The Government says it wants to help the elderly live at home. Now pilotschemes are putting the idea into practice, says Anne Dempsey
Like all good ideas this one is simple, blindingly obvious and long overdue: give people grants to buy vital hours of care which can enable elderly relatives to stay at home. Although Government policy on services for older people accepts that the best place for most of them is at home, funding for services has been strongly biased towards their leaving it.
So while families may apply for state subvention towards private nursing home costs, there has been no funding entitlement, other than the long-established carer's allowance, to maintain a relative in the family home.
The effect, says Janet Convery, director of services for older people at the East Coast Area Health Board, has been a "perverse incentive" that has encouraged people into nursing homes and hospitals even though Government policy documents have repeatedly recommended that they be supported in the community for as long as possible.
"In recent years funding of private nursing-home care has escalated exponentially," says Convery. "Nursing-home beds have been identified as the single solution to meeting the needs of older people. Since hospital waiting lists and the perception that older people are blocking acute beds is high on the political agenda, the pressure to continue funding additional nursing-home beds has escalated, in spite of spiralling costs and concerns about the quality of care provided in some residential settings."
Typical is Julia, an 82-year-old who used to live with her son. Bright as a button but physically frail, Julia needed help with dressing and preparing her midday meal. When a fall emphasised the hazards of leaving her on her own - her son went out to work every day - a local patchwork of services provided inadequate cover and the family could not afford extra care. Julia is now in a nursing home, away from her son and costing the State more than €2,000 a month.
Julia's case is only too familiar. Most of the people surveyed by the National Council on Ageing & Older People for a 2001 report said they would rather stay at home with the support of local services. But that has not been a real option. Until now. In a national outbreak of common sense, a number of schemes are being put in place, some on a pilot basis, to keep older people happily and safely at home and to facilitate a speedier and sustained return home from hospital.
The North Western Health Board, which serves Cos Sligo, Leitrim and Donegal and their 30,000 over-65s, has been a pioneer in overturning a blinkered view of older people. "We knew we needed to change from being service-driven to needs-led," says Bridget Smith, the board's service manager for older people. In other words, to see services designed for people rather than services with which people had to fit in.
In 2001 it surveyed the area's older residents about their needs. "At the very top of the list, 97 per cent wanted to stay at home. Out of this was born an approach to care based on the wishes and needs of older people," says Smith.
A key component is Choice, a programme that pays successful applicants up to €150 a week to buy services that help an older relative to stay at home. "You could have a situation where an older person is on their own and need someone to help them get up in the morning, light a fire, get a midday meal. Or there may be one older person caring for another who needs some time off. Or you could have a son or daughter working full- or part-time, so the older person needs some support during the day.
"Some people need a relatively short visit three times a day, seven days a week; others may need one longer visit. The family source carers themselves - often a friend or neighbour - and pay for it out of the grant. The public-health nurse ensures the person has the necessary skills and continues to monitor the scheme.
"The difference is that we sit down with the older person and listen. Some people were afraid that, if you ask an older person what they want, they would want a 24-hour service, but it's not like that at all. We have 80 families currently participating in the scheme with the potential for many more to apply, because it is very cost-effective. We have been able to see some positive results in reduced admissions to hospital, but caring for older people is about much more than hospital beds: it's about working with them rather than deciding for them."
The Eastern Regional Health Authority recently commissioned research to evaluate two of its home-care-grant schemes: the Home Care Grant Pilot Project and Slán Abhaile. The former began in August last year with a budget of €500,000. Open to the over-65s and their families, it currently enables 90 families to buy much-needed services.
Janet Convery describes the board's flexible approach. "Someone receiving intermittent respite - say, spending two weeks out of six in residential care - can still get the grant for the time they are at home. Recipients can also continue to avail of community services such as meals on wheels, home help, day care. In fact we would look for confirmation that available services have been explored before approving the grant. We wouldn't be happy with people who refuse all statutory services but say they will take the money.
"Each applicant's dependency needs and financial circumstances are individually assessed. We have been struck by the financial assistance and direct help families are already giving. Far from families not caring about an older relative, our work shows us how caring and committed most are." People receiving a carer's allowance can also avail of this scheme.
