Last reviewed 18 January 2012
A term recently adopted by the care home industry is “a home for life”, an expression that encapsulates with directness, style and economy exactly what the best care regimes aspire to for their customers. Whether a residential home, a nursing home, a sheltered or very sheltered housing unit, or a domiciliary care agency supporting people in their own residences, everyone seems eager to offer their customers a settled location on that they can depend “for life”. But, wonders Jef Smith, how true can these claims be?
If one were to be strictly honest and absolutely explicit, one would have to say “a home for the rest of your life”. Such frankness, however, would rather give the game away, drawing attention to the rather disagreeable fact that whatever arrangement is being made will in due course be brought to an end, perhaps at a not very great distance of time, by the death of the service user.
The point of promising a home for life is not to deny that some sort of terminal illness or incident will eventually intervene, but to give an undertaking that between now and then, with luck, no further unwelcome moves will be necessary. No one can give an absolute guarantee of an uninterrupted care environment for individuals who are vulnerable to the vagaries of ill health and may unpredictably need an increased level of support, but it is clearly a great comfort to many older people to know that every effort will be made to protect them from having to move home again during the remainder of their days.
The risks of moving
Shifting from one place to another and between different caring regimes is peculiarly damaging for elderly people. This is one reason why stays in hospital can be so harmful to patients, often leaving even those who were not confused when they were admitted seriously disorientated by the time of their discharge.
In-patients have been known to have been shifted as many as a dozen times during a two-week stay, having to adapt on each move to a fresh physical environment, a new staff team, and even a different set of rules. For people with dementia, even for those in the early stages, such changes can be near-fatal.
So powerful is the acute medical lobby, however, that successive discussions of health service reorganisation have left the general hospital more or less unreformed in many of its operating patterns.
It seems unlikely that the dominance of powerful self-protecting professional interests in such change-resistant institutions will ever allow them to respond realistically to the key fact that around three quarters of patients are now elderly, a proportion set to rise steadily over the coming years. The typical health service customer is not a psychologically resilient young man who has fallen off a motorbike, but a very old lady, perhaps with a degree of dementia, who has taken a damaging tumble in her bathroom. Hospitals still have to adjust to that reality.
The move that the promise of a home for life most often fails to prevent, however, is precisely that seriously disturbing admission to a hospital. People living in care homes know that certain health crises will almost inevitably require the sort of specialist or intensive treatment that can only realistically be provided on a hospital ward. Elderly residents should certainly not be deprived of the very best resources the health service can provide, particularly in relation to issues of life or death, but nor should they be whisked off to hospital simply because a home has insufficient staff to provide a reasonable level of support for people with minor or moderate health troubles.
Community health services
Particularly towards the end of life, residents must also not miss out on quality community health services in the form of GPs and community nurses simply on the grounds that a home already provides 24-hour personal care. The role of care staff is certainly expanding to take on a range of tasks previously seen as the preserve of nurses, and such flexibilities, responsibly overseen, are to be encouraged. Although certain examinations and procedures must only be undertaken by qualified health service personnel, such aid can often be accessed on a community basis rather than in hospital.
The degree and type of health services available (or not available) to care home residents has been a controversial topic over recent years, and managers of residential care facilities should be prepared to fight for the very best for their clients, not least to enable them to remain, even when quite ill, in familiar surroundings. The home, after all, is their home.
It has been darkly rumoured, although the evidence is scanty, that some homes arrange for terminally-ill residents to be moved to hospital simply to minimise the numbers of deaths occurring in their establishments. If true, this is a dreadful example of the perverse operation of statistical gathering exercises, and management must take an ethical and professional stance to ensure that no one’s welfare is prejudiced simply to play the numbers game. The totals of the deaths occurring in a home may be a cause for concern, but such figures can also indicate that the staff are doing a good job by preventing the distress of unnecessary hospital admissions among their terminally sick clients.
Regulators must also be cautious and discriminating in their interpretations of such crude data.
Homes that offer nursing as well as personal care using their own in-house staff can claim, with some justice, that their providing a range of services helps more people to stay put as their needs intensify. The downside is that relatively healthy residents can be propelled into an excessively medicalised environment before they need regular access to immediately available nursing.
One resolution to this is the combination of residential care and nursing units within a single building or, better still, the availability to residents of the opportunity to take up more advanced or complex support options — albeit for an additional payment — without having to move physically.
Where a part of a home is designated specifically as the nursing wing or floor, however, it tends unfortunately to attract stigma among the resident population as a whole, and move into it being negatively construed as a rather public step towards death. The “home for life” promise may be technically kept, but the service user’s experience can still be psychologically adverse, with a shift of room hastening precisely the deterioration it was intended to arrest.
Hospices have a distinctly ambiguous role in this debate. Still widely perceived as “a place to die”, entry to a residential hospice — even one offering expertly sensitive and skilled care — would appear to involve just the sort of move in the last days of life that most people want to avoid. Alert to this criticism, the hospice movement over recent years has downplayed its role in providing beds or places and strengthened its capacity in the wider community, for example by giving a base to palliative care nurses who visit people in their own homes or advising and training the staff of care homes.
This is obviously a positive development, though most hospices’ continuing bias towards cancer care, however much they claim to want to broaden their clientele, undermines both their usefulness and their appeal to those with other terminal conditions such as dementia. If people who are approaching death, including residents in homes, can be admitted to a hospice for a brief period to help them manage their illnesses and the accompanying pain and fear and then return to their own environment, the home-for-life guarantee can still be honoured.
Extra care housing
The living/caring services that may be thought to make the most plausible home-for-life claim are the sort of very sheltered or extra care housing schemes that both the public and independent sectors are increasingly seeing as the environment of choice for most older people. The quality and size of the individual units, offering a bedroom, double if necessary, with en suite facilities, a sitting area, a kitchenette enabling some meal preparation and good storage space, mean that the tenants or leaseholders retain both a high degree of privacy and the rights associated with housing. This means that they are likely to experience the move from a fully independent house or flat as prudent trading down, not a step towards dependence and death.
In addition, there are usually some communal facilities such as a small shop, a restaurant, and generous spaces for sitting, recreational activities and socialising. Best of all from the point of view of gaining a home for life, there is an in-house domiciliary care service to which residents have flexible access according to their needs, an integrated care planning system, and availability on the same terms as anyone else in the neighbourhood to community health services.
Such schemes cannot guarantee that hospital admissions will always be avoided, but the statistics demonstrate that they offer a very good chance of dealing with crises without the need for another move. It’s also true that some people will elect or be obliged to progress eventually into a residential or nursing care home as their needs intensify, but the flexibility of care packages within extra care schemes minimises this possibility. The combination of a tailor-made physical environment, the culture of independent housing, the presence of peer support and the ready availability of care at a variety of levels really does seem to meet changing needs effectively.
It is easy for care personnel, in all sorts of settings, to make the seductive claim that what they offer can indeed provide the home for life to which most older people aspire. But professionals should pause to ask themselves whether they really can deliver on the series of promises that they are implicitly making. More positively, they should be examining whether there are ways in which their service could be enhanced to bring those undertakings closer to being a reality.