1. The PSSRU Evaluation of the Extra Care Housing Funding Initiative Robin Darton and Theresia Bäumker Housing and Care for Older People Research Network, 22 October 2008

2. Project Team Ann Netten Robin Darton Theresia Bäumker Lisa Callaghan Jacquetta Holder Ann-Marie Towers Jane Dennett Lesley Cox PSSRU at Kent Joice Amos Angela Andrews Sue Blackford Rosemary Carlson Marion Cole Vicki Cook Lynne Cullens Angela Everett Christine Hall Lynda Hance Alan Pollard Hilary Poole Zoe Poole John Rushton Rebecca Smith Bernard Styan Jane Wistow Janet Wistow Julie Yazdanjoo Local Researchers 2

3. Presentation Background and aims of the evaluation Some emerging findings Rowanberries: costs and outcomes Discussion 33

4. The Extra Care Housing Fund: Aims To develop innovative housing with care options To stimulate effective local partnerships between the NHS, local housing authorities, social services authorities, care providers, housing associations and private sector and other developers of extra care housing in the interests of older people (Department of Health, 2003) 4

5. The Extra Care Housing Fund: 2004/05 – 2008/10 Financial yearFundBids Successful bids No.Units 2004/05£29.0m205161422 Preallocated£17.7m6306 2005/06£40.3m>140211238 2006/07£20.0m5(4) 2007/08£40.0m4314967 2008/10£80.0m61252035 5

6. The Extra Care Housing Initiative: PSSRU Evaluation (22 Schemes) 2004/05 2 retirement villages: 258 & 270 units 7 newbuild: 344 units (38-75) 2 newbuild/remodelled delayed: 42 & 49 units 2005/06 1 retirement village: 242 units 1 retirement village delayed: 124 units 9 newbuild/remodelled: 372 units (35-48) 6

7. PSSRU Evaluation: Aims Short- & long-term outcomes for residents & schemes Costs and funding Comparison with care homes Factors associated with costs & outcomes Role in overall balance of care 7

8. PSSRU Evaluation: Linked Studies Main evaluation of ECHF funded schemes Additional scheme in Wakefield JRF-funded study of social well-being JRF-funded study of Rowanberries EVOLVE: EPSRC-funded study of design evaluation (Sheffield/PSSRU) 8

9. PSSRU Evaluation: Progress to Date 18 of the 19 schemes open Data available from 15 schemes Initial report Interim report & literature review for JRF Rowanberries study complete JRF report due shortly 9

10. PSSRU Evaluation: Data Collection Resident data Functioning, services, expectations & well-being Moving in, and 6, 12 & 18 months later Schemes Contextual information on opening Social activities at 6 months Costs and context a year after opening 10

11. Entrants to Extra Care: Data Collection Baseline assessment data: 505 residents in 15 schemes (September 2008) 463 residents moved in during 1st 6 months Comparison with 494 (personal) care home residents admitted in 16 authorities in 2005 11

12. PSSRU Evaluation: Response (September 2008) NumberNo. units Perm/ care units No. residents Residents assessed (6 months) Residents assessed/ units (%) Smaller schemes 1355952160837171 Villages25281806269251 Total151087701123446366 12

13. Entrants to Extra Care (2006/7) & Care Homes (2005): Demographics Extra CareCare Homes Mean age [Range]77 [45-100]85 [65-102] Female (%)6573 Single/divorced/separated (%)2614 Married (%)2817 Widowed (%)4668 Non-white (%)41 Lived alone (%)6177 13

14. Entrants to Extra Care (2006/7) & Care Homes (2005): Housing Extra Care (%)Care Homes (%) Domestic household6227 Sheltered housing2110 Care home1112 Hospital438 Rent6973 14

15. Entrants to Extra Care (2006/7) & Care Homes (2005): Dependency Extra CareCare Homes Mean Barthel score [0-20]14.310.4 Barthel score 0-12 (%)3266 MDS CPS score 0 (%)6315 MDS CPS score 1-3 (%)3446 MDS CPS score 4-6 (%)439 Total cases463494 15

16. Summary Resident profiles differ from care homes Average level of dependency lower in extra care Very few with severe cognitive impairment Substantial need for help with IADLs & mobility 16

17. The Rowanberries Study JRF-funded study: April 2007 for 1 year Rowanberries: Joint project between MHHA, part of MHA Care Group and Bradford Adult Services Mixed tenure dev. of 46 self-contained apartments Care services on-site provided by MHA 17

18. The Research Aims Aims: Assess comparative cost before-and-after move to a new extra care scheme in Bradford Evaluate methodology for future studies Context: Financial investment in extra care by DH since 2003 Limited evidence base about costs-effectiveness DH-funded PSSRU large-scale evaluation of 19 schemes 18

