst the local dementia strategy makes a commitment to the above principles, health and
social care budgets in the city are under extreme pressure. The most critical context for all
services including dementia services in Birmingham currently is the overarching impact of
the Government's austerity measures. By the end of March 2014 the City Council reduced
its budget by £461 million since 2010 and is expected to find a further £360m of savings
before March 2018. 31
However the Council estimates that over the period 2010 - 2018 the combination of cuts in
grants and increased spending pressures in areas such as social care and children's services
will require the local authority to make a cumulative total of £822m per annum of savings.32
The local Authority workforce will be reduced from 20,000 in 2010 to 7,000 in 2018. 33
28
See: Gilliard, J., Means, R., Beattie, A. and Daker-White, G. (2005) Dementia care in England and the social
model of disability. Dementia 4: 576–586. See also French, S. and Swain, J. (2012) Working with Disabled
People in Policy and Practice: A Social Model. Basingstoke: Palgrave Macmillan.
29
http://www.govtoday.co.uk/community-care/16962-the-care-bill-and-its-implications-for-carers
See also HM Government (2014) Care Act, HMSO, London
30
All Party Parliamentary Group on Dementia (2014) Building on the National Dementia Strategy: Changes,
Progress and Priorities (page 5). APPG, House of Commons, London
31
Birmingham City Council website accessed December 2014
32
Birmingham City Council Council Business Plan and Budget 2014+
33
Birmingham City Council ‘Forward’ newsletter Autumn 2014
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3.
Evaluation approach and methodology
The evaluation was designed to be both formative and summative over the 3 years. The key
objectives can be summarised as follows:

To gather robust evidence of health and wellbeing outcomes for clients.

To gather robust evidence of health and wellbeing outcomes for carers.

To gather robust evidence of the economic benefits of the service.

To assess the delivery of the service and inform further development, improvement and
refinement.
3.1
The Evaluation Framework
The evaluation has been set within the framework of Theory of Change (ToC) which is
designed to enable evaluators to explore the extent to which the outcomes sought by an
initiative have been achieved. Theory of Change was developed in the United States (Weiss
1995) and helps to show "a charity’s path from needs to activities to outcomes to impact."34
The rationale behind the Older Adults Outreach Service was based on both experience and
current thinking at the time. Birmingham Mind had previously run a pilot service in North
Birmingham that had achieved positive feedback from clients and referral agencies. There is
a body of evidence from that period that demonstrates the role ‘befriending’ services can
play in supporting older people’s wellbeing. 35 It is acknowledged that individually tailored
interventions ‘in the home’ have better outcomes for clients and carers. Mind wanted to
continue the service and also extend more support to carers as well as clients. They had
learnt from the pilot that carers benefited from the visits by receiving some respite but also
that they could benefit further, once relationships had been built, by being offered
signposting to information and other sources of support, as required. For this reason Mind
decided to build a dedicated carers strand into the service.
The Older Adults Outreach Service was also a good fit with the 2009 National Dementia
Strategy36 and the National Dementia Declaration, which described what people with
dementia and their family carers would like to see in their lives.
34
National Philanthropy Capital website accessed January 2013
Martin Knapp and Margaret Perkins “The role befriending can play in older people’s well-being” Community
Care 15 July 2010
36
Living Well with Dementia, the National Dementia Strategy 2009
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
35
11
National Dementia Declaration Call to Action
1.
People with dementia will have personal choice and control or influence over
decisions about themselves.
2.
People with dementia will know that services are designed around them and their
needs.
3.
People with dementia will have support that helps them live their life.
4.
People with dementia will have the knowledge and know- how to get what they
need.
5.
People with dementia will live in an enabling and supportive environment where
they feel valued and understood.
6.
People with dementia will have a sense of belonging and of being a valued part of
family, community and civic life.
7.
People with dementia will know there is research going on which delivers a better
life for them now and hope for the future .
The 2014 - 2017 Birmingham & Solihull Dementia Strategy recognises the contribution
informal carers make in achieving substantial savings in public funding. It also acknowledges
that many carers feel isolated and excluded and that their lives can be significantly affected
in a number of ways by their caring responsibilities, with little attention paid to the impact
on them.
“We recognise (…) the need for increased investment in support that helps people remain at
home, and a move away from a reliance on residential or acute care where it can be
avoided. The experience of other areas of the country shows that these community services
can be provided as part of a more cost-effective model.37”
Consultation with carers in Solihull and the North and East of Birmingham for the
Birmingham and Solihull strategy found at there was very little non-residential respite care
available for people.
In the ‘Living well with dementia’ section of the strategy there is a commitment to ensuring
people with dementia have access to support to help them to stay at home and remain
independent and also to carers being aware of what they can expect in terms of carers’
assessments and support for their caring role, which the Mind service is already providing.
In the strategy, people with dementia and their carers said that where they found services
and support that made them feel at ease it had a significant impact on their wider
wellbeing. Helping people feel at ease is a strong element in the Mind service and the
37
“Give me something to believe in” Birmingham and Solihull Dementia Strategy 2014-2017
12
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
evaluation findings demonstrate the impact of this approach using the Theory of Change
framework illustrated at Figure 1.
Theory of Change elements
Enabling factors
The Older Adults Outreach Service accepted referrals from external agencies and self
referrals to achieve its target of 90 cases over three years. External referrals were received
from a number of key local agencies including Adult Social Care, the Alzheimer’s Society and
the local Perry Tree Centre which provides day care, short term residential care,
rehabilitation and a range of other services for older people and people with dementia. The
demand for the service increased to the extent that a waiting list was in operation.
Activities
On referral, clients and carers were visited at home for an initial needs assessment and
prevention of risk assessment (for the client) and the main focus of the OAOS interventions
was agreed. The Older Adults Outreach Service offered three strands of activity:
1. Tailored activities with people with dementia
This was the core element of the service. OAOS support workers provided home visits,
usually once a week, where they engaged in activities determined with the client and
usually based on something the client enjoyed or liked to do. This was a bespoke service,
tailored to each client’s wishes and interests. It varied every week or fell into an agreeable
pattern that the client looked forward to, for example going for a walk to the shops or
looking at family photographs. The aim was to support emotional, physical and mental
wellbeing and functioning.
“Active therapies that were sought by the people (…) included a number that would have a
positive effect on the condition of people with dementia. It could range from doing a word
search puzzle, to a trip to the cinema, the opportunity to go for a walk, gardening, and
meeting friends for lunch in a local café. All those things that people without dementia take
for granted as the rich texture of living a normal life. 38”
38
“Give me something to believe in” Birmingham and Solihull Dementia Strategy 2014-2017
13
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
Other
service
needs
identifed
client/carer
Referrals into
service
Tailored
activities
with clients
Respite for
carers
Figure 1
Access to day
care/other
services
Referrals to
other
services
Weekly visits
Carer
assessment
Physical
activity
Mental
stimulation
Social
engagement
Relationship
with client
maintained/
improved
Theory of Change key: Enabling factor
Activities
Client
cognitive
ability
maintained /
reduction
slowed
Carer able to
continue
Outputs
Outcomes
Goal
Service user
stays in own
home for
longer
2. Respite for carers
Where the client had a carer, they were offered the opportunity to be referred for a formal
carers assessment. Carers were engaged in the initial needs assessment to identify their
own support needs as well as those of the client. The home visits provided an opportunity
for carers to have a break which might include, for instance, visiting the dentist or
hairdresser, or getting the housework done without being interrupted. Some carers liked to
join in with the activities the OAOS support worker was doing with the client, or just to have
a chat.
3. Identification of and response to other needs
OAOS support workers did identify other needs, often practical issues, when they did
regular home visits and they were able to refer clients on for additional services, where
appropriate. This might include, for example, contacting a social landlord about repairs or
referring them to Aids and Adaptations services. Carers were signposted to information
sources and local carers support networks and services.
4.
Saturday Club
The service developed a regular Saturday Club that operates on a monthly basis. The club
offers a simple lunch, is facilitated by the OAOS support workers and Mind managers and
offers quizzes, music, activities. On occasion the group will have the chance to take part in
practical activities for example complementary therapies such as hand massage
The club is open to all those using the service, and offers an opportunity for carers and
clients to meet together, share experiences, socialise and explore opportunities for peer to
peer support.
Outputs
The outputs measured by the service include:

Number of clients / carers supported

Number of visits / hours with client

Number of review assessments

Length of time clients remain out of residential or nursing care, as measured by
quarterly ‘prevention of risk’ assessments

Number of carers assessments
Outcomes
The following outcome areas were identified with the staff team (through focus groups and
interviews) based on where they thought they were making the most difference:
15
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)

Level of mental and emotional wellbeing improved, or sustained, or the rate of decline
reported as reduced: includes stimulating language, memory retention, playing games.

Level of physical health improved, or sustained or rate of decline reported as reduced:
includes going for walks, exercise classes, dancing.

Reduction in social isolation (client and carer): includes visiting local centres, cafes,
library and free time for carer.

Able to live safely at home: any practical issues on safety referred to appropriate
agencies.

Access to appropriate services to sustain independent living: such as day care, aids and
adaptations.

Client relationship with carer maintained, or improved.

Carer able to continue caring for longer.

Quality of life for client and carer improved or maintained.
Goals
The goals of the Older Adults Outreach Service are:

To improve the quality of life for each client and carer.

To support carers to carry on caring.

To enable clients to stay in their own homes for longer.

To delay the need for clients to access residential or nursing care.
3.2
Evaluation tools
It was always intended that the evaluation team would use data gathered by the OAOS staff
team and initially it was anticipated that data and information from the Outcomes Star that
Mind was implementing across all its service areas would be available for this evaluation. In
practise the rollout of the Outcomes Star to the Older Adults Outreach Service took longer
than expected and as a result the Merida team agreed with Mind to design data capture
tools for the evaluation that could be used by staff. Merida also designed Excel
Spreadsheets for Mind to complete to so that the anonymised data gathered by the OAOS
workers from clients and carers could be shared with the evaluation team. The tools were
designed with the OAOS staff team and details of this process are available in the interim
evaluation report (January 2014).
The evaluation team provided annual training sessions for staff on the use of the evaluation
tools to ensure consistency.
16
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
Staff training covered:

Familiarising staff with the tools and how the tools and the evaluation framework
related to each other.

Using the tools with clients to gather data.

How to encourage clients and carers to respond to the questions.

How to be consistent in asking the questions.

How to record data from clients and how to capture the interventions they had
delivered during the same period.
The tools were developed to have a strong fit with and relevance to Birmingham City
Councils (BCC) changing approach to service design and delivery and subsequent Joint
Strategic Plans and associated commissioning intentions. In early 2012 the then Joint
Director (across all 3 Birmingham Primary care Trusts and Social Care) of Public Health
consulted widely with the Third Sector on prevention in relation to health and social care.
The consultation was closely aligned to the Prevention Framework and Prevention Strategy
endorsed by the Public Health Prioritisation, Prevention and Prediction Board and identified
that both health and social care commissioners were committed to making the strategic
change to commissioning for prevention as a mechanism for reducing high levels of demand
for the most expensive to provide services. Combined with this shift to prevention, health
and social care commissioners were moving to evidence based commissioning and were
expecting voluntary and community organisations to demonstrate how they delivered
evidence based approaches that meet identified outcomes. The strategic drive was to work
with and support the sector to deliver sustainable, evidence based, cost effective prevention
services.
The evaluation tools were also designed to provide evidence that Mind could draw on in
relation to the Protective Factors 39 identified by BCC that help reduce the vulnerability and
risk factors for the older adults.
Merida produced an outcomes and activities grid showing strategic prevention outcomes,
evaluation measures, outcomes for clients and examples of activities. In order to identify
the examples of activities, Merida undertook a review of case files to understand the types
of activities and interventions provided by the service in response to client need; these
activities (menu of service provision) were then mapped against the key prevention
outcomes developed by BCC which can be summarised as:


Health and wellbeing
Remaining Independent
39
Protective Factors refer to anything that prevents or reduces vulnerability for the development of an illness
or condition and can include social support and healthy coping strategies. Source Birmingham City Council
(November 2011) Strategic Shift to Prevention - Prevention Glossary Adults and Communities Public Health
Service.
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
17



Reducing Social Isolation
Living Safely at home
Support for carers
Merida developed standardised questions against each of the measures that were suitable
to be administered by OAOS support workers.
Informed consent to participate in research
Before any data gathering could take place consideration was given to a primary principle
for participants in social research i.e. that they should come to no harm by taking part. It
was of particular importance in this evaluation that due consideration be given to
vulnerable clients and carers to ensure they were not distressed by the research. It was
essential that clients and carers give informed consent to take part in the research. Working
with vulnerable people can take more time to enable them to engage in a meaningful way
but it is important that people understand what the research is about, that they have a
chance to ask questions beforehand and that they know they are free to withdraw from the
research at any time. Before any clients and carers were able to be involved in the research,
Merida designed a consent form for Mind staff to complete with clients and carers that gave
people information about the research and explained what would happen to any data and
information gathered through the research. The consent form informed clients that they did
not have to participate in the research and sought to reassure people that engaging in the
research activity was not a condition of receiving the service.
The following tools were used by OAOS staff to capture data for this evaluation:

An outcome monitoring tool for staff to administer with clients. The tool was designed
to be used both to set the baseline for clients and for regular reviews.

A prevention of risk assessment tool to help determine the contribution of the OAOS
service in preventing or delaying client referrals into other services. This tool was
designed to be used for both an initial baseline assessment and for regular reviews.

