Asignación de servicios sociales a personas mayores: revisión y modelo de toma de decisiones

431Cuad. trab. soc. 31(2) 2018: 431-444 Cuadernos de Trabajo Social ISSN: 0214-0314 http://dx.doi.org/10.5209/CUTS.55454 ARTÍCULOS Allocating social services to the elderly: a review and decision making model Patricia María Iglesias Souto1; José Eulogio Real Deus2; Agustín Dosil Maceira3; María Emma Mayo Pais4; Eva María Taboada Ares5 Recibido: 10/03/2017 / Revisado: 24/04/2017 / Aceptado: 09/01/2018 Abstract. As a result of population ageing and a reduction in informal care, public institutions must assume a higher responsibility in caring for the elderly and providing services that respond to their needs. The aim of this study is, on the one hand, to investigate the profiles of elderly people using social services; and, on the other hand, to examine whether any classification systems and/or assessment tools are available to guide professionals in the assignment of services. A systematic literature review was carried out using PsycINFO, Web of Science, Dialnet, CSIC and Teseo, and a total of 44 studies were selected. The following variables were identified as predictors of service usage: functional dependency, cognitive impairment, lack or deficit of social support and bad housing conditions. No classification systems or assessment tools were found for facilitating the assignment of services according to profiles. A DecisionMaking Model is proposed – based on the identified predictor variables - that aims to ensure an appropriate fit between the needs of the elderly and the social services provided. Key words: Elderly; social services; Social Welfare; quality of life; decision-making. Summary: Introduction. 1. Method. 2. Results. 2.1. Variables associated with the use of social services. 2.2. Models and systems for the allocation of the elderly to social services. 3. Discussion. 4. References. Cómo citar: Iglesias, P. M.; Real, J. E.; Dosil, A.; Mayo, M. E.; Taboada, E. M. (2018) Allocating social services to the elderly: a review and decision making model, en Cuad. trab. soc. 31(2), 431-444. 1 Universidade de Santiago de Compostela, España [email protected] 2 Universidade de Santiago de Compostela, España [email protected] 3 Universidade de Santiago de Compostela, España [email protected] 4 Universidade de Santiago de Compostela, España [email protected] 5 Universidade de Santiago de Compostela, España [email protected] Introduction The combination of aging populations and changes in family structures has led to a reduction in the number of people who can provide informal support, entailing increased responsibility for public institutions attending to elderly people. In Spain, in recent years there has been a significant increase in the number of places in social services (IMSERSO, 2017). Telecare is the service with the highest coverage ratio (8.89%), followed by Nursing Homes (4.4%), Home Care Services (3.77%) and Day Care Services (1.05%). Nevertheless, this growth in supply has been insufficient to cover growing demand and current needs remain unsatisfied. At the same time, the decentralization in the field of Welfare Assistance has led to considerable disparity across the regions in TERCERAS_Cuadernos de Trabajo Social 31(2).indd 431 27/8/18 11:35 432 García Giráldez, T. Cuad. trab. soc. 31(2) 2018: 285-295 features, funding, eligibility criteria and coverage ratios. At this juncture, various studies have demonstrated that the care given in certain services does not correspond, in all cases, to the user profile (Grando, et al., 2002). This means, on the one hand, that resources and services are being used inappropriately, and, on the other hand, that user necessities are not being properly fulfilled, generating dissatisfaction in both the user and the service workers. Against this background, actions must be initiated that enable an appropriate answer to be given to each situation, attaining the greatest possible fit between the real necessities of each elderly care applicant and the corresponding services. Accordingly, adequate coordination between sanitary and social structures, and the optimization of available resources should be a priority. The aim of this paper is twofold: to analyze the functional, cognitive and social profile of elderly users of social services; and to ascertain the existence of classifications, systems or any type of instrument that facilitate the allocation process. 