19. Methodology Before-and-after study Data collection: Residents Baseline assessment data about new residents Interview at moving in (by local fieldworker) Follow-up interview at six months Self-completion informal carer questionnaire Scheme-level MHA: Capital costs, and operating costs at 6 months Bradford Adult Services: Local costs and care contracts 19

20. Rowanberries Sample Sample At moving in: 40 out of 52 residents At six months follow-up: 22 residents Before-and-after comparison only possible for sub-sample Representativeness of sub-sample? 20

21. Findings: Characteristics Demographic characteristics Mean age 78 and 76, slightly more residents under 70 for sub-sample Similar proportions of Males (30%) to females (70%) Residents in each marital status category (45% widows) Residents living in their own homes ( >80%) Physical and cognitive functioning: Mean score on Barthel Index of ADL, 16.1 vs. 17.1 Some evidence that more severely impaired did not participate in the follow-up; but not significant difference 21

22. Costs (1) Costing principle: Opportunity cost to society Estimates for each of the broad cost components Costs per person per week increased from £382 to £473 as a result of moving to Rowanberries (excl. informal care) Cost componentsFindings AccommodationIncreased Social careIncreased Health servicesDecreased Informal careDecreased 22

23. Costs (2) 23

24. Costs (3) Health care services: decreased by £68 on average Nurse visit at home: increase in receipt (7 to 16), but decrease in average no. visits per recipient (23 to 11 in 6 months) GP at scheme/surgery, nurse visit scheme/GP surgery Pattern of service use: increase access vs. decrease freq. Acute services (hospital: A&E, outpatient, inpatient) decrease in both access & frequency Social care services: Increased by £128 on average (incl. meals) Two-fold increase in home care costs after move ‘Well-being charge’ of approx. £52 per person per week 24

25. Funding Approx. 76% of formal care costs per resident per week falls to public sector This includes estimates for: Subsidised capital cost Rent/service charge paid by Housing Benefit Care package funding by Bradford Adult Services Benefits/allowances received by residents Like-for-like comparison problematic, but clearly increase in costs to public sector Claiming what they were previously also entitled to Level of receipt and costs of services increased in part due to meeting previously unmet needs 25

26. Outcomes (1) Costs in context: incurred to achieve outcomes and quality of life Measures: Problems of recall MeasuresInitial interviewSix months Well-being (CASP 19) Self-perceived health Current situation at moving in Resident current perception at six months Quality of life Social Care Outcomes (ASCOT) Situation before moving in Resident level of functioning Situation before: third-party 26

27. Outcomes (2) Improvements in social care outcomes Reflects decrease in unmet need across all seven ASCOT domains E.g. nearly two-thirds reported good social life at Rowanberries, compared to >50% feeling lonely and socially isolated previously Improved quality of life on seven-point scale 68% reported very good/good compared to 23% before move Well-being (CASP 19) and self-perceived health measures did not show any change Based on situation after move and six months later Abilities in activities of daily living : no real change 27

28. Costs and Outcomes Overall costs per person increased, but these increases were associated with improved outcomes Reductions in unmet need appear to reflect the impact of increased level of formal support No real change in self-perceived health or levels of functioning Reductions in informal care input, increase in home care costs Number of methodological challenges to be met 28

29. Rowanberries Methodology Study limitations Representativeness of sub-sample One scheme not representative of extra care Scheme costs level out after 2-3 years of operation Data collection Drop out in follow-up: design/length of questionnaire Problems of recall: ideal timing - point of assessment Before-and-after study design: What would have happened otherwise? 29

30. ECH Evaluation Methodology Ideal study design: Data collection stages (point of assessment + follow-ups) Comparison groups Series of comparisons with different data sources: Previous PSSRU studies on care homes 1995, 2004/05 Other (e.g. ELSA pop. study), tbc To compare Outcomes: Functional ability (Barthel, MDS) at 0m, 6m, 18m Self-perceived health qu. at 0m + 12m Quality-of-life qu. at 12m Well-being (CASP 19) at 6m + 18m Costs 30

31. ECH Evaluation Cost Data Individual level Resource use of health and social care services at 6m + 18m Receipt of benefits at 0m + 6m Scheme-level Charges to residents Capital/development costs of scheme Operating costs of scheme after 12 months: Understanding of scheme arrangements (Manager questionnaires) Variation in unit costs: e.g. home care To explore Relationship between costs and outcomes Cost of extra care schemes, and in comparison to other provisions Variation in costs between individuals & between schemes 31

32. PSSRU Evaluation: Other Issues Timescale of developments (resiting, redesign) Mixed tenure (demand) Future proofing (1-bed flats) Communal facilities and links with community Setting-up and participation in social activities Transport within and outside scheme Division of responsibilities for housing and care Expectations of partner organisations How to reflect variations between schemes in reporting 32