The work of older people and informal caregivers in managing a change in health
Petra Mäkelä is based in the Department of Health Services Research and Policy at the London School of Hygiene & Tropical Medicine. She tweets at @Petra_OB. Sasha Shepperd is based at the Nuffield Department of Population Health, University of Oxford.
Out of hospital care for older people, such as hospital-at-home, is being delivered in a number of countries as an alternative to hospitalisation for a select group of older people. In our Age and Ageing paper, we report the qualitative interview findings from a process evaluation within a randomised trial that compared geriatrician-led ‘admission avoidance hospital-at-home’ with admission to hospital. We compared older people’s and family caregivers’ experiences across both settings, and considered how these related to the person-centred principles that underpin Comprehensive Geriatric Assessment. We also illustrate how older people and family caregivers supported the provision of healthcare and managed complex relational processes. Caregivers monitored their relatives, identified changes and potential risks, and mobilised resources that included managing care at night if the older person was at home. Through their previous experience, knowledge and social networks they also developed strategies to integrate the acute episode into longer-term ways of managing changing health and functional ability, and attempted to avoid further emergency healthcare.
Informal mechanisms of support underpin the feasibility of achieving the ambitions of the NHS Long Term Plan in the shift to ‘care closer to home.’ The management of chronic illness in the community, including coordination of formal services, relies on significant caring contributions by unpaid partners, family and friends. During the COVID-19 crisis, and the sudden increase in demand for hospital-based healthcare, some healthcare providers have rapidly transformed services to provide alternatives to hospitalisation for some groups of older people. The maintenance of routines of care for those living with fluctuating long-term conditions has been impacted by physical distancing requirements, and brought increased focus to the challenges faced by older people, particularly those who are living alone.
Our findings emphasise how older people and their informal caregivers adapt, employing personal, social and environmental resources when managing a deterioration in health. There are opportunities to strengthen collaboration between older people, informal caregivers and healthcare providers within the processes of Comprehensive Geriatric Assessment. Such collaboration could integrate the work of older people and caregivers, their social context and relationships, as well as clinical factors. This might be facilitated within assessments, during care planning and monitoring, use of CGA-related documentation that is meaningful to older people and families, and more formal involvement in decisions about discharge from acute healthcare.