1. Method A literature review was carried out: in PsycINFO and Web of Science (WOS) databases from 2000 onwards, of all papers listed in Dialnet and in the Consejo Superior de Investigaciones Científicas (CSIC) from 1978, and in TESEO from 1994. The search process for studies on elderly user profiles was carried out using the following keywords (either alone or in combination): personas mayores, elders, older people, old people, residencias, centros de día, viviendas comunitarias, apartamentos tutelados, servicio de ayuda a domicilio, nursing homes, day care centres, home help service and home care service. To identify research papers on resource allocation, the following combined terms were used: mayores, elders, olders, old people, aging, asignación recursos, modelo, servicios sociales, ubicación, resource allocation, allocation of resources, models, model, provision of services, resource use, placement of elders, balance of care, balance of resources and social services. The papers which were included focused either on population samples of over 65s (exceptionally over 55s) or contained data broken down by age and which: 1) compiled profiles for social services usage, 2) identified risk factors for the use of social services, or 3) proposed models for allocating elderly people to social resources. TERCERAS_Cuadernos de Trabajo Social 31(2).indd 432 27/8/18 11:35 433García Giráldez, T. Cuad. trab. soc. 31(2) 2018: 285-295 2. Results In total, 44 studies (Table 1) were included, all of which focused on the user profile or factors which predict the use of different services for elderly people. No work was found on models for guiding professionals in the decision-making process of resource allocation. The flowchart in Figure 1 illustrates which studies were excluded from this review - by title, by not meeting the objectives of this research, because they were duplicated or, after reviewing the abstract and/or full article, because they did not fulfill the inclusion criteria. The initial search resulted in 8,042 publications; a following search in the references of the selected items led to the identification of a further 22 publications. 2.1 Variables associated with the use of social services Home Care Service (HCS) In Spain HCS is of a more social nature and less bound to formal healthcare than in programmes which are run in other countries under the term “home care”. The prototype HCS user in Spain is female, with an average age of 80 (IMSERSO, 2015) and, generally, widowed or single, uneducated and living alone (Fernández del Valle & García, 1994; Martínez, Dávila & Vicente, 2003; Serrano & Tena-Dávila, 2004). They tend to be frail individuals, without cognitive impairment, who suffer geriatric problems which impact on their functional ability, with mild dependence for basic activities of daily living (ADLs) and mild to moderate dependence for instrumental activities (Prados, 2001; Serrano & de Tena-Dávila, 2004). Frailty is determined by multi-morbidity – highlighting coronary artery disease, hypertension, osteo-articular impairments and sensorial disabilities - pain, subjective memory complaints, sad mood, recent hospitalization and polypharmacy (Serrano & Tena-Dávila, 2004). This, together with the lack of social support (Fernández del Valle & García, 1994; Sabartés, Galí, González, Román & González, 2004; Serrano & Tena-Dávila, 2004) and poor housing (Sabartés, et al., 2004), is one of the triggers for a HCS request. This profile corresponds to that found, for example, in the USA, where home care services attend to people with less cognitive and functional deterioration than nursing homes (Lee, Kovner, Mezey & Ko, 2001) unlike in other countries where home care agencies provide for people with greater levels of inability (Kim, Chou & June 2006). Records identified through database searching (CSIC=990; Dialnet=1.280; PsycINFO= 4.869; WOS=832; TESEO= 71) (n=8.042) Additional records identified through other sources (n=22) Records screened (n=8.064) Abstracts assessed for eligibility (n= 612) Full-text articles assessed for eligibility (n=584) Studies included in qualitative synthesis (n= 44) Records excluded by title and duplicated (n= 7.452) Records excluded as did not fulfill inclusion criteria (n= 28) Articles excluded as did not fulfill inclusion criteria (n= 540) Figure 1. Flowchart describing the literature review process. TERCERAS_Cuadernos de Trabajo Social 31(2).indd 433 27/8/18 11:35 434 Iglesias, P. M.; Real, J. E.; Dosil, A.; Mayo, M. E.; Taboada, E. M. Cuad. trab. soc. 31(2) 2018: 431-444 Day Care Centers (DCCs) The available data indicate that, in the majority of the Autonomous Communities, between 60% and 79% of DCCs users are female