An outcomes tool for staff to administer with carers. The tool was designed to be used
both to set the baseline for carers and for regular reviews.
Mind staff were asked to record their interventions with clients on a spreadsheet, using an
agreed taxonomy of interventions, to enable the evaluation team to reflect on any potential
correlations between interventions delivered and outcomes reported by clients in data
gathered using the outcome tools.
In addition to the client and carer data collected and collated by OAOS staff, for this final
report staff views were sought in focus groups and an online survey, clients and carers
participated in a focus group held during one of their regular Saturday get togethers and 4
referral agencies participated in short telephone interviews.
18
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
Merida undertook a number of case studies each year of the of the project to triangulate
the data gathered by OAOS staff. The case studies allowed the evaluation team to develop
an in-depth understanding of clients and carers’ experiences of living with dementia or
functional mental ill health and their perspectives of the OAOS service. Narrative data
gathering approaches 40 were used (within an overarching framework) to gather qualitative
data from clients and carers and semi-structured interview schedules with referral agencies
and the OAOS support workers. In developing and implementing the narrative data
gathering approach, the Merida team drew on work undertaken by Jovchelovitch and
Bauer. 41 These case studies form the core of the cost consequence analyses discussed in
section 4.5 of this report.
In order to identify clients for the case studies, the Merida team developed a sampling
framework to ensure that the profile of the individuals chosen for case studies were
reflective of the total client cohort. A sampling matrix was arrived at following a careful
review of the client profiles as of July 2012. The clients to that point were then analysed
against the sampling framework which included age, family circumstance/carer
relationship/no carer, condition, access to other non-Mind services, gender, ethnicity, how
long the service had been provided for and referral route. The same sampling matrix was
used for both the interim and final reports.
Copies of the evaluation tools, taxonomy of activities, guides for staff on using the tools with
clients and sampling matrix can be found at Appendices 1 and 2 respectively.
Copies of the Prevention Outcomes, Measures and Evaluation Questions can be found at
Appendix 3.
40
Narrative data gathering is a robust technique that encourages interviewees to their story in their own
words and at their own pace. It allowed clients and their carers to respond to prompts from the research team
without having to follow a linear or chronological sequence.
41
Jovchelovitch, S; Bauer, M W, (2000) Narrative Interviewing (online) London LSE Research Online
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
19
4.
Findings
93 clients and 68 carers have accessed the Older Adults Outreach Service across the 3 years
of the project and these findings are based on data gathered by OAOS staff with the cohort
who used the service up to October 2014 and case studies conducted by the Merida team in
October/November 2012, October /November 2013 and August /September 2014.
The findings also include data from a client and carers focus group, staff focus groups, an
online survey and interviews with 4 referral agencies.
4.1
Profile of clients
Of the 93 clients:




61 are women and 32 are men
The age of clients when they started to receive the service ranges from 58 -99 check
The majority of those using the service some 82 are white British
Over half of clients have a diagnosis of dementia
The following tables give more information about clients.
Table 3 Age on entry
Age band
50-59
No of clients
1
%* of all clients
1%
60-69
6
6.4%
70-79
33
35.4%
80-89
40
32.2%
90-99
13
14%
*% rounded to one decimal place
Table 4 Ethnicity
Ethnicity
White
British
No of clients
% of all clients
White
Irish
White
Welsh
8
1
1%
81
87%
*% rounded to one decimal place
Caribbean
7
8.6%
Indian Pakistani
1
1%
Other
1
1%
2
2.1%
Other = 1 Maltese and 1 Italian
Table 5 Diagnosis
Diagnosis
Dementia
Vascular dementia
Alzheimer's
Alzheimer's and dementia
Alzheimer's and vascular dementia
Depression and Anxiety
Bi-polar
Depression and Bi-polar
Dementia and anxiety
20
Number of
clients
53
11
10
2
2
5
2
1
1
%* of all clients
56.9%
11.8%
10.6%
2.1%
2.1%
5.3%
2.1%
1%
1%
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
Diagnosis
Dementia and Picks Disease
Paraphrenia
Mental health
Mixed dementia
Paranoid Schizophrenia
Paranoid/Anxiety
Number of
clients
1
1
1
1
1
1
%* of all clients
1%
1%
1%
1%
1%
1%
*% rounded to one decimal place
4.2
Client Outcome Data Analysis
The client outcome data analysis focuses on 40 clients with whom four or more outcomes
assessment reviews have been undertaken. The outcome monitoring tools for both clients
and carers were completed as soon as practical following entry to the service to provide a
baseline and repeated on a quarterly basis. Not all clients stayed with the service for
sufficient time to complete four assessments, the reasons for which included moving into
residential services, being ill, deciding the service was not for them, at least one client died
during the evaluation period whilst others chose not to participate in the evaluation
monitoring activity.
The data analysis focuses on clients where four or more outcomes assessment reviews have
been undertaken as the evaluation team anticipated that this would provide a clearer sense
of each individuals trajectory.
It is important to note that:

Qualitative evidence strongly indicates that clients have 'good' and 'bad' days. These
variations do show up in the data. Bad days might result in the postponement of the
outcomes assessment for one or more weeks, so the assessment intervals are not
consistent across the cohort.

These are self-reported outcomes by older people with dementia.

The fluctuations in outcome reporting at an individual level reflect the varying levels of
frailty and ill health clients are experiencing. Few are dealing with just dementia.

Unsurprisingly across the 3 years of the project the way the outcomes tool is completed
by or with clients has not been consistent. Often staff found that clients and or carers
didnot want to complete the forms and they had to overcome their resistance.
Sometimes clients were simply asked the questions rather than engaged in a meaningful
way, sometimes carers completed the form on behalf of clients and sometimes clients
were given the form to complete themselves. These differences reflect the differing
abilities of clients but also highlight some inconsistencies of approach within the staff
team and staff changes during the period.
21
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
The tool seems to work well in gathering data about individual clients and the outcomes
they experience, especially over a longer period of time.
The evaluation team made the following assumption in analysing this data:
The goals of the Older Adults Outreach Service for clients are to improve their quality of life;
to enable them to stay in their own homes for longer and to delay the need for them to
access residential or nursing care. By the nature of referral criteria, clients are on a pathway
to more specialised care so the assumption is that ‘no change’ in an outcome score is
deemed a positive in that clients have remained stable and not ‘declined.’
There were six outcome areas that clients were asked to assess themselves against and the
chart below shows the data against each area.
Chart 1
30
Client data showing movement (against baseline) across outcomes
28
25
25
25
24
23
21
19
20
15
17
15
15
16
12
stable/improvement
10
Declined
5
0
No = 40
4 clients (10%) reported improvements across all outcome areas, with a further 20 (50%)
having a higher than baseline score when looking at the aggregated score across all
outcome elements.
70% (28) of all clients in this group report that they are enjoying life more and 63% (25) are
feeling less isolated which supports the approach taken by the service to stimulating and revitalising people's interest in life and the world around them. This evidence shows that the
bespoke, personalised approach of OAOS that builds on listening to what clients say they
22
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
want to do, improves the quality of life for clients. Support workers demonstrated their
commitment to engaging people in pleasurable activities such as walking, visiting local
places of interest, undertaking reminiscence work, engaging people in their own community
by going to local cafes or events and encouraging clients to interact with people when they
are out and about that enabled the achievement of these outcomes.
The indications are that after 4 or more assessments most clients felt happier and healthier
than when the service commenced. The positive score for the ‘coping with everyday tasks’
outcome is interesting in that an aim of OAOS staff was to encourage people to practise
basic tasks such as making a cup of tea or a sandwich. Qualitative data suggests that
sometimes carers may get into the habit of doing things for clients and they can risk losing
basic skills.
It would be useful to understand a little more why clients might be feeling healthier. The
decline in feeling safe appears to increase in longer term cases, as people become older and
presumably frailer, and less able to move around their homes as confidently as they used to.
Table 6:
Collated scores for clients with 4 or more outcomes assessments
Enjoy Health Cope Isolation Relationships Safe Overall
score
Total
movement
all clients
+47
+18
+3
+36
-17
-26
+111
Aggregate
movement
across
clients
+1.2
+0.5
+0.1
+0.9
-0.4
-0.7
+2.8
These figures indicate that clients achieved some overall positive outcomes, particularly in
enjoying life. There is not huge movement in terms of improvement, which was to be
expected. Neither, however, is there significant decline overall and the evidence shows that
clients are being sustained in their homes for more than a year.
A table with details of the collated information on client outcomes can be found at
Appendix 4.
4.3
Carer Outcome Data Analysis
The findings are based on data from 29 carers who had completed 4 outcome monitoring
reviews (including the initial baseline assessment). As with clients, OAOS staff aimed to
complete the outcomes assessment tool with carers in a regular review session about every
3 months. However for reasons discussed in the clients section this was not always possible.
23
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
The data analysis focuses on carers where four or more outcomes assessment reviews have
been undertaken as the team evaluation anticipated that this would provide a clearer sense
of each individual’s trajectory.
Carers were asked to respond to 5 questions to indicate how they were feeling across key
health and wellbeing areas.
Chart 2 Carer data showing movement (against baseline) across outcomes
25
20
20
19
18
15
15
14
11
9
10
18
10
11
stable/improvement
Declined
5
0
Enjoying life
Continue to Physical health
care
Mental
wellbeing
Relationship
with client
No = 29
70% of carers are enjoying life more since the OAOS service began to support them and the
person they are caring for, 66% report improvements in their own mental wellbeing and
62% report that their relationship with the person they care for has improved because of
the respite break, support, signposting and practical tips for coping that are provided by the
support workers.
In the group that felt their ability to care had diminished, the key fact to note is that they
are continuing to care, and quantitative data from carers strongly indicates that the OAOS
service is a significant factor in their ability to carry on caring. Many clients and carers are
married couples with husbands caring for wives and vice versa, all are older and many of the
carers have health issues of their own to contend with which combined with the ageing
process will continue to impact on their ability to provide care.
The data shows that 26 carers (90%) in this group reported remaining stable or improving in
at least one of the outcome areas. 4 carers (14%) reported feeling stable or better across all
24
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
5 outcome areas and 13 carers (45%) had a higher than baseline score when looking at the
aggregated score across all outcome elements.
It is also worth noting that baseline data for carers may not necessarily accurately reflect
how the carer felt when the service first started. Anecdotal evidence from OAOS staff
suggests that carers will often initially report that they feel fine, coping well and getting
along with the client and score themselves highly across all or some outcome indicators in
the baseline assessment. It is not until the second outcome measures assessment that
carers start to reveal how difficult life can be at times and reduce scores accordingly. This
trend is reflected in the data where there is a much lower score across one or more
outcome measures at second assessment.
Table 7
Collated scores for carers with 4 or more outcomes assessments
Enjoy
Continue Physical
Mental
R'ship
Overall
life
caring
Health
Wellbeing with
Client
Total
movement
all cases
+16
-5
-8
+5
0
+8
Aggregate
movement
across cases
+0.6
-0.2
-0.3
0.2
No change
+0.3
Details of the collated information on carer outcomes can be found at Appendix 5.
4.4
Risk Data Analysis
In order to help determine the contribution of the Older Adults Outreach Service to
preventing clients’ entry into other services, the risk assessment looked at the following
risks:




Client being moved into residential care
Client moved into nursing home care
The caring relationship breaking down (where a client was living with or supported by a
spouse or family member)
Additional services being provided in the home such as domiciliary care, or short term
residential care placements as respite for carers.
Risks were rated as green (no or low risk) amber (medium risk) and red (high risk) by OAOS
staff.
25
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
The findings in this section are based on risk data gathered and reported on 93 clients. In 21
(23%) cases there was only one set of risk assessment data available. In most cases this was
because they had only been supported by the service for a short time. In one case there was
no risk assessment data because the service user was only supported for one month before
leaving the service. Across the cohort 351 risk assessments had been carried out with
between 1 - 13 per person. Appendix 6 has a table shows the range.
The risk assessment data shows that:

32 (34%) of the clients were classified as low risk (5 greens) in their most recent
assessment, as opposed to 46 (50%) in their first risk assessment.

34 (37%) of the services users were medium risk (at least one amber) in their most
recent assessment, as opposed to 33 (35%) in their first risk assessment