The maximum subvention for private-nursing-home fees is €190 a week. As a grant the money buys about 20 hours of home-care services - typically washing, dressing, shopping, preparing meals, doing housework and, occasionally, nursing care. Some families need more services, according to Convery; in exceptional circumstances €350 a week is available. Carers may be found by the family or provided by private agencies.
How does it work in practice? In 1986 Bill and Kathleen Ward sold up and came to live with their daughter, Gay Graham, and her husband and children in a new apartment attached to her family home in Co Wicklow. "For many years they were completely independent, and the children grew up with a close relationship with their grandparents," says Graham, who works full-time. Kathleen was the first to falter; today, at 87, she suffers from dementia and needs total care. Bill, who at 92 is mentally well but physically frail, needs help to manage his day.
By last year the family was at full financial and emotional stretch. "The four siblings took out a deed of covenant which paid for a carer from 10 a.m. to 4 p.m., Monday to Friday. I took over every evening and two weekends out of three. Every third weekend my sister left her family home, miles away, to come and give me a break. A brother who lives locally is also involved; our other brother works abroad. But it was becoming intolerable, and when I heard of the health-board subvention we applied for it."
The family is still paying for the daily carer, but the extra funding helps to pay for someone to give the elderly couple their tea each evening, settle Kathleen down for the night, spend time with them on Saturdays and help them up to breakfast on Sundays.
"The early-evening cover is the single most liberating aspect for me and has made a qualitative difference to our family life. It means I don't have to charge home from work each evening to look after my parents before setting foot in my own home. I still put my mother to bed occasionally and make sure my father has what he needs - and Sunday is a family day when they come to us anyway. The people we have are exceptional and most responsible. I can have a little normal life with my family.
"The effect is that two elderly people can remain together at homewith us and be cared for in surroundings they know. Without it, it is most unlikely we would have been able to continue to care for my mother. Everyone is winning: my parents are winning, we are winning and the health board is winning, as it is getting such good value for its investment. I think this is a wonderful initiative and would urge many more health boards to adopt it," says Graham.
The board's other initiative, Slán Abhaile, aims to get elderly people home as soon as possible if they have had to spend time at a nursing home after being in hospital; it also tries to reduce hospital stays by providing services at home. Care co-ordinators tailor care plans to the needs of the clients and their families.
The scheme was responding to the problem for some patients who never return from hospital, not because they need full nursing care but because there is no way to look after them at home - as confirmed by Home From Home?, a report published this month by Age & Opportunity, which asked the views of older people in three care centres. "An unexpected finding was the unresolved issues that many residents had about the way they had been admitted - that is, their lack of decision-making participation and lack of preparation for the move to long-stay care," says Ann Leahy, the organisation's director of communications.
Over the next year the initiative should get €1.3 million. "SláAbhaile has been successful because it is giving the older person a real choice and the opportunity to see if it's possible to continue to live at home," says Convery.
One patient is an 82-year-old woman who lives alone. As she has multiple health problems, there was very little expectation that she would ever be able to leave hospital. She is now back at home, however, her 30 hours of extra care each week divided into four visits a day. Another woman, Miss G, needs six and a half hours of purchased care to live happily at home, including her carer accompanying her to Sunday Mass. Mr E, who is 71, needs two workers to lift and move him; his care package is 42 hours a week. "He is a lover of the Irish language and asked for carers who speak Irish. So they were found them for him," says Convery.
• For more information about home-care grants contact your local health board
Making a difference
Nursing-home matron Teresa Brolly set up Life at Home to give families a choice. "A crisis involving an old person at home usually shows up that there is an inadequate amount of support from the health board or 24-hour care but nothing in between," she says.
Life at Home offers trained nurses, carers, home helps, gardeners and maintenance staff, with care packages tailored to each family. Staff are also trained in first aid, manual handling, health and hygiene.
Nurses cost €18 an hour and carers and home helps cost €12.50 an hour, with gardening and maintenance on assessment. "We also offer an information and advisory service on elderly provision and entitlements, whether people avail of our services or not. This service is badly needed, and I have gone into it with my heart as well as my head," says Brolly.
• Life at Home is at 01-2811837or lifeathome@eircom.net