and, generally, with an average age of 80 (IMSERSO, 2015). They often suffer from dementia and their care generates high stress levels, which causes low subjective well-being in caregivers, and is a risk factor for institutionalization (Gaugler, Kane, Kane & Newcomer, 2005). Although there are DCCs which specialize in care for people with dementia (García-Alberca, et al., 2008), in Spain the majority of them care for people both with and without dementia, with moderate or severe dependence and adequate family support. Studies on other aspects, such as functional ability, cognitive status and social support are rare in Spain and limited to concrete social health services in specific areas. Various studies have found a profile characterized by the presence of dementia (Laborda, Murguía, Rabanaque, Zeballos & Pascual, 2002), as well as by memory loss and disorientation, mood and demotivation problems, mobility impairments and health problems (especially breathing and cardiovascular problems, and sensory disabilities) which in some cases require special attention (oxygen, catheter, frequent cures etc.) and dependency for activities for daily living (Soldevila & March, 2002). Nursing homes (NHs) More studies have been carried out on NHs than on any other resource, considering their effects and the factors that determine their use. For the latter, predictors have been identified in a wide variety of groups of elderly people: those who live in the community (Buys, et al., 2013; Sheppard, Sawyer, Christie, Allman & Brown, 2013); those who have been hospitalised in acute units (Mora, et al., 2009) or in rehabilitation centers (Aditya, Sharma, Allen & Vassallo, 2003); people with dementia (Gaugler, et al., 2000; Gaugler, Leach, Clay & Newcomer, 2004); elderly African Americans (Gaugler, et al., 2004) etc. These factors can be grouped into three categories (Lee, et al., 2001): socio-demographic factors, those related to physical and cognitive status, and those linked to social support. 1. Socio-demographic factors: NH use is linked to being female, not having a spouse, not having children, being elderly (Luppa, et al., 2010), being white (rather than being Hispanic or African American) and having a low socioeconomic status (Lee, et al., 2001; IMSERSO, 2015; Lim, 2009; Noël-Miller, 2010; IMSERSO, 2015). 2. Factors related to health, and physical and cognitive status: the institutionalized elderly, or those at risk of being institutionalised, tend to be people with mobility difficulties (Aditya, et al., 2003; Von Bonsdorff, Rantanen, Laukkanen, Suutama & Heikkinen, 2006; Sheppard et al., 2013) and, in general, with poor health (Miller & Weissert, 2000; Tomiak, Berthelot, Guimond & Mustard, 2000; Aditya, et al., 2003; Maxwell, et al., 2013) characterized by: sensorial disabilities, musculoskeletal problems, strokes, confusion, Alzheimer’s disease, incontinence, use of tranquilizers and recent hospitalizations). Thus, it has been observed that dependency for carrying out ADLs (Tomiak, et al., 2000; Lee, et al., 2001; Bharucha, Pandav, Shen, Dodge & Ganguli, 2004; Damián, Valderrama-Gama, Rodríguez-Artalejo & Martín-Moreno, 2004; Bernal & Barbero, 2006; Lim, 2009; Cohen-Mansfield & Wirtz, 2011; Almomani, McDowd, Bani-Issa & Almomani, 2014; Helvik, Skancke, Selbaek, & Engedal, 2014; IMSERSO, 2015) above all, in disadvantaged environments (Buys et al., 2013), and the presence of cognitive deterioration and dementia (Tomiak, et al., 2000; Gaugler, Kane, Kane, Clay & Newcomer, 2003; Bharucha, et al., 2004; Damián, et al., 2004; McCallum, Simons, Simons & Friedlander, 2005; Lim, 2009; Sabartés, et al., 2009; Lekuona & Calvo, 2010; Cohen-Mansfield & Wirtz, 2011; Maxwell, et al., 2013; Almomani, et al., 2014; Helvik, et al., 2014;) are variables which characterize the users of NHs or which significantly increase the risk of admission. One of the main collectives of NH users is people with dementia. To this effect, there are numerous studies on TERCERAS_Cuadernos de Trabajo Social 31(2).indd 434 27/8/18 11:35 435Iglesias, P. M.; Real, J. E.; Dosil, A.; Mayo, M. E.; Taboada, E. M. Cuad. trab. soc. 31(2) 2018: 431-444 the factors which predict institutionalization for this collective (Gaugler, et al., 2000; Pot, Deeg & Knipscheer, 2001; Hebert, Dubois, Wolfson, Chambers & Cohen, 2001; Yaffe, et al., 2002; Gaugler, et al, 2003; Chan, Kasper, Black & Rabins, 2003; Ander, Hyer & Slack, 2007). At the same time, the probability of being institutionalized is increased when behavioural problems are present (Gaugler, et al., 2000). 