27 (29%) of the clients were high risk (at least one red) in their most recent assessment,
as opposed to 14 (29%) in their first risk assessment.
Number of risk assessments
Chart 3
50
45
40
35
30
25
20
15
10
5
0
Comparison between first and last risk assessment.
46
33
First risk
assessment
14
Low risk
Medium risk
Number of clients
Most recent risk
assessment
High risk
The findings suggest that OAOS helped to prevent people moving into residential care and
enabled people with dementia to remain in their own homes for longer than would have
been the case without the support of the service. Some clients were supported to access
day services as a means of helping to sustain the caring relationship, enable the client to
remain in their own home and prevent (or delay) entry into residential or nursing care.
Of those clients classified ‘low risk’ at their most recent assessment, in 8 cases there is only
one assessment, in 15 cases they have been assessed as low risk each time and in 9 (28%)
cases they have been considered at a higher risk at some point in the past, showing that for
these 9 people OAOS is making a contribution to maintaining them in their own home.
In the nine cases where the risk is now low but had been judged higher at an earlier point
the details were as follows:
26
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
Table 8 Movements across risk factors
No. of Pattern of risk
Details
R.A.
4
All low risk except 2nd risk
2nd RA medium risk for day care and high risk
assessment
for change of carer / family
8
First three RAs medium risk
1st – 3rd RAs medium risk for day care
then all low risk
10
First two RAs were high risk
1st RA was high risk for everything except
then all low risk
nursing care, 2nd high risk for day care
9
All low except 7th and 8th
7th RA was medium risk for day care and 8th
each had one medium
medium risk for adult social care
th
8
All low except 6 which was
6th RA was medium risk for day care
medium
8
All low except 6th which had
6th RA was medium risk for day care and
two medium risks
adult social care
5
First three were medium risk 1st – 3rd RAs medium risk for day care, with
then last two low risk
the 2nd also medium risk for adult social care
5
First RA was medium risk
1st RA was medium risk for day care and
then all low risk
change of carer / family
3
First two RAs were medium
1st and 2nd RAs were medium risk for day
risk then third low risk
care
RA = risk assessment
Four or more risk assessments have been completed with 42 (45%) clients. The change for each
of these 42 clients between first assessment and their most recent assessment shows that in
exactly half of these cases (21) the risk level has increased over time. These changes in risk need
to be considered within the context of an ageing client group, many of whom have other health
issues in addition to dementia, and while some risks have increased OAOS works with clients
and their carers to address risk and to sustain clients and their carers in their own homes as far
as possible.
However in 17 (40%) cases the level of risk has stayed the same, and in 4 (10%) it has actually
decreased, showing that for 50% of clients risk factors have been stabilised or reduced.
27
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
Chart 4
Movement between first and last risk assessment for those people with 4
or more assessments.
2
3
1
12
7
Remained low risk
Remained medium risk
5
12
Increased from low to medium risk
Increased from medium to high risk
Increased from low to high risk
Decreased from medium to low risk
Decreased from high to low risk
In 10 of the 21 cases where the risk has increased there was a significant period of stability
where the service user was assessed as lower risk before the level of risk began to increase,
in 9 cases the risk increased gradually, and in 2 the picture is more mixed.
Across all the risk factors the most commonly identified risk identified was the breakdown
of the caring relationship. 42 More information can be found at table 2 of appendix 6.
4.5
Clients and carers experience
The evaluation team held a focus group at one of the Saturday Get Together sessions. The
group was attended by 16 clients and 9 carers/close relative not primary carer. Participants
talked about Mind being a "safe pair of hands", trusting the service/finding the staff and
service trustworthy as important aspects of the service. All the focus group attendees felt
that they had positive relationships with the support staff, people talked about how quickly
time passes when the workers are there and how well staff listen to them.
Some clients feel that the service helps give them confidence to carry on connecting to their
local community, with comments such as "I like to get out, but I’ve lost confidence getting
on buses. So she (names worker) takes me to places on the bus which is really useful. We go
together and then I come back by myself which has given me more confidence."
Relatives who are not carers were present and they too talked about their satisfaction with
the service. One commented "as a daughter, the support means a lot to my mother and it
means I can have quality time with my mother on her own as this is the only time they are
42
Based on 351 risk assessments - medium (29%) or high (3%)
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
28
apart." Another described it as a "lifeline for mum and dad". Relatives as well as carers
welcome the chance to learn about how to respond to situations -: "It is useful for us as a
family to talk (with the worker) and get help on how to react to situations at home with my
parents".
Clients and carers anticipate and look forward to the support worker visits, and reflected on
how much the weekly sessions gave them something to look forward too. One person
commented "If you are down in the dumps when she (names worker) arrives, you are not
when she leaves." Another said "It can seem unimportant – but it isn't. Getting people away
from the house and that little environment you are in all the time."
The users and carers interviewed by the evaluation team for the case studies also all talked
about how much they appreciated and valued the service. Carers (who were mainly
spouses) talked about how the service had helped them to cope often through very difficult
times and about the support and practical information OAOS support workers had provided
a lifeline that enabled them to carry on caring for their loved one.
Carers described in great detail how difficult it was to watch their loved ones 'change' in
front of their eyes, often describing personality changes and talking about how people
became aggressive or verbally abuse when they had not been like this before the onset of
their dementia. One carer talked about how tired he became because his wife often got up
during the night feeling confused about where she was and how he wasn't able to leave her
in a room on her own. Others talked about the physical demands of toileting, washing and
physically caring for their partner. Some talked about how distressing it was not to be
recognised by someone to whom you've been married for most of your adult life, who
seems to have no memories of that shared life together and about how difficult it is to care
for someone with dementia. Other shared feelings about not being able to cope and how
the Mind service was "such a help" in supporting them to continue to care.
Some carers also had serious health issues and talked about the challenges they faced in
attending to their own needs, such of which are reflected in the case studies later in the
report. One carer (a son who didn't necessarily identify as being a carer) commented about
the OAOS support worker:
"She’s got a particular skill set, which I don’t have. If I try to go out with my mom I’m not
that good at things, I’ll put it that way. Whereas (names worker) got patience and she’s
comfortable with her".
Another carer said: “It gives him sort of something to think about for a couple of days
because they’ve done something together and he’ll go back to it, .... and he’ll say ‘do you
remember when I did that with names worker… which is a good thing”.
People with dementia found that the service had helped them to come to terms with their
dementia, one man noted that the OAOS support gave him an opportunity to do things for
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Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
himself, as he tended to get cross when his wife had to help him. One client talked very
movingly about how enjoyable his retirement had been prior to a series of strokes, mini
strokes (transient ischemic attacks) and his diagnosis of dementia, how mourning the loss of
this life tended to make him 'grumpy and cross' with this family and how the OAOS worker
was helping him to deal with these feelings. Others felt the support workers helped them to
enjoy and get more from life, clients talked about laughing with staff, and how much they
valued the one to one support, conversations and outings.
4.6
Referral agencies experience
Referral agencies rated the Mind OAOS highly and appreciated that they could refer the
people they were working with directly into the service, as one interviewee noted:
"A lot of services require a referral from a GP or other professional and with the Mind service
you can refer to them directly".
Referral agencies appreciated being able to refer their clients into a service that is free at
the point of delivery, interviewees expressed concerns about the number of services that
had closed due to funding cuts, or which were now charging anything up to £16.00 an hour
for a similar service.
The service model of offering tailored support in the clients own home was valued. Referral
agencies were aware that day care is not always the simplest answer for older people with
dementia. As one referral agency commented: "....the other thing is that some people don’t
want to go to respite. They maybe have lived with their husband or wife for years and are
not used to or confident in mixing with a big group… So Mind gives a one to one service that
really suits some people.." and another noted "It’s important that it’s a home service. The
trouble with a day centre is that it can take so much energy to get someone there. It takes
time to get a person with dementia ready, they get confused. By the time they are ready to
go the to the day service the carer can be shattered and begin to wonder if it was worth the
effort."
Others noted that the service gives carers 'peace of mind' and improved relationships
between the carer/family and the person with dementia.
Referral agencies valued the weekly nature of the service, the time staff invest in building
relationships, the approaches taken to retain memory and cognitive skills and the fact that
the service helped to reduce social isolation for both clients and carers. Referral agencies
also talked about the work done to enable people with dementia to be as self determining
as possible, as one interview said: "It is about giving people choice and the less choice they
have, they’re losing their voice."
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Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
For one (statutory) referral agency the fact that OAOS helped to increase the length of time
people continued to live in their own homes was increasingly important.
Interviewees noted that OAOS staff were sometimes able to mediate in some instances
where tension has developed between the person with dementia and their carer, for
example ".... the support worker has encouraged him to visit a day centre once a week and
that has really helped the wife who is the primary carer. … It has also broken down a bit of a
barrier because the wife was speaking for him before (he won’t want to go) but he did".
When asked what could be done to improve the service, all the referers talked about the
waiting lists that had been in operation at various times and expressed concerns that the
delay in starting the service often meant that people's conditions and circumstances
deteriorated while waiting for the service. Some agencies offered suggestions for improving
communication about the waiting list, for example an email to say the person they had
referred was on the waiting list and then an email to say the service had commenced.
Others would like to see the service extended across the city.
4.7
Staff reflections
The evaluation included opportunities for Mind staff, both support workers and those
management, to reflect on the learning from delivery of OAOS. The OAOS team participated
in a focus group, the management team were interviewed and all staff had access to an
online survey to record their views individually.
4.7.1 What has worked well

Bespoke service - staff felt that a key strength and success factor of OAOS is that support
is tailored individually; the service has a structure but is able to be flexible to client
needs

Taking people out – getting out into the community is an important element of the
service for clients and carers

Signposting – providing information about other services and support, especially for
carers, identifying additional needs and making onwards referrals, highlighting benefit
entitlements

Working with other agencies – making connections with other agencies is important to
enable people to stay in their own homes and to provide reassurance and additional
support for carers

Saturday Get Together events for clients, carers and support workers at Birmingham
Mind venues – opportunities for mutual support and broadening clients’ social
interaction
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Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)

Some staff use the evaluation outcomes survey data to reflect on what has changed
from one client review session to the next and what factors might have impacted on
changes in the scores
4.7.2 The difference OAOS has made
In the online survey, staff rated a set of potential outcomes based on their own experience
of supporting clients and carers and identified outcomes achieved in the following order:
1.
2.
3.
4.
5.
6.
7.
Improved client wellbeing and happiness.
Respite for carers.
Reduced social isolation.
Able to stay in own home longer.
Improved carer wellbeing and happiness.
Support to carers.
Improved physical activity.
Staff felt that the service did help carers to carry on caring for longer, that it increased the
confidence of clients in going outside and provided benefits through social interaction.
In addition, they identified that OAOS had made a difference in the following ways:

Listening to clients and carers, providing reassurance and emotional support.

Providing companionship on the dementia journey, sharing the experience with clients
and carers.

Providing enrichment for clients, improving their quality of life through variety of
experience.

Working alongside personal care providers to create a package of support around
clients.

Reducing the stigma associated with dementia, bringing people with dementia into the
community to participate in activities.

Helping people to retain motor and language skills, promoting their independence
safely.
4.7.3 Barriers encountered
The barriers identified by staff mostly related to the operating constraints of delivering
within limited resources and communication issues.
Resources
OAOS was operating at full capacity in the last 12-18 months, to the extent that the waiting
list had to be closed. This made it impractical to promote the service and meant it was
32
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
difficult to raise awareness of it with the professionals, such as GPs, who were supporting
existing clients. The demand for the service has been exacerbated by the closure of other
support services for clients and carers due to funding constraints elsewhere. People on the
waiting list may have been unable to access a service anywhere else. Some clients on the
waiting list deteriorated before they received a service at which time it was no longer
suitable for them.
OAOS was funded to deliver in North Birmingham only and the team have received
increasing numbers of requests for a service from other areas of the city that they have
been unable to respond to. This was known from the inception of OAOS but the reduction in
services elsewhere has highlighted those gaps in provision.
OAOS operates during office hours (9am-5pm), Monday-Friday and staff felt that this was a
barrier as a lot of people are isolated at weekends and some carers may appreciate the
service at weekends. Some workers had ‘out of hours’ calls and they tried to deal with them
on Mondays, however they felt the restricted hours of the service created a lack of flexibility
to clients’ needs.
There are issues around referral to transport providers who are not able to provide the level
of support often needed to help people who get confused about how to get into minibuses
and cars. More people would like to attend the Saturday Gt Together events but lack of
transport prevents them.
Communication
Some staff felt that more could be done to raise the profile and value of the service with
some professionals, such as GPs, social workers and Community Health Teams, who they
felt did not recognise the value of the service and of working in partnership with the support
workers. Staff felt that working in collaboration with other agencies could be improved,
perhaps with shared support pathways for clients.
Some staff felt that not having an end date to service could sometimes be a barrier and that
a conversation agreeing the circumstances in which the service might end would be useful
for workers, clients and carers. They were not suggesting putting a hard deadline on a
service as people deteriorate with dementia at different rates so each person’s conditions
should be considered.
Staff reported that some carers have found it difficult to understand why it is important to
complete paperwork on a regular basis, particularly wellbeing surveys for the evaluation.
They start well initially but become less prepared to take part in the wellbeing research over
time.
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Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
4.7.4 What staff would do differently
All support workers thought the following changes would be helpful:

Clearer criteria linked to regular reviews for ceasing the service.

More events like the Saturday Get Togethers to enable clients to meet up and socialise.
Some staff would like to meet up in the community with other workers and clients, to
support clients to build on friendships made at Saturday Get Togethers.
4.7.5 Thoughts for the future
The staff team were of the view that some clients would be willing to pay for a service and
they suggested that OAOS could become a paid service, with provision for these unable to
pay, and maybe offer a ‘direct payments’ service which could be even more tailored to the
needs of clients. Alternatively, they suggested Mind could ask for donations and ringfence
any received to support OAOS.
Staff identified that the service could be strengthened at transition points for clients and
carers. For instance, when clients transition into residential care the continuation of OAOS
for a time-limited period could help them settle into their new environment. OAOS could
also offer some transition planning with carers to signpost them into alternative support
when a client moves into residential care or dies.
Staff suggested Mind could offer the following for carers when a client leaves the service:




Telephone support
Wellbeing check
Coffee visit
Option to drop into the Saturday Get Together events to keep in touch with people
Staff noted that they are receiving increasing numbers of referrals for working-age dementia
clients and suggested that the service could be developed to provide support specifically for
this group and their carers.
4.7.6 Staff learning points
Strategic view
OAOS had a strong strategic fit with the work Mind had been doing with older adults
through their residential care facilities and the pilot service before OAOS had been part of a
long term strategy to support people experiencing mental ill health as they got older.
However they had not anticipated at that pilot stage working with so many people with
some form of dementia, which quickly became the core client group of the service. A key
strategic learning point has been the positive impact that relatively low levels of support can
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Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
have for someone with dementia and their carer and this has become a growing area of
interest for the organisation.
Mind had not expected to have such a high demand for this service, particularly given it got
off to a fairly slow start in terms of numbers and referrals, and as a result they had not really
given sufficient thought or preparation to managing the waiting list, waiting times and the
associated communications both internally and externally. Thinking about how people
access and exit the service is something Mind is keen to work on in the future.
Operational view
When asked what they had learnt, support workers talked about what they have learnt from
the clients they support, they reflected that older people have a lot to offer:
“How enjoyable and rich life was many years ago despite certain hardships and setbacks”
“Increased awareness of resilience of the human condition”
Staff also noted how “sitting with someone for a couple of hours can make all difference“.
In operational terms, support workers recognised the value of good communication in the
team, good communication between support worker and carer and the importance of
maintaining a sense of humour. They identified that the earlier support commences the
more beneficial it is for clients and carers and how important it is for clients to be able to
stay in their own home.
4.8
Case Studies
The evaluation team carried out 3 in depth case studies in year 1 (2012), 4 in year 2 (2013)
and a further 4 in year 3 (2014).
Case studies enabled rich qualitative data to be gathered and involved:

a review of client case files

a face to face interview with clients (where this was practicable) and their carers (where
clients had one)

a one to one interview with the Mind Older Adults Outreach Service support worker

telephone interviews with referral agencies or other agencies as appropriate
From these 11 case studies 9 cost consequence case studies have been compiled which
reflect the range and complexity of clients that used the service. These draw mainly on
interviews conducted over years 2 and 3 to reflect the services long term engagement with
clients and carers.
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Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
4.8.1 Approach to Cost Consequence Case Studies
The following cost consequence case studies are based on:

Actual Mind Older Adults Outreach Service income rather than a full cost recovery basis
(FCR). 43

The latest national data calculations of health and social care unit costs 44
Cost consequence analysis aims to monetise the value of preventative or early interventions
in terms of the potential savings to acute, or more intensive, services. It is a model which,
whilst widely recommended, has been adopted by a limited number of charities 45 and has
been subject to some criticism in that:

It does not measure non-financial health and wellbeing/quality of life indicators. 46

The benefit to cost ratio can be inflated (particularly using Social Return on Investment
models 47) by assuming that any intervention prevents worst case scenario outcomes for
all clients. 48
The case study approach adopted in the evaluation allows for a nuanced approach to
developing a monetary value of service interventions.
There are, however, other ways of analysing the cost-benefit of the Older Adults Outreach
Service. For example, it is estimated that the annual cost of median level health and social
care costs for a person with dementia living in the community is £29,938 49. While the
Birmingham and Solihull Dementia Strategy for 2014-2017 arrives at a cost per annum of
around £27,647 50. The strategy then compares this with the cost per cancer patient of
£5,999, stroke £4,770, or heart disease £3,455 and comments "Additionally of note is that,
43
See for example http://www.biglotteryfund.org.uk/fcr and http://www.thinknpc.org/publications/full-costrecovery-2 for guidance on full cost recovery calculations.
44
Curtis, L. (2012) Unit Costs of Health and Social Care 2012. Personal Social Services Research Unit, University
of Kent
45
The National Audit Office ( Office of the Third Sector: Implementation of Full Cost Recovery: 2007) has
suggested, based on anecdotal evidence, that a substantial number of charities do not calculate interventions
on a full cost basis
46
See for example Kay, A. (2011) Prove, Improve, Account: The New Guide to Social Accounting and Audit.
Social Audit Network, Wolverhampton and Organisation for Economic Co-operation and Development
indicators - http://www.oecdbetterlifeindex.org/
47
Cabinet Office (2009) Social Return on Investment – an introduction. Office Of the Third Sector, Cabinet
Office, London
48
Arvidson, M., Lyon, F., McKay, S. and Moro, D. (2010) The ambitions and challenges of SROI. Third Sector
Research Centre, University of Birmingham
49
Service costs draw on Prince, M, Knapp, M, Guerchet, M, McCrone, P, Prina, M,Comas-Herrera, A,
Wittenberg, R, Adelaja, B, Hu, B, King, D, Rehill, A and Salimkumar, D. (2014) Dementia UK: Second Edition.
Alzheimer’s Society, London. See also www.alzheimers.org.uk/statistics
50
Figure arrived at by dividing the estimated costs of dementia at national level with the national figures for
people with dementia.
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
36
compared with cancer, stroke and heart disease, the costs for social care for a person with
dementia substantially outweigh those for healthcare."
This would mean that, at current costings, the service ‘repays’ itself by sustaining 2.7 clients
per annum (or 5.4 over 6 months) in their own homes without accessing more intensive
care packages. The average cost of annual residential care is estimated at £36,738. Based on
this figure, investment in the service is ‘repaid’ if it prevents 2.1 people (from a case load of
90) entering residential care for one year (or 4.2 for six months).
However it is estimated that, once informal care in the community is deducted (£21,965 per
annum) the direct costs to health and social care are £7,806. This means that, if MIND Older
Adults Outreach Service is the only service accessed there is a direct cost-benefit once 10
clients have been supported for one year.
The figures for residential care are substantially greater, with only 6.7% of the total cost
relating to informal/family care, suggesting that the service is cost efficient if it prevents 2.3
people entering residential care over any one year.
Using this model, and drawing on the case study material and other data held by MIND
(which indicates often long term engagement) the service represents substantive value for
money.
A second approach is to identify the cost savings of the service to its users. In two case
studies, people identify access to a local day centre at a cost of £10.50. This is, very much, at
the very affordable end of care services and can be offered as this is primarily provided by
volunteers. Where voluntary organisations charge for home sitting services the average cost
to the client is between £15 and £17 per hour and is usually offered in two hour blocks. This
represents a real cost to the family, or lone client, of:

between £360 and £408 per 3 months

between £720 and £816 per 6 months

between £1,440 and £1,632 annually.
Whilst this is substantially lower than the cost of residential care, it places a considerable
financial burden on older people on low incomes without recourse to state support and
impacts on their quality of life.
As well as monetised outcomes, there is substantial evidence from the evaluation that Mind
Older Adults Outreach Service achieves a number of positive ‘soft’ outcomes for clients,
carers and their families that cannot be expressed in purely financial terms.
For example, people with dementia retaining positive (and predictive) memories, remaining
physically active and the ability of carers to:
37
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)

Retain social contacts outside the home and spend time with other family members
which counters the social isolation reported by many carers. 51

Undertake routine household tasks (e.g. shopping etc) without the added anxiety of
leaving the person with dementia alone in the home.
These soft outcomes were aspects of the service that were particularly valued by the clients
and carers who participated in case study interviews. Carers in particular identified that the
support they received from the service benefitted both them and the person they cared for.
Carers commented for example:
“It (support worker visit) gives him something to look forward to and it’s a bit of an outlet
from me”.
"I get a bit of time to myself when he is out with (names OAOS worker). A bit of time to
relax or do the things that need doing - shopping things around the house. It’s 2 hours, but 2
hours that he really looks forward to and it helps me out”.
Clients commented for example:
“ I am calm… I don’t have any worries because I know she [the support worker] is there to
solve it.”
Having [the support worker] constantly coming, you know, I look forward for her to
coming…. And if she does not come, I don’t know what I will do.”
Stakeholders also valued these soft outcomes and told us:
"Now she's happy. The main thing is she can do her own shopping - not household but for
personal things."
"She'd probably be more down and more depressed." (about the client without the service)
About the carer "she was at breaking point."
"For some people this service means they can carry on with their life." (in relation to carer)
4.8.2 Criteria for Case Study Selection
From an analysis of the caseload carried by the Mind Older Adults Outreach Service a
number of criteria have been adopted in terms of the selection of case studies from the
overall caseload:
•
Clients and carers have had a longer term contact with the service (over 11 months) as
such cases lend themselves to economic/cost-benefit analysis in ways that one off
interventions or short-term client contacts do not.
51
See Findlay, R. (2003) Interventions to reduce social isolation amongst older people: Where is the evidence?
Aging and Society No 23 pp647-658 and Carers Trust
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
38
•
Account has been taken of the gender profile of current clients as well as age and the
severity of dementia at point of diagnosis.
•
The sample reflects caseloads in terms of examples where Mind is the sole service
provider (Studies 4,5 and 6) and instances where the service is one of a number being
delivered to the carer and client from a range of agencies and organisations and which
has increased cost implications (Studies 1-3). Drawing on original Theories of Change
literature (Weiss: 1995 52) this reflects the nature of the current caseload and
acknowledges the difficulties of ascribing positive outcomes, in complex cases and multiagency interventions, of any one organisation/intervention, whilst still allowing for
robust cost-consequence analysis.
4.8.3 The Cost Calculation Model
The hourly delivery costs of Mind Older Adults Outreach Service have been calculated on
the following basis:
annual intervention costs per employee
÷ working weeks a year (44)
÷ working hours a week (37.5)
The annual intervention costs per employee include individual staff salary and on-costs such
as National Insurance and pension. This equates to £13.44 per hour plus
% of indirect costs (travel, publicity, phone etc ) at 6.8% of total budget
% of central/organisational management and administration support costs at 10% of
total budget
Total cost per intervention hour = £15.69 53
In presenting cost-consequence data, no one assumption on alternative care interventions
(or the duration of those interventions) has been made given the variable rate of decline in
people with dementia and increasingly high thresholds for access to residential care,
particularly in cases where there is a carer in the home/the carer is receiving home support
services. The cost of hospital admissions has not been included as these vary according to
the severity of a condition and are unpredictable.
52
Weiss, C. (1995). Nothing as Practical as Good Theory: Exploring Theory-Based Evaluation for Comprehensive
Community Initiatives for Children and Families in ‘New Approaches to Evaluating Community Initiatives’.
Aspen Institute.
53
MIND’s unit costs have remained the same since 2012.
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
39
Case Study 1
Gloria is a 70 year old African Caribbean woman. She lives alone but has three sons one of
whom lives locally and visits on a regular basis. She was referred to OAOS by the Social
Services Day Centre in September 2012. In addition to vascular dementia, Gloria has poor
physical health and has been diagnosed with arthritis, osteoporosis and a collapsed vertebra
and has mobility problems. As a result of her condition Gloria is on the Palliative Care Gold
Standard Framework, 54 meaning that primary care services had identified a likelihood that
Gloria’s life expectancy was between one year and 18 months.
Gloria had received OAOS support for 15 months. On initial assessment in September 2012 a
variety of risk factors were identified. Gloria was withdrawn and she was forgetting to eat
and drink, wasn't getting dressed properly and the referral agency interviewee noted that
she was in danger of becoming depressed and of her physical health and mobility
deteriorating. The support worker gradually increased involvement over the period of
delivery and was providing 4 hours of support a week at the time of the case study. This
involved trips out, socialising with neighbours and practical support such as taking Gloria to
the laundrette, shopping and helping with food preparation. For the past year, she also
received domiciliary support with getting out of bed, washing and dressing and, with Mind
support, moved into extra care housing.
Gloria feels that OAOS helped her to stop feeling miserable about not being able to go out
and commented about her support worker "she gave me confidence. To know that the
service is there, it's like medicine. It's not only company I'm telling you it's medicine". Since
OAOS started working with Gloria both family members and other professionals have
noticed a substantial change in Gloria’s wellbeing. Whereas on initial assessment she lacked
social contacts she now does the shopping, meets other residents on a regular basis, is less
depressed and has maintained a degree of independence that was not anticipated on
referral.
Cost Assumptions
Over 15 months, Gloria received 343 hours support from OAOS at a total cost of £5,390.00.
Approximately 7 hours per week was provided in additional home care/domiciliary support
(not by Mind) over the past year at an average cost 55 of £181 per week (£9,412 over 52
weeks), making the total estimated value of Gloria’s care package (excluding housing costs)
over the period of the OAOS interventions £14,794.
54
See http://www.goldstandardsframework.org.uk/cdcontent/uploads/files/Library,%20Tools%20%26%20resources/A%20Full%20GSF%20Guidance%20Paper%20on
%20Primary%20Palliative%20care%20for%20QOF.pdf
55
All external agency costings for case studies 1-5 are based on Curtis, L. (2012) Unit Costs of Health and Social
Care 2012. Personal Social Services Research Unit (PSSRU), University of Kent. Unit costs for case studies
undertaken in 2014 draw on the updated PSSRU report for 2013.
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
40
External stakeholders reported that, in their assessment, Gloria would have required a more
intensive community, and potentially residential care home, support. The costings (below)
are based on the assumption that Gloria may have entered either median/high cost
community or residential care.
Table 9 Cost Analysis Case Study 1
A median cost
A high cost
community care
community care
package at £822
package at £349
(median 24 hours
(median £10 hours
support) per
support) per week week
Residential care
Cost of direct
home cost
OAOS
(£1,208 per
intervention
week) and with
additional care
costs - £1,734 per
week
56
3 months £4,188
3 months £9,864 Range for 3
£1,077
months
£14,496 - £20,808
6 months £8,376 6 months £19,728 Range for 6
£2,153
months
£28,992 - £41,616
One year £16,752 One year £39,456 Range for one
£4,036
year
£57,984 - £83,262
OAOS plus
current
home
support
services
(total care
package
£3,430
£6,859
£13,718
Note: cost books estimate that home care support for those with severe dementia (requiring a
minimum of 30 hours per week home support) costs £1,046 – excluding housing and living expenses.
Assuming that Gloria would have required additional community or residential support for
the mid-point of 6 months, the current care package represents a saving of between £1,517
(median cost care package), £12,923 (high cost) and £22,133 - £34,757 (residential).
In arriving at this cost consequence figure it has been assumed that OAOS interventions
alone would not have prevented Gloria requiring more intensive/residential care. The
figures are therefore based on the cost of the whole care package. Similar assumptions have
been made in case Studies 2 and 3.
Case Study 2
Joan is 79 and is of Irish origin. She lives alone but is supported by her daughter, who lives
nearby, usually in the evenings after work. In addition to dementia she has had a diagnosis
of schizophrenia for the past 40 years which is monitored by a Community Psychiatric Nurse
and treated via depo injections. Joan has been accessing Mind Older Adults Outreach
Service for 11 months. Over this period her condition has stabilised, though the risks
identified on first assessment (forgetting to eat, take her medication, lack of social
contacts/isolation) remain. In addition to OAOS support, she received 20 hours per month
56
External service costs are based on 48 week calculations.
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41
home care support, half of which was funded by social services and the remainder by
Joan/the family. She had two weeks of respite care over the year whilst her daughter was
on holiday. OAOS interventions included taking Joan to activities at the local community
centre, walking and trips to the park and city centre.
Joan was identified as being very isolated and not confident about going out on her own.
She sometimes forgot to eat and take her medication. She was referred to Mind by the
community outreach worker at a Social Services Day Centre who was concerned that,
without additional support, there was the risk of the breakdown in care arrangements
requiring residential care. Indeed the major change observed by external stakeholders has
been the daughter’s wellbeing and capacity to cope which, in their view, had delayed the
need for residential care. The referring agency interviewee who had referred Joan
commented "This is a really good service, it's not just support for that person it's the
family...for some people this service means they can carry on with their life."
“You don’t feel so on your own, so isolated… We’re having such a good experience, it’s
working for mum.” (Daughter/carer)
Cost Assumptions
Over the 11 months that Joan accessed Mind Older Adults Outreach Service she received
173 hours of support at a cost of £2,714. She also had two weeks of fully-staffed residential
care at a total estimated cost of £2,416 and 20 hours of home care support (over one
month) at a median cost of £18.77 per hour (£375.55 per month).This supplemented the
OAOS support of just under 16 hours on average per month (cost £246 per month). In total,
the monthly cost of support for Joan in the home was £621.25.
Assuming that OAOS delayed the necessity of additional home care support by three
months, this represents a cost saving of £1,126.65 of which half (depending on financial
assessment) may have been paid by the family (a saving personally of £563.32 to the
family). Assuming a six month delay this figure rises to £2,253.30 and £1,126.65
respectively.Each month that residential care was delayed for Joan represented a cost
saving of between £597 and £1,113, depending on the level of residential care required (see
costings in Case Study 1).
Case Study 3
Mandy is a White British woman aged 87 and lives with her husband. In addition to
dementia she has a thyroid problem, is registered blind and has limited mobility and
diabetes which is controlled by diet, she has had both knees replaced and has some issues
with her carotid artery. She lives with her husband Alan, who is also in his late 80s who is
her carer.
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At initial assessment it was noted that Mandy’s short term memory was very poor, that she
had problems dressing, needed help with going to the toilet, became easily agitated and
slept poorly. John did all the washing, cooking and cleaning and showered and dressed
Mandy daily. He commented “she can't always remember how to dress herself and it can be
very frustrating for her when she can't do it." John found Mandy's personality changes very
hard to cope with sometimes; she could become very restless and on occasion let herself
out of the house and wandered off. John reported that Mandy can be delusional often
becoming distressed at the children she 'sees' and 'hears'. He found some of the things
Mandy said distressing - such as asking where her husband is and why she's not at home.
Both John and Mandy look forward to the support worker’s visits.
Mandy had a fall which further restricted her mobility. She also attended a day centre for
three hours per week, though she found the unfamiliar surroundings distressing and there
were problems with access to suitable transport and Mandy settling at the day centre unless
accompanied by a family member.
Mandy and John accessed Mind Older Adults Outreach Service for a year. The support
worker’s focus was on sustaining Mandy’s mobility, supporting socialisation and
memory/reminiscence work. Mandy loved to talk and John thought that the service gave
her time to talk. John also found that Mandy slept better on the day the support worker
came which meant he got a better night's sleep too as she didn't wake him up so frequently.
There was also substantial support for Mandy’s husband as there were concerns during June
2013 that, without some respite and addition support the care arrangements would break
down.
John could not leave Mandy on her own in a room and found that "sometimes caring can
get me down". John appreciated the support he received from the service "it means that I
can get out of the house for a couple of hours, without the support I don't know what I'd do.
I can get a lot done in 2 hours..."
Cost Assumptions
Over the year Mandy and her husband received 80 hours of project support to a total value
of £1,255. In addition Mandy attended a Day Centre for three hours a week at an estimated
cost of £35.50 57. The total annual cost of interventions was therefore £3,101. The major
concern in the summer of 2013 was that Mandy’s husband would not be able to continue
caring for her as she become increasingly agitated and confused.
Assuming that additional day care respite were to be provided two days per week in the day
centre Mandy already attended over the past 6 months this would have cost £3,559
compared to the cost of existing interventions of £1,550 over the same period. However, as
Mandy had difficulties in settling in day care settings, this may not be an option even in
57
Based on full day cost of £69 per day.
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
43
future. Assuming, given her state of confusion, that Mandy would require high input
residential support over this same period at £1,046 per week for total for 6 months
(£27,196). This represented a potential cost saving of £26,046. Again, whilst Mandy’s
husband, daughter and the support worker acknowledged the real risk of the breakdown in
care arrangements, the family expressed reluctance around residential options. However
John is clear that "if this service stopped I'm not sure what I'd do. I'd go back to the GP and
to Perry Tree and they would have to do something and give me more support."
Case Study 4
Tom is 77 and of Irish origin. He lives with his wife Betty (aged 60) and he was referred to
OAOS in April 2012 by the Alzheimer’s Society. Tom also has diabetes, arthritis and he walks
with the aid of a stick. Although case notes made reference to his slow cognitive
deterioration, which both Tom and Betty find distressing, he remains physically active. Tom
has difficulty recognising people, he finds it hard to remember his way around and has a
poor short term memory. He needs regular prompting to remember to eat and drink
regularly.
The OAOS support worker focused on keeping Tom physically active and regular
assessments indicated that physical and emotional health were sustained. Sessions included
trips out and Tom also took part in activities at local clubs – singing, bingo and so forth.
Tom enjoyed going out with his support worker and said that the visits take the boredom
out of his life. He felt that getting out and about helped his memory and Betty commented
that while Tom had bad days and good days, Tuesdays (the day of the support worker visit)
never seems to be a bad day. Betty appreciated the respite the service provided and she
particularly appreciated the flexibility of OAOS when his support worker was able to arrange
to take him out on a day trip to enable her to have a whole day off and join her old work
colleagues on a trip to Leeds. Knowing that Tom was "in safe hands" meant that Betty could
relax and enjoy herself. The respite she got was valued by Betty who commented “He can
still look after himself up to a point, but I wouldn’t want to leave him too long, sometimes he
doesn’t eat……..It means I’ve got a couple of hours to myself, which is great……..’
Cost Assumptions
Since the first intervention/assessment in May 2012, Tom received 305 hours of support,
over 19 months, at a total cost of £4,785. As noted, although Tom had ‘good days and bad
days’ (Betty interview), Mind’s intervention stabilised, and indeed improved, Tom’s physical
and mental wellbeing. Betty also felt well supported and both looked forward to the
support worker’s visits and the activities undertaken.
In this case no additional risk factors (e.g. requiring additional home/day care or respite)
were identified. As such, therefore, there are no cost savings to be identified.
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Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
However, both Tom and Batty repeatedly stressed during interviews that their quality of life
had improved with OAOS support and Tom was sustained, despite increasing memory loss,
within his home over a 19 month period.
Case Study 5
John is White British, aged 72, and lives with his wife, Pat and his son. He has been
experiencing increasing difficulties with his mobility but needs a lot of persuasion to use a
wheelchair. The case notes identified he often has little appetite and some weight loss has
been noticed. A urinary tract infection in 2012 resulted in some incontinence and an
increase in issues around personal hygiene.
Two daughters lived close by and visited with the grandchildren on a regular basis. John
found the noise in a busy house upsetting and, in Pat’s words, ‘retreats into the kitchen’. He
was referred to Mind by Age UK and, with a break of three months during staff changes, was
involved with the service since October 2011. At the time of the case study there were no
other services involved – although John did attend a Day Centre for 10 weeks (one day per
week) over the summer of 2012. This facility then closed.
John was diagnosed with mid-term dementia and there are concerns over his deteriorating