3. Social support: this is considered a critical factor for NH use and it is widely known that NH residents have informal networks made up of few members, most of whom are relatives (Calvete, 1994). The spouse is the principal support provider, but children, other friends and relatives can also provide the support necessary to prevent institutionalization. Living alone (Aditya, et al., 2003; Mora, et al., 2009) or having little social support (Bharucha, et al., 2004; Luppa, et al., 2010) are key factors in admission, although the lack of an informal caregiver may not be decisive if a community care programme is available (Friedman, Steinwachs, Temkin-Greene & Mukamel, 2006). Another important aspect to consider regarding social support is appraisal of the quality of relationships with carers. Supervised Apartments and Community Housing (SA/CH) Studies in Spain on SA/CH are practically non-existent and, furthermore, these services do not correspond clearly to those in other countries. 2.2. Models and systems for the allocation of the elderly to social services Despite increasing knowledge and clarification of the criteria to be met by the elderly in order to access social and social health services, deficiencies and existing problems with allocation have failed to be resolved. Work at international level has shown that elderly patients requiring a large amount of care were attended to in less complex centers and, at the same time, others who required less care were attended to in more sophisticated centers (Spector, Reschovsky & Cohen, 1996). Similar data has been found in Spain regarding the use of nursing homes for non-disabled and disabled people (Solano & López, 1998). Work carried out by Fundación SAR (2007), is proof of an attempt to unify the type of care given in situations of dependency to elderly people with a similar profile. Their objectives include the definition of a normative base model and reference scenarios that would enable services to be assigned to user profiles according to their level of dependency. The result of this work led to the elaboration of reference scenarios which identified six user types, their personal environment and the services which they needed, although this model does not allow systematic decisions to be made for placement in different social services. In the field of social health services, Balance of Care (BoC) can be highlighted as a strategy for planning assistance. It assumes that people can be attended to via various care options or by different resources, and aims to analyze the different possible contexts for planning social or geriatric services, whilst at the same time improving the balance between supply and needs of potential users. In the field of gerontology, BoC usually refers to the prioritization of community-based care rather than residential (Hughes & Challis, 2004). It focuses on identifying those subjects who qualify to be admitted to a centre, but who could remain in the community if there were adequate social and health resources to meet their needs at a reasonable cost. The BoC estimates the proportion of people who could be reliably attended to in their homes, with good results, and defines the priorities for economic investment which could affect the combination of these two care systems.This would establish the correct combination of community services and specialized services for any given geographical area (Challis & Hughes, 2002; Hughes & Challis, 2004). The Planificación Optimización Dinámica Asistencial (PODA) (Planning Optimization Dynamic Assistance) system, drawn up by “Antares Consulting” consultants, is an example of how the BoC model can be applied to the field of social and social health services for the elderly in Spain. PODA is a BoC principle-based support system for making decisions on planning services. It defines the care needs of a population, translates them into resource requirements and analyzes their cost and financing. TERCERAS_Cuadernos de Trabajo Social 31(2).indd 435 27/8/18 11:35 436 Iglesias, P. M.; Real, J. E.; Dosil, A.; Mayo, M. E.; Taboada, E. M. Cuad. trab. soc. 31(2) 2018: 431-444 The BoC based systems allow strategies and funding policies to be defined, but do not provide a model that facilitates decision making when allocating services based on specific user profiles. 3. Discussion Limitations in functional ability, at both basic and instrumental level, have been related to the use of community social services such as HCS (Prados, 2001; Serrano, et al., 2004), or DCCs (Soldevila & March, 2002; Huges & Challis, 2004; García-Alberca, et al., 2008), and with NH admission (Gaugler, et al., 2000; Yaffe, et al., 2002; Bharucha, et al., 2004; Bernal & Barbero, 2006; Andel, et al., 2007; Lim, 2009; Luppa, et al., 2010; Helvik, et al., 2014). People with cognitive impairment and/ or dementia are habitual users of NHs, above all when they also have behavioural problems (Gaugler, et al., 2000; Hebert, et al., 2001; Pot, et al., 2001; Yaffe, et al., 2002; Chan, et al., 2003; Gaugler, et al., 2003; Andel, et al., 2007; Luppa, et al., 2010), and of DCCs due to the positive influence which these have on their behaviour (Zank & Schake, 2002). The absence of an informal support network can be palliated through HCS. In fact, the average size of the social network of users of this service in Spain is smaller than that of the elderly population in general (Fernández del Valle & García, 1994) and a large number of users are in a situation of social risk (Serrano & Tena-Dávila, 2004). Social support is also a critical factor in NH use (Calvete, 1994; Friedman, et al., 2006; Luppa, et al., 2010; Nöel-Miller, 2010), with the quality of the relationship with carers being especially decisive in institutionalization. Service usage is directly and indirectly related to housing. On the one hand, admission to services which include accommodation (such as NHs or SA/CHs) becomes necessary when housing conditions do not guarantee the elderly person’s safety. But in addition, the physical environment is a critical factor for the maintenance of functional ability. With that in mind, the variables we have discussed should serve to establish profiles which allow the features and benefits of services to be adjusted to the needs of the elderly. In this sense, the review carried out brings to light that functional ability, cognitive status, social support and housing conditions are the fundamental variables in developing a decision-making model for professionals. Proposal of a Decision Making Model (DMM) for allocating social services to the elderly The structure of the Model takes into account the foremost services for attending to the elderly in Spain (NHs, DCCs, SA/CHs and HCS), and the predictor variables of their use as identified by the revision process: two external variables (social support and housing) and three internal variables (functional ability for basic activities of daily living, functional ability for instrumental activities of daily living and cognitive condition). Users of these services are characterized by the following profiles: • NHs: people with severe dependency, lack of social support and housing problems. • DCCs: people with moderate dependency who require personalized therapeutic or social attention, who have adequate accommodation and a network of social support which suffices to ensure their care outside the hours when they attend the centre. • SA/CHs: people who are functionally independent or have mild dependency and who find residing in their habitual environment difficult due to housing deficiencies or coexistence problems with the core family. • HCS: people with: 1) mild/moderate dependency, whose homes meet habitability conditions but who lack the necessary informal support, or 2) moderate/severe dependency, who receive adequate social support from informal caregivers who need respite from care tasks. Levels are defined within each variable: • Social support: 1) bad (a network size of zero, or with an instrumental support frequency of less than once a month), 2) insufficient (instrumental support frequency of once or twice a month), and 3) adequate (instrumental support frequency of weekly or higher). Díaz Veiga´s Scale of Social Resources in the Elderly (Díaz, 1985) TERCERAS_Cuadernos de Trabajo Social 31(2).indd 436 27/8/18 11:35 437Iglesias, P. M.; Real, J. E.; Dosil, A.; Mayo, M. E.; Taboada, E. M. Cuad. trab. soc. 31(2) 2018: 431-444 can be referred to in order to obtain this information. • Housing conditions: evaluated as good or bad according to the scores obtained on an evaluation scale designed ad hoc for the creation of the Model, which would include living conditions, services and architectural barriers. • Functional ability: capacity in both basic and instrumental activities is considered ‘good’ when, according to the scores of the Barthel Index (Mahoney & Barthel, 1965) and the Lawton and Brody Index (Lawton & Brody, 1969) respectively, the subject is independent or has mild dependence, and ‘bad’ when dependency is moderate, severe or complete. • Cognitive status: this is categorized according to the scores obtained on the Short Portable Mental Status Questionnaire (SPMSQ) (Pfeiffer, 1975): ‘good’ when performance is normal or with mild impairment, and ‘bad’ when impairment is moderate or severe. Taking into account the aforementioned variables and levels, a hierarchical classification with 16 conditions has been established (see Figure 2). Social support Bad Insufficient Good Housing characteristics IADL functional ability Good Bad IADL functional ability IADL functional ability IADL functional ability Bad Bad Bad Bad Good Good Good Good BADL functional ability BADL functional ability BADL functional ability Bad Bad Bad Good Good Good Cognitive status Cognitive status Cognitive status Bad Bad Bad Bad Bad Cognitive status Cognitive status Good Good Good Good Good SA/CH NH HCS DCC OUT OF THE SYSTEM Figure 2. Decision Making Model for allocating social services to the elderly Elderly people’s quality of life depends on both their functional and cognitive status, but also on the capacity of their environment to support their needs. Hence, and with the main objective of favouring the elderly staying in their own home for as long as possible, the decision-making process begins with informal social support. When precarious social support is combined with housing deficiencies, the person requires a residential service. If the person has adequate functional capacity at instrumental level, he/she would be candidate for admission to a SA/CH. Neither basic activities nor cognitive condition would need to be analyzed, as good instrumental capacity already implies appropriate performance in these two areas, in fact, a high positive correlation has been found between the Lawton Index and the Barhtel Index, whilst both scales correlate negatively with Pfeiffer´s SPMSQ (Serrano & Tena-Dávila, 2004). On the other hand, if functional autonomy is limited at instrumental level, the person would be derived to a NH, as would those who, in spite of having good quality housing, are functionally and cognitively dependent. People with good functional capacity and good housing can have their needs met through HCS, as can those who, despite needing help on an instrumental level, retain their cognitive status and ability for carrying out ADLs. TERCERAS_Cuadernos de Trabajo Social 31(2).indd 437 27/8/18 11:35 438 Iglesias, P. M.; Real, J. E.; Dosil, A.; Mayo, M. E.; Taboada, E. M. Cuad. trab. soc. 31(2) 2018: 431-444 Insufficient social support leads to an analysis of instrumental ability. In this case, an evaluation of the housing situation is not necessary as, even though social support may not reach the minimum requirements, it may still be sufficient to offset the limitations resulting from inappropriate housing. When a person is capable of instrumental activities, he/she is derived to HCS. If he/she not only has difficulties in carrying out ADLs, but also has insufficient social support, his/her basic activities must be assessed. Cognitive performance is considered whether the person is independent in this area or not. Accordingly, those who suffer deterioration are assigned to DCCs whereas HCS is considered sufficient for those who retain cognitive capability. As with the previous case, when social support is adequate, housing is not taken into consideration. If people with good functional instrumental capacity have sufficient social support, this is judged to be enough for them to remain at home, with an adequate quality of life, without having to resort to any of the services contemplated in the Model. If the person has instrumental difficulties, their functional ability is assessed at a basic level, and independently of this, if cognitive performance is adequate, HCS is considered sufficient in caring for them, while people with cognitive deterioration are derived to DCCs. The Model we propose is presented as a contribution to the work of professionals in the social and gerontology field, and also to those responsible for social policies for the elderly. On the one hand, its implementation would not only ensure a better fit between user needs and service features, but would also facilitate the advice and guidance given to the users and their families, thereby resulting in an improvement in the quality of care received. On the other hand, it could be used to estimate the needs of future services by devising different possible situations in accordance with the care model that is to be developed. User opinion should be taken into account, however, when applying the model, to guarantee the principles of choice, autonomy and participation. The main limitation of the study has been the difficulty in comparing the features