physical health and his withdrawal from family life:
“I think, without the service, John would have completely withdrawn from the family. I think
he would have ended up in residential a while ago. Or maybe not, but he’d have withdrawn
into the bedroom and become bedridden because he is proud and would not want
residential. So it would have been no life at all really.” [support worker]
Pat commented:
“I dread to think what would have happened if (OAOS) were not coming. I’d have gone mad
and he probably would not be here.”
Interventions initially focused on John’s emotional wellbeing and keeping him physically
active. This involved trips out (John was a train driver and particularly enjoyed – and
remembered – a day out at the Severn Valley railway earlier in the year), shopping locally
and visits to the museum, local library and shops. Pat felt that the visits have been very
successful in getting John to reminisce about what was important to him and felt that he
seemed to be physically and mentally better particularly after a visit to somewhere he
remembered.
There was also practical and advocacy support for Pat in terms of sorting out housing
repairs, securing aids and adaptations including handrails at the front door and negotiating
with the GP practice for a full medical examination for John. Pat particularly valued this part
of the service, feeling without that support she would have been unable to sort out
problems with the house such as repairs to the boiler, flooring and electrical sockets.
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Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
Pat valued having some time to herself while the support worker was with John.
Cost Assumptions
Over two years (allowing for the 3 month gap in service) Tom has received 208 hours
support at a total cost of £3,264. Given the concerns about deteriorating physical health and
increasing isolation Mind is actively seeking two days day centre support in the immediate
future.
John, whilst increasingly frail, remains able to wash, dress and feed himself although he
needs prompts and reminders to do so. In the medium to longer term he may require more
intensive community support and/or respite/residential care. However, given that the
current plan is to increase day care support, the following cost assumptions are based on
the delay in requiring additional day centre support or low to median cost community care
interventions.
Table 10 Cost assumptions case study 5
Two days per week
A low cost
day centre support
community care
at £69 per day
package at £185
(median 7 hours
home and day care
support) per week
3 months
£828 3 months
£2,220
6 months
£1,656
6 months
One year
£3,312 One year
A median cost
community care
package at £349
(median £10 hours
support) per week
Mind support –
based on 104 hours
intervention per
annum
3 months
£4,188
£408
£4,440 6 months
£8,376
£816
£16,752
£1,632
£8,880
One year
Even assuming only a three month delay in more intensive community support this
represented a cost saving of between £420 (day care) and £3,780 (median cost community
care package). These cost-consequence ratios rise substantially if the option of fully staffed
residential care (see Case Study 1) were taken into consideration.
Case Study 6
Elizabeth is an African Caribbean woman, aged 79. She has a daughter, Corinne, who works
full time and referred her to the service because of the limited time she could spend with
her mother and concerns that Elizabeth was becoming increasingly isolated, fragile and
vulnerable. Elizabeth‘s short term memory is poor, she also has arthritis and has, on
occasion, fallen.
She received OAOS services for 22 weeks (to end of August 2014), after waiting nearly a year
for a service. This usually consisted of two to two and a half hour visits which mostly
involved engaging Elizabeth in conversation. The support worker had taken Elizabeth out to
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Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
the shops occasionally (not often due to mobility difficulties) and offered other light physical
activities to increase her mobility and reduce her sense of isolation. Elizabeth was originally
from the Caribbean and particularly enjoyed reminiscence sessions with the support worker.
On one visit the worker discovered that Elizabeth had fallen and called Corinne and an
ambulance. She helped the carer collect clothes for Elizabeth once she was admitted to
hospital and visited her during her stay, offering conversation and activities such as
crosswords. The worker also provided ‘wellbeing checks’ during the week when Corinne was
on holiday. Elizabeth loved flowers and wanted to keep her garden tidy so the support
worker arranged a gardening service and took her to a garden centre to buy a plant.
In addition, the support worker worked with Elizabeth on retaining her cultural identity and
language skills which both she and her daughter felt are particularly important for her
wellbeing. Since the start of OAOS’s involvement, assessments recorded that Elizabeth’s
enjoyment of life increased and that, after an initial decline there was an overall
improvement in her health, social relationships and safety. Elizabeth, however, found it
increasingly difficult to manage day to day tasks and the service explored the possibility of
culturally appropriate day care with the carer.
Whist aids and adaption's were made to Elizabeth’s home no other service was being
accessed. For Elizabeth, visits were ‘a God-send…she’s lovely ’ and her daughter noted that
‘It’s made an awful lot of difference to her quality of life…very comforting …that couple of
hours on a Thursday … It’s made a massive difference to me, I don’t feel as isolated as I did
before … I don’t feel so alone.’
Cost Assumptions
Elizabeth received, since initial assessment, visits totalling 55 hours direct contact time and
a further 10 hours in case administration. This represented a total ‘spend’ of £1,020.
Identifying a cost-saving to other services of OAOS’s support for Elizabeth is problematic.
Overall her physical and mental health remained stable or improved. She was, therefore,
unlikely to meet the threshold of eligibility for more intensive day care services and, unless
there was a rapid deterioration in her health, residential care was unlikely in the medium
term. Elizabeth could, however, purchase in a sitting service at between £15-£17 per hour.
Assuming this service, as with OAOS, were to be for 2 hours per week the Older Adults
Outreach Service has, potentially, saved Elizabeth between £660 and £748 over the twenty
two weeks of intervention.
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Case Study 7
Audrey, aged 80, is White British and is supported by her son, Mike, who does not live with
her. She has been diagnosed with early stage Alzheimer’s . Audrey can forget to eat, take
her medication and has limited mobility. There have been concerns about weight-loss and
concerns that she is being exploited by a neighbour who may have taken money off Audrey.
Mike has recorded that, since diagnosis, his mother increasingly has mood swings and can
become angry and aggressive.
Audrey was allocated 3 OAOS workers whilst receiving a service, she was therefore
suspicious of the 3rd support worker in the first instance, and initial work focused on gaining
Audrey’s trust. Her son noted that, prior to OAOS’s intervention, his mother had been going
out less and was reluctant at first to leave the house. At the time of the case study, every
visit involved a trip out and assessments record improvements in overall wellbeing, coping
with routine tasks and social networks. Further, Audrey’s outbreaks of emotional anger
decreased since the start of the service, but there were re-occurrences of aggression
towards the son and the worker.
The major concern was the potential breakdown of care in the home. Mike felt his mother’s
aggression and ‘constant demands’ could impact on his ability to offer ongoing care:
‘If I didn’t get the time off that I do get off I probably couldn’t keep going as long as I can as
I guess it’s only a matter of time before she goes into sheltered housing or a home or
something but it helps to keep her here a bit longer…… I know that when (the worker) is
coming I can do things without having to worry about mum phoning and getting back.’
Audrey reported that ‘It’s something to look forward to for me and it gives (my son) a break
because he is here all the time.’
Cost Assumptions
Audrey accessed Mind services for 54 weeks, amounting to 135 hours of direct contact time
and a further 8 hours for non-contact support with a total value of £2,244. Audrey, following
support from OAOS, also visited a day centre in the local Church. This cannot be costed as it
was a volunteer-based service. The following table therefore presents a series of scenarios
related to the prevention, or at least delay, in the breakdown of current care arrangements.
Given that Audrey has early stage Alzheimer’s, the costings in Table 11 assume that
residential care is unlikely at this stage, but that the service has delayed the need for more
intensive community care packages.
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Table 11 Cost assumptions case study 7
Two days per week
A low cost
day centre support
community care
at £69 per day
package at £185
(median 7 hours
home and day care
support) per week
3 months
£828 3 months
£2,220
A median cost
community care
package at £349
(median £10 hours
support) per week f
OAOS support –
based on 130 hours
intervention per
annum
3 months
£4,188
£510
£8,376
£1,020
£16,752
£2,040
6 months
£1,656
6 months
£4,440 6 months
One year
£3,312
One year
£8,880
One year
Case Study 8
Pete, aged 73, is White British and lives with his wife, Eileen, who is 70. They have a son who
lives at home but who has severe and enduring mental health problems and is not involved
in caring for Pete. In addition to a diagnosis of dementia, Pete has had three strokes which
have affected his speech. He also has mobility problems, partial paralysis of his left side and
increasing memory loss. Pete was referred to the service by his Social Worker.
Initially OAOS worked with Pete to provide emotional support, reduce his isolation and
promote his personal independence and to provide regular respite to his wife as his sole
carer. Following his third stroke in July 2014, at Pete's request OAOS focused on improving
his mobility and speech. This involved weekly trips to the gym followed by a coffee to
encourage conversation and, through this, language retention The time spent at the gym
built on the 12 weeks physiotherapy support that OAOS put in place for Pete by working
with his GP following his third stroke.
Life changed significantly for Pete and his wife, who were both looking forward to an active
retirement pursing their own hobbies and meeting up regularly with friends and family.
Prior to his illnesses, Pete had been very physically active, attending to his allotment and
going fishing on a regular basis. Following his first stroke, Pete became anxious about falls
and was reluctant to go as far as the garden.
Assessments indicated an improvement in Pete’s physical health, posture and mobility as
well as a reduction in social isolation. The main concern was the breakdown of care as Eileen
often feels unable to cope:
‘Sometimes I feel as though I'm dead, he wants me by his side all the time - if I go into the
garden he say's I'm ignoring him, same if I go upstairs or out of the room…… Sometimes I
just want to walk out and just leave them to look after themselves and then I think no who's
going to look after them?’
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Pete's personality changed as a result of his dementia and in response to his reduced
mobility and he could, on occasion, become aggressive towards Eileen. He recognised this
but felt it was caused by frustration:
‘I want to be able to do things for myself, I don't like my wife helping me I get cross with my
wife helping me all the time.’
For Eileen, even short respite sessions were vital for her mental wellbeing and capacity to
cope:
‘My sister comes when (the worker) takes him out, and it's my free time, it's such a relief i
know he's my husband and I feel free when he's not here’.
Both Pete and Eileen felt that their situation, both in terms of health and Pete's ability to
remain in their home, would deteriorate rapidly without OAOS support.
Cost Analysis
MIND was involved with the family over 76 weeks since February 2013. This represented a
total of 406 contact and non-contact hours on the part of the service to a value of £6,370.
Pete attended a day centre one day per week (cost £1050 per session). Attendance was,
however, intermittent and has since ceased. This element of support has not therefore been
costed. Given Pete’s physical condition and increasing mood swings, there was a risk of the
breakdown of current care arrangements. The cost assumptions in Table 12 are based on
the assumption that the Older Adults Outreach Service has delayed the need for more
intensive community care packages or residential care.
Table 12 Cost Analysis Case Study 8
A median cost
community care
package at £354
(median £10
hours support)
per week
A high cost
community care
package at £833
(median 24 hours
support) per week
Residential care
home cost (£1,026
per week) 58
3 months £4,258
6 months £8,496
3 months £9,996
6 months £19,992
3 months
6 months
£14,496
£28,992
£1,089
£2,179
One year£16,992
One year £39,984
One year
£57,984
£4,358
58
Cost of
direct OAOS
intervention
Residential care costs have been recalculated since the 2012 Unit Costings Report used in earlier case
studies. Weekly costs are therefore slightly lower than previously
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
50
Case study 9
Neil is White British, aged 85, and lives with his wife, May, who is the same age, in sheltered
accommodation. Neil is reluctant to take up the extra care provided through the housing
provider and OAOS, until recently, hds been the only service involved, although Neil recently
agreed to attend a local day centre .They have two children in their 50’s who are not directly
involved in care due to ill health and living away from Birmingham.
Neil, as well as a diagnosis of dementia dating back eight years, has prostate cancer, an
irregular heart- beat, has partial hearing and takes medication for severe arthritic pain in his
hips and hands. He can become extremely withdrawn and is on occasion aggressive towards
May:
‘Some days he just so wicked, he's not hit me but he has pushed me over when he's confused
he pushes me like that when he's in the bathroom…….He wasn't like this you know, this isn't
what he was like.’
The focus of OAOS interventions was on keeping Neil physically and mentally active. This
involved trips to local cafes, parks and garden centres. With the worker Neil also visited
Aston Villa football stadium and the Midlands Air Museum.
The respite offered by MIND is seen as vital by May:
‘I find it such a great relief to go downstairs to a class knowing he's safe and being looked
after, although I am worried about the future he's getting progressively worse… Every day is
a struggle and everyday I think I can't go on. If this service stops it would be a great loss to
me and I think I would really give up..’
This concern became more acute following May’s diagnosis with cardiomyopathy. There
were also concerns, expressed by the GP, that she needed a more sustained period of
respite and negotiations were undertaken for a two week care home break to enable May
to visit her daughter.
Cost Analysis
OAOS was involved with Neil and May for 50 weeks. This involved three hour visits every
week, plus worker travel, administration and assessment. Over the period OAOS committed
249 hours to the family with a monetary value of £3,907. OAOS also introduced Neil to a
local day centre which he attended, two days per week, for 6 weeks at the time of the case
study. This cost the family £10.50 per session.
Assessments indicated that interventions, overall, stabilised Neil’s physical health and ability
to manage routine tasks, though those fluctuated and there was a gradual decline in mental
wellbeing. There was also a growing concern about May’s physical and emotional capacity
to remain primary carer. The costs are based on the assumption that, if care arrangements
broke down, Neil would require residential care with additional support to meet his health
care needs. Higher rate residential care costs £1,580 per week. This contrasts with
combined OAOS and day care support costs of £68.07. This savings ratio is high, but reflects
the additional costs of residential health and social care costs for people over 75 with
dementia and, in comparison with previous case studies (and taking into account both Neil
and May’s health) is a realistic, if worst case, scenario. However, if Neil were to remain in his
current accommodation and take up extra care services, the weekly cost would remain
substantially higher at £430 per week.
5.
Conclusions
The Mind Older Adults Outreach Service aimed to support older people experiencing
dementia or functional mental health difficulties by providing short, regular (usually 2-4
hours weekly) home visits and respite for carers. The aim of the service was to help
maintain people in their own homes by offering bespoke activities and interventions that
support and maintain physical and mental wellbeing. In addition, the intention was to
support carers (through the provision of these short and regular respite breaks) to continue
to care, to help relieve some of the pressures associated with caring and as a consequence
support the carer to continue to provide care and delay or prevent a move into residential
or nursing home care.
A key strength of the service is that it is underpinned by the values, ethical approach and
experience of working with people with mental health problems offered by Mind. This
organisational ethos ensured that both clients and carers were considered and treated as
individuals, and that a person-centred approach was embedded in the service by staff.
Understanding the importance to the quality of service that the underpinning value base
provides has enabled Mind to more clearly emphasise its values within training for
volunteers and staff and recruitment processes.
Engagement with the evaluation process has stimulated both managers and delivery staff to
develop their reflective practice and to gain a deeper understanding of the impact of the
Older Adults Outreach service on physical and mental health and wellbeing. As a result of
reflection staff and managers have a better understanding of when and how clients need to
transition out of the OAOS into more intensive or sustained support, at the point when
Mind interventions become less therapeutic and more purely respite for carers, or when
carer needs change and more frequent respite is required.
Mind have consistently demonstrated their commitment to learning from the formative
elements of the evaluation, for example they have acted on the recommendation that the
service needed to have clarity about accessibility criteria, length of service and at what point
the service is no longer suitable, to help staff, current and potential clients and referral
partners to understand what the service aims to achieve and entry and exit points.
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Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
These conclusions are based on data and findings gathered from across the lifetime of the
project. From reviewing the quantitative and qualitative data it is clear that the service:

Was valued by both the clients and their carers.

Offered regular respite to carers and this helps them to continue to care and prevents
caring relationships from breaking down.

Offered practical advice and tips for living with and caring for older adults with dementia
who are often being cared for by their partner or spouse who is also aging and dealing
with age related illnesses themselves.

Provided clients with physical activity and mental stimulation to help them to "live well"
with their dementia. 59

Helped carers access other support and services, such as carers assessments, aids and
adaptations for the home and additional respite care in the form of day centres and
short (week/two week) breaks.

Built carer resilience.

Was valued by referral agencies and that for some referral agencies both in the statutory
and voluntary sectors was an established element in referral pathways.
As one stakeholder commented: "It’s important that it’s a home service. The trouble with a
day centre is that it can take so much energy to get someone there. It takes time to get a
person with dementia ready, they get confused. By the time they are ready to go the to the
day service the carer can be shattered and begin to wonder if it was worth the effort."
(Stakeholder interview year 1 case study)
Qualitative evidence 60 from carers and referral agencies strongly suggests that for many
clients the Mind Older Adults Outreach Service (and access to other support and services
that people get as a result of OAOS signposting and advocacy) actively contributed to
preventing clients moving into more expensive care provision and helped to reduce/prevent
reliance on mainstream services.
As part of the recommendations in the 2014 Interim Evaluation Report, Merida wanted to
review client and carer data to test for correlations, trends and differences in self-reported
outcomes data to explore if both client and carer report feeling the same or better about
the same or different outcome areas. Analysing the records across 27 clients and their
carers, where both have 4 or more assessments against outcomes, has not shown any
significant trends or particular correlations. For example, only 8 clients and carers both
59
Birmingham & Solihull Dementia Strategy 2013-1659, currently out to public consultation (January 2014).
Gathered by the evaluation team through case studies, and anecdotally from Mind front line staff and
managers.
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
60
53
showed an improvement (including remaining stable) from the aggregated scores across all
outcomes.
Initially the evaluation team was interested to explore any correlations and potential
causality between client outcome data and movement between levels, particularly where
clients were reporting improvement or no change, and the intervention from the Older
Adults Outreach Service support workers. Working with staff, the evaluation team agreed a
taxonomy of interventions and asked staff to record their activity against this for each client
in advance of the regular client outcomes review. It has not, however, been possible to
correlate the client outcomes data with the intervention monitoring data generated by staff
members.
The lack of correlation between client self-reported outcomes and staff activity appears to
support a view that it is not what the staff members do during visits but the fact that they
do visit regularly, and provide attention specific to the clients’ expressed needs each time,
that makes the difference. Staff listen to both the person with dementia and their carer, and
from this deliver personalised support services designed to meet specific needs and that
change and develop as needs change.
We heard many times in case study interviews how both clients and carers value being
listened to, having a relationship with someone who is interested in them and who is able to
spend quality time with both clients and their carers.
Comments and observations made by case study respondents also suggest that the key
critical success factor for the project is the relationship between the support worker, the
client and the carer:
“She just clicked with us…I felt she was secure with him.” “She certainly makes a difference,
she just comes across that she cares .. they’ve got a real rapport between ‘em.”
“Sam took to him (OAOS worker) straight away. They could talk to each-other and had
interests they could talk about.”
Partly due to the sensitivity of engaging with vulnerable clients, partly to make the most
efficient use of resources and to embed data gathering for management purposes into the
service, it was decided that staff would gather the outcomes data with clients and carers.
This has, however, presented some methodological challenges in ensuring consistency and
regularity of data capture, mainly to do with changing personal and both clients and carers
resistance to completing the monitoring forms. However we are confident that the data
that has been received has been both reliable and robust.
54
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
6.
Recommendations
If these recommendations were being made by clients (both clients and carers) then the
only things that it would say is please can we have visits more than once a week, and please
keep the service going for as long as we need it.
Overall, this is a hugely effective service, that helps people to live longer in their homes,
supports carers to continue to care and helps clients get other community level support
services as they move towards needing them, where such services a)exist and b) are
affordable.
It is against this backdrop that we make the following recommendations and suggestions for
improvements and future actions.
High level strategic recommendations
While Mind is well respected and well engaged with commissioners, policy makers and
others around the mental health and wellbeing agenda, the Older Adults Outreach Service
appears to have a low profile at strategic level amongst commissioners in health and social
care. While we understand that demand for the service overtook organisational capacity to
deliver on occasion, we still feel that the model of delivery is one that is worth sharing even
given that the future for the service is uncertain at the moment.
We would recommend that Mind look at how they can share the information about what
works in terms of supporting older adults with dementia drawing on both their practical
experience of delivering the service and this evaluation. For example we would suggest that
you consider submitting an article to a relevant journal or network, or consider hosting a
small symposium or seminar to share findings and raise the profile of the learning gained
from this service. We would further recommend drawing on the skills and expertise of
Board members for both these recommendations.
Service design and delivery recommendations
If Mind does intend to continue to deliver or even expand the service we would recommend
that you consider the following:
•
Improve communication with referral agencies
A simple system for keeping in contact with referral agencies would both improve
relationships and help OAOS to become better integrated into service pathways for people
with dementia. This in turn has some potential to raise Mind's profile with planners and
policy makers.
55
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
•
Explore the potential to use volunteers
There are some elements of the Older Adults Outreach Service delivery model, such as the
befriending and weekly visits, that could be delivered using volunteers. Using volunteers
could potentially enable the organisation to extend the reach of its delivery making the
service more widely available.
However, it would mean that Mind would need to invest in learning how to train, manage,
motivate and support volunteers. Moreover, there would need to be a clear volunteer
recruitment and selection protocol to ensure that volunteers were fully informed about the
values, ethos and ethics underpinning the approach to the service. Notwithstanding these
issues we feel this is an area that is worth exploring as the benefits may well outweigh the
upfront costs and associated risks around working with volunteers.
•
Explore the potential for putting in place a charging policy
At the moment the service is free at the point of delivery for both the one-to-one home
support and the Saturday Get Together sessions. Some (albeit limited) anecdotal evidence
suggests that some of your clients would like to make a contribution to the organisation
and/or be able to pay for the service, and /or to be able to buy additional support hours.
While it may never by within Mind’s value base to exclude from services those who cannot
afford to pay, we would recommend that the organisation explores putting in place a sliding
scale of fees, even if you are only intending to ask people to make a voluntary contribution
to the service, or to ask them to make a donation towards petrol for longer trips out etc.
•
Put a plan in place to manage waiting lists and waiting times
It is frustrating for staff, potential clients/carers and referral agencies when waiting lists
occur, and whilst creating a waiting list may be unavoidable at times, proactively managing
the list, confirming that they are on a waiting list and keeping people informed of wait times
would improve communication channels.
56
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
Appendix 1
Outcome monitoring tool: service users
Name of service user _________________________
Completed by:
Date ______________________________
Service user
Service user and carer
Carer on behalf of service user
Health and well-being
1. How much are you enjoying your life at the moment?
Not at all
Very much
Comments:
2. How would you describe your health at the moment?
Very poor
Excellent
Comments:
Remaining independent
3. How well are you coping with everyday tasks at the moment?
Not at all well
57
Very well
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
Comments:
Reducing social isolation
4. How isolated do you feel?
Very isolated
Not at all isolated
Comments:
5. How well are you getting on with other people?
Not at all well
Very well
Comments:
Living safely at home
6. How safe do you feel in your home?
Not at all safe
Very safe
Comments:
58
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
Taxonomy of Activity To be completed by support worker:
During the period between now and the last time the outcome monitoring tool was used with this
service user, which outcomes have you focussed on? (Please tick all that apply)
Health and well being
1a Activating long term memory
1b
Increasing physical activity
1c
Increasing mental activity
1d
Support with practical tasks
1e
Encouraging regular eating and drinking
1f
Behaviour management
1g
Language retention
1h
Supporting cultural identity
1i
Emotional support
1J
Experiencing pleasure / enjoyment
Remaining independent
2a Managing own money
2b
Managing time / supporting daily living
2c
Managing personal hygiene
2d
Managing own food and drink
2e
Making choices
Reducing social isolation
3a Interacting with people outside home
3b
Companionship
3c
Supporting access to appropriate services
Living safely at home
4a Liaising with other agencies to improve safety of environment
4b
Liaising with other agencies to improve physical well-being
4c
Liaising with other agencies to protect from exploitation
59
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
Outcome monitoring tool: carers
Name of service user _________________________
Date ______________________________
Name of carer ______________________________
7. How much are you enjoying your life at the moment?
Not at all
Very much
Comments:
8. How able do you feel to continue to provide care?
Not at all able
Very able
Comments:
9. How would you describe your physical health at the moment?
Very poor
Excellent
Comments:
60
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
10. How would you describe your mental well-being?
Very poor
Excellent
Comments:
11. How would you describe your relationship with the person you are caring for?
Very poor
Excellent
Comments:
61
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
Taxonomy of Activity To be completed by support worker:
During the period between now and the last time the outcome monitoring tool was used with this
carer, which outcomes have you focussed on? (Please tick all that apply)
Support for carers
6a
Performing a task normally undertaken by carer
6b
Practical support for carer
6c
Respite for carer
6d
Liaising with other agencies on behalf of carer
6e
Emotional support
6f
Support for carer to manage difficult / challenging behaviour
62
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
‘Prevention of risk’ assessment
Name of service user
To determine the contribution of the Older People’s Service to preventing or delaying
service users’ referral into higher levels of care.
To be completed at initial assessment and regular review meetings (3 months).
In your opinion, to what extent is this person at risk of the following:
Risk
Being moved into
residential care
Being moved into
nursing care
The caring
relationship
breaking down
Needing to be
supported through
day care
A change in
family/carer
circumstances
Needing to be
supported through
adult social care
services or local
health budgets e.g.
Respite care
Domiciliary care
Other please note
Initial
assessment
(date)
Review
(date)
Review
(date)
Please state
which service
Please
Please
state which state
service
which
service
Review
(date)
Review
(date)
Please
Please
state which state which
service
service
Risks rated as follows:
No risk
Some risk
High risk
63
Green
Amber
Red
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
Completing the evaluation Questions with clients and carers. Information Sheet for Staff ‘
1. There are 2 purposes for completing these forms:
a. Gathering evidence to show to funders that the project is supporting people to remain in
their own homes for longer, preventing them from having to go into residential or
nursing care
b. Helping the team and Mel keep track of how things are going, what is working well, and
flagging up where a client may need more support
2. The outcomes sheets (back page of smiley face forms) should be completed BEFORE the review
visit so that the worker reflects on what the client/family member recorded last time & why – to
help you to be prepared for the review
3. When completing the smiley faces forms with clients & family/friends, the key is to have a
meaningful conversation with each person to discuss where they think they are on the scale and
where you think they are, with your reasons, and find a point you both can agree on. You can
refer to their previous responses in review sessions.
4. Monitoring questions are subjective to each client and family member/friend – you are not
comparing clients & what they can do against each other, we are measuring the CHANGE or
MAINTENANCE of a score rather than the level – things don’t have to get better, staying the
same is a success. E.g. Every client will have a different interpretation of what ‘coping with
everyday tasks’ means – you score on the basis of what is usual/recent behaviour for that
particular client, using your notes from the last review to guide you.
5. We are looking to see if there is matching up between what the support worker does (the back
sheet) and how the client & family member/friend report they are feeling (smiley faces).
6. It is important to try to ask the questions in the same way each time, you can adapt the language
of the questions so that clients/carers understand them so long as you do the same each time –
so make a note to remind you what is the best approach for each client.
7. It is important not to lead people to the answers you want to hear, or they think you want to
hear – you are enabling them to understand what they are being asked and to really think about
what difference, if any, having your service has made to them/their lives together (if
appropriate) – remember – staying the same is a WIN.
8. If a client has a number of family members or friends supporting them, you may need to
complete a form for each one, so it may be better to talk to them all on the phone to complete
the family member/friend forms. You could discuss this on a case-by-case basis with Mel. Talking
on the phone may be a better option for some lone carers too.
Ideas for asking the questions
Health and well-being questions
Put these questions in the context of the service you are providing, and refer to the activities you
have been doing together, e.g.
64
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
How are you feeling in yourself? / How is your health at the moment?
Since I’ve been coming to see you…
Do you enjoy yourself when we…?
go to the café / park / shops etc.
In the last 3 months you’ve been able to…
…get out in the fresh air more
…walk to the shops
… talk to me about …
You’re walking much more at the moment – are you getting more exercise than you were
before I started coming to see you?
Remaining independent
Refer to the kind of everyday tasks that are relevant to that individual, based on your knowledge
about them.
How are you managing with …?
Are you still managing to…?
getting dressed etc.
sort out your breakfast etc.
Reducing social isolation questions
Put this in the context of your visits or activities that you do that involve seeing other people, and
refer to particular people that the service user has contact with. Include impact of e.g. holding
someone’s hand or the service user just seeing another face.
How are you getting on with … and how would you rate that on the smiley face chart?
Are you getting out and about more now that we are going to …?
Living safely at home
Refer to any advice or practical support you have been able to give.
Do you feel safer now that we’ve…?
Got that hand rail fitted
Sorted out an anti-slip mat for you etc
Questions for family / friend / carer
Focus on what difference your service has made to them.
How have you been able to use the time while I’ve been here…?
65
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
Appendix 2 Sampling Matrix
Category
No of clients
client identifier number
Age
Under 59
60 – 69
70 - 79
80 – 89
90 and over
No age/DOB
Family circumstance
Living alone – no live in carer and MIND is only service going in
Living alone - no live in carer but MIND and other services are
supporting
No carer no other information
Living with spouse/partner who is now caring for the client
Living with the family
Disability/Condition
Depression
Vascular dementia
Dementia
Alzheimer’s
Bi-polar
PICTS disease
Gender
Female
Male
Ethnicity
White British
White Irish
Pakistani
Caribbean
Referral status
Social worker
Age UK
Alzheimer’s Disease Soc
Perry Tree Centre
Short stay NHS rehab - http://benpct.nhs.uk/your-services/healthcentres/perry-tree-centre/
Older Adults Services
Self Referral
Community Links
Friend
66
% of
cohort
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
Appendix 3 Evaluation Questions mapped against BCC Prevention Outcomes
Outcome measures and evaluation questions
Prevention
outcomes
Measure
Questions
1. Health and
well being
Percentage of service users
report that their lifestyle has
improved for the better
How much are you enjoying your life at the
moment?
Percentage of service users
report that their relationship
with their carer has improved
How would you describe your health at the
moment?
2. Remaining
independent
Percentage of individuals using
the service feel confident that
they can cope with everyday
tasks and remain independent
How well are you coping with everyday
tasks at the moment?
3. Reducing
social
isolation
Percentage of individuals using
the service report that they feel
less lonely and depressed
How isolated do you feel?
4. Living safely
at home
Percentage of service users
report that their lifestyle has
improved for the better
Percentage of users report an
improvement in their living
conditions
How well are you getting on with other
people?
How safe do you feel in your home?
Prevention
outcomes
Measure
Questions
Support for
Carers
Percentage of carers say they feel
supported to continue providing
care by using the service
How able do you feel to continue to provide
care for (name of client)?
Percentage of carers using the
service report an improvement in
their physical and mental wellbeing
Percentage of carers report that
their lifestyle has improved for the
better
Percentage of carers report that
their relationship with the person
they care for has improved
67
How would you describe your physical
health?
How would you describe your mental wellbeing?
How much are you enjoying your life at the
moment?
How would you describe your relationship
with (name of client)?
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
Appendix 4 : Collated recorded outcomes for client with four assessments 61
Case No
3
Baseline
Most recent
Movement
4
Baseline
Most recent
Movement
7
Baseline
Most recent
Movement
12
Baseline
Most recent
Movement
14
Baseline
Most recent
Movement
61
Duration in
service from
baseline to last
assessment (No.
times assessed)
12 months (x4)
32 months (x12)
32 months (x9)
12 months (x6)
13 months (x4)
Dimension 1 –
enjoying life
Dimension 2 –
health and
wellbeing
Dimension 3 –
Coping with
everyday life
Dimension 4 –
feeling of
isolation
Dimension 5 –
getting on
with other
people
Dimension 6 – Overall score
safety in home
4
8
+4
8
8
No change
4
5
+1
4
4
No change
8
10
+2
7
9
+2
35
44
+9
5
9
+4
6
6
No change
5
6
+1
9
8
-1
10
9
-1
10
8
-2
45
46
+1
9
9
No change
8
7
-1
9
5
-4
4
8
+4
8
No answer
No change
(using last
answer)
10
9
-1
48
38
-10
5
8
+3
2
6
+4
2
3
+1
8
8
No change
10
9
-1
8
9
+1
35
43
+8
2
1
-1
5
1
-4
1
1
No change
1
1
No change
6
1
-5
10
10
No change
25
15
-10
Note: in tables - + = improvement in terms of risk assessment and - = deterioration
68
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
Case No
17
Baseline
Most recent
Movement
19
Baseline
Most recent
Movement
20
Baseline
Most recent
Movement
21
Baseline
Most recent
Movement
22
Baseline
Most recent
Movement
23
Baseline
Most recent
Movement
24
Baseline
Most recent
69
Duration in
service from
baseline to last
assessment (No.
times assessed)
31 months (x11)
19 months (x7)
12 months (x4)
35 months (x10)
15 months (x5)
11 months (x4)
25 months (x9)
Dimension 1 –
enjoying life
Dimension 2 –
health and
wellbeing
Dimension 3 –
Coping with
everyday life
Dimension 4 –
feeling of
isolation
Dimension 5 –
getting on
with other
people
Dimension 6 – Overall score
safety in home
3
9
+6
2
8
+6
2
6
+4
1
9
+8
8
9
+1
7
9
+2
23
50
+27
9
5
-4
3
3
No change
6
5
-1
8
5
-3
10
10
No change
8
9
+1
44
37
-7
4
5
+1
5
5
No change
4
6
+2
5
4
-1
10
5
-5
9
6
-3
37
31
-6
6
9
+3
7
9
+2
6
5
-1
10
7
-3
10
9
-1
10
9
-1
49
48
-1
7
6
-1
8
6
-2
5
4
-1
8
6
-2
6
7
+1
9
6
-3
43
35
-8
4
6
+2
9
8
-1
3
7
+4
5
5
No change
8
10
+2
10
7
-3
39
43
+4
5
8
4
8
9
8
8
7
9
10
8
8
43
49
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
Case No
Movement
27
Baseline
Most Recent
Movement
28
Baseline
Most Recent
Movement
30
Baseline
Most Recent
Movement
33
Baseline
Most Recent
Movement
34
Baseline
Most Recent
Movement
35
Baseline
Most Recent
Movement
40
Baseline
70
Duration in
service from
baseline to last
assessment (No.
times assessed)
13 months (x5)
27 months(x8)
23 months (x8)
25 months (x9)
21 months (x10)
25 months (x9)
22 months (x7)
Dimension 1 –
enjoying life
Dimension 2 –
health and
wellbeing
Dimension 3 –
Coping with
everyday life
Dimension 4 –
feeling of
isolation
Dimension 5 –
getting on
with other
people
Dimension 6 – Overall score
safety in home
+3
+4
-1
-1
+1
No change
+6
2
8
+6
3
8
+5
3
1
-2
4
8
+4
5
5
No change
6
9
+3
23
39
+16
8
5
-3
8
5
-3
9
2
-7
4
3
-1
4
4
No change
7
5
-2
40
24
-16
7
2
-5
8
2
-6
8
1
-7
7
3
-4
8
5
-3
9
5
-4
47
18
29
6
5
-1
9
6
-3
5
6
+1
9
7
-2
10
9
-1
10
7
-3
49
40
-9
6
7
+1
9
7
-2
7
8
+1
10
8
-2
10
5
-5
10
8
-2
52
43
-9
7
7
No change
2
8
+6
1
5
+4
10
8
-2
8
9
+1
10
9
-1
38
46
+8
5
3
8
8
10
10
44
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
Case No
Most Recent
Movement
42
Baseline
Most Recent
Movement
43
Baseline
Most Recent
Movement
45
Baseline
Most Recent
Movement
46
Baseline
Most Recent
Movement
49
Baseline
Most Recent
Movement
50
Baseline
Most Recent
Movement
54
71
Duration in
service from
baseline to last
assessment (No.
times assessed)
12 months (x5)
17 months (x7)
22 months (x8)
21 months (x6)
17 months (x7)
12 months (x5)
14 months (x5)
Dimension 1 –
enjoying life
Dimension 2 –
health and
wellbeing
Dimension 3 –
Coping with
everyday life
Dimension 4 –
feeling of
isolation
Dimension 5 –
getting on
with other
people
Dimension 6 – Overall score
safety in home
7
+2
7
+4
6
-2
10
+2
7
-3
8
-2
45
+1
6
8
+2
8
7
-1
4
7
+3
8
7
-1
9
8
-1
8
7
-1
43
44
+1
5
8
+3
7
9
+2
8
7
-1
3
9
+6
8
9
+1
10
9
-1
41
51
+10
7
6
-1
7
7
No change
6
6
No change
6
4
-2
9
9
No change
9
7
-2
44
39
-5
1
9
+8
2
9
+7
10
8
-2
5
8
+3
10
9
-1
10
9
-1
38
52
+14
5
5
No change
4
4
No change
2
6
+4
1
4
+3
8
9
+1
10
5
-5
30
33
+3
6
10
+4
5
10
+5
10
10
No change
8
10
+2
10
10
No change
10
10
No change
49
60
+11
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
Case No
Baseline
Most Recent
Movement
57
Baseline
Most Recent
Movement
58
Baseline
Most Recent
Movement
59
Baseline
Most Recent
Movement
61
Baseline
Most Recent
Movement
62
Baseline
Most Recent
Movement
63
Baseline
Most Recent
Movement
72
Duration in
service from
baseline to last
assessment (No.
times assessed)
15 months (x5)
14 months (x6)
15 months (x6)
13 months (x5)
14 months (x5)
16 months (x6)
Dimension 1 –
enjoying life
Dimension 2 –
health and
wellbeing
Dimension 3 –
Coping with
everyday life
Dimension 4 –
feeling of
isolation
Dimension 5 –
getting on
with other
people
Dimension 6 – Overall score
safety in home
7
6
-1
6
5
-1
8
6
-2
9
6
-3
9
7
-2
10
10
No change
49
40
-9
6
8
+2
6
8
+2
6
8
+2
5
8
+3
8
9
+1
10
9
-1
41
50
+9
9
7
-2
9
7
-2
5
6
+1
6
8
+2
10
9
-1
10
9
-1
49
46
-3
10
6
-4
10
6
-4
6
6
No change
8
6
-2
8
7
-1
8
9
+1
50
40
-10
5
8
+3
9
5
-4
4
6
+2
6
7
+1
8
9
+1
6
7
+1
38
42
+4
5
7
+2
6
6
No change
6
6
No change
3
7
+4
7
8
+1
10
9
-1
37
43
+6
5
8
+3
5
3
-2
7
8
+1
5
10
+5
7
10
+3
10
10
No change
39
49
+10
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
Case No
65
Baseline
Most Recent
Movement
68
Baseline
Most Recent
Movement
69
Baseline
Most Recent
Movement
70
Baseline
Most Recent
Movement
71
Baseline
Most Recent
Movement
72
Baseline
Most Recent
Movement
78
Baseline
Most Recent
73
Duration in
service from
baseline to last
assessment (No.
times assessed)
14 months (x5)
13 months (x5)
12 months (x5)
13 months (x5)
12 months (x4)
12 months (x5)
12 months (x5)
Dimension 1 –
enjoying life
Dimension 2 –
health and
wellbeing
Dimension 3 –
Coping with
everyday life
Dimension 4 –
feeling of
isolation
Dimension 5 –
getting on
with other
people
Dimension 6 – Overall score
safety in home
8
5
-3
8
7
-1
7
7
No change
7
8
+1
8
8
No change
8
10
+2
46
45
-1
6
8
+2
8
7
-1
5
2
-3
6
7
+1
8
9
+1
8
9
+1
41
42
+1
10
8
-2
5
7
+2
8
7
-1
9
10
+1
10
10
No change
10
10
No change
52
52
No change
1
6
+5
3
5
+2
1
6
+5
3
6
+3
9
7
-2
10
10
No change
27
40
+13
7
9
+2
7
5
-2
8
5
-3
5
8
+3
9
9
No change
10
9
-1
46
45
-1
5
7
+2
5
9
+4
8
8
No change
3
8
+5
9
8
-1
9
10
+1
39
50
+11
7
7
7
8
8
8
6
8
8
8
9
9
45
48
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
Case No
Movement
80
Baseline
Most Recent
Movement
Total
movement
all cases
Aggregate
movement
across cases
Duration in
service from
baseline to last
assessment (No.
times assessed)
10 months (x4)
705 months (255
assessments)
18 months (6
assessments)
Dimension 1 –
enjoying life
Dimension 2 –
health and
wellbeing
Dimension 3 –
Coping with
everyday life
Dimension 4 –
feeling of
isolation
Dimension 5 –
getting on
with other
people
Dimension 6 – Overall score
safety in home
No change
+1
No change
+2
No change
No change
+3
5
7
+2
+47
5
7
+2
+18
3
7
+4
+3
3
6
+3
+36
8
8
No change
-17
7
7
No change
-26
31
42
+11
+111
+1.2
+0.5
+0.1
+0.9
-0.4
-0.7
+2.8
Dimension 1 –
enjoying life
Dimension 2 –
able to
continue with
care
Dimension 3 –
physical
health
Dimension 4 –
mental wellbeing
Dimension 5 –
relationship
with person
cared for
Overall score
6
7
+1
8
8
No change
5
7
+2
6
7
+1
8
8
No change
33
37
+4
10
6
10
7
10
8
10
7
10
7
50
35
Carers with four or more assessments
Case No
4
Baseline
Most recent
Movement
12
Baseline
Most recent
74
Duration in
service from
baseline to last
assessment (No.
times assessed)
29 months (x11)
12 months (x6)
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
Case No
Movement
14
Baseline
Most recent
Movement
9
Baseline
Most recent
Movement
21
Baseline
Most recent
Movement
22
Baseline
Most recent
Movement
27
Baseline
Most recent
Movement
30
Baseline
Most recent
Movement
33
Baseline
75
Duration in
service from
baseline to last
assessment (No.
times assessed)
13 months (x4)
19 months (x7)
24 months (x9)
15 months (x5)
12 months (x5)
23 months (x6)
19 months (x7)
Dimension 1 –
enjoying life
Dimension 2 –
able to
continue with
care
Dimension 3 –
physical
health
Dimension 4 –
mental wellbeing
Dimension 5 –
relationship
with person
cared for
Overall score
-4
-3
-2
-3
-3
-15
2
1
-1
9
6
-3
7
8
+1
7
5
-2
8
4
-4
33
24
-9
7
10
+3
7
10
+3
10
10
No change
9
10
+1
9
10
+1
42
50
+8
6
7
+1
10
8
-2
8
8
No change
6
8
+2
6
9
+3
36
40
+4
5
8
+3
5
9
+4
7
7
No change
4
7
+3
2
6
+4
23
37
+14
7
8
+1
6
6
No change
7
7
No change
7
4
-3
8
7
-1
35
32
-3
10
7
-3
9
6
-3
10
8
-2
9
9
No change
10
8
-2
48
38
-10
8
9
8
8
7
40
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
Case No
Most recent
Movement
34
Baseline
Most recent
Movement
35
Baseline
Most recent
Movement
40
Baseline
Most recent
Movement
42
Baseline
Most recent
Movement
43
Baseline
Most recent
Movement
45
Baseline
Most recent
Movement
76
Duration in
service from
baseline to last
assessment (No.
times assessed)
21 months (x9)
25 months (x9)
21 months (x7)
12 months (x5)
20 months (x7)
19 months (x6)
Dimension 1 –
enjoying life
Dimension 2 –
able to
continue with
care
Dimension 3 –
physical
health
Dimension 4 –
mental wellbeing
Dimension 5 –
relationship
with person
cared for
Overall score
6
-2
5
-4
8
No change
8
No change
8
+1
35
-5
6
6
No change
6
8
+2
10
7
-3
4
8
+4
10
8
-2
36
37
+1
9
8
-1
10
8
-2
6
7
+1
10
8
-2
10
10
No change
45
41
-4
8
8
No change
6
6
No change
8
7
-1
9
7
-2
6
7
+1
37
35
-2
4
7
+3
9
7
-2
9
7
-2
6
8
+2
10
8
-2
38
37
-1
3
6
+3
8
7
-1
9
7
-2
3
7
+4
8
8
No change
31
35
+4
6
8
5
8
5
8
+3
+3
9
No answer
(last time 8)
-1
34
39
+2
9
No answer
(last time 7)
-2
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
+5
Case No
46
Baseline
Most recent
Movement
50
Baseline
Most recent
Movement
51
Baseline
Most recent
Movement
54
Baseline
Most recent
Movement
57
Baseline
Most recent
Movement
58
Baseline
Most recent
Movement
59
Baseline
Most recent
77
Duration in
service from
baseline to last
assessment (No.
times assessed)
17 months (x6)
12 months (x5)
14 months (x5)
11 months (x4)
12 months (x5)
14 months (x6)
15 months (x6)
Dimension 1 –
enjoying life
Dimension 2 –
able to
continue with
care
Dimension 3 –
physical
health
Dimension 4 –
mental wellbeing
Dimension 5 –
relationship
with person
cared for
Overall score
8
6
-2
10
9
-1
9
6
-3
8
6
-2
9
8
-1
44
35
-9
10
10
No change
10
10
No change
10
10
No change
10
10
No change
10
10
No change
50
50
No change
7
7
No change
8
7
-1
7
7
No change
7
7
No change
7
8
+1
36
36
No change
1
7
+6
5
7
+2
6
7
+1
4
7
+3
7
7
No change
23
35
+12
4
7
+3
10
7
-3
5
7
+2
9
7
-2
8
7
-1
36
35
-1
7
8
+1
5
7
+2
8
8
No change
8
8
No change
10
7
-3
38
38
No change
8
5
10
6
9
6
10
6
10
8
47
31
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
Case No
Movement
61
Baseline
Most recent
Movement
62
Baseline
Most recent
Movement
65
Baseline
Most recent
Movement
68
Baseline
Most recent
Movement
69
Baseline
Most recent
Movement
72
Baseline
Most recent
Movement
78
Baseline
78
Duration in
service from
baseline to last
assessment (No.
times assessed)
13 months (x5)
14 months (x5)
11 months (x5)
20 months (x4)
12 months (x5)
12 months (x5)
9 months (x4)
Dimension 1 –
enjoying life
Dimension 2 –
able to
continue with
care
Dimension 3 –
physical
health
Dimension 4 –
mental wellbeing
Dimension 5 –
relationship
with person
cared for
Overall score
-3
-4
-3
-4
-2
-16
1
2
+1
4
5
+1
4
2
-2
3
8
+5
2
6
+4
14
23
+9
6
5
-1
4
8
+4
4
6
+2
6
7
+1
7
9
+2
27
35
+8
6
5
-1
6
8
+2
9
8
-1
8
8
No change
6
9
+3
35
38
+3
3
3
No change
7
8
+1
5
4
-1
3
4
+1
6
6
No change
24
25
+1
3
7
+4
3
5
+2
4
5
+1
8
7
-1
10
10
No change
28
34
+6
7
9
+2
9
8
-1
7
8
+1
9
9
No change
9
9
No change
41
43
+2
7
8
9
8
8
40
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)
Case No
Most recent
Movement
Total
movement
all cases
Aggregate
movement
across cases
79
Duration in
service from
baseline to last
assessment (No.
times assessed)
470 months (173
assessments)
16 months (6
assessments)
Dimension 1 –
enjoying life
Dimension 2 –
able to
continue with
care
Dimension 3 –
physical
health
Dimension 4 –
mental wellbeing
Dimension 5 –
relationship
with person
cared for
Overall score
7
No change
+16
7
-1
-5
9
No change
-8
9
+1
+5
10
+2
0
42
+2
+8
+0.6
-0.2
-0.3
0.2
No change
+0.3
Mind in Birmingham Older Adults Outreach Service Evaluation Final Report January 2015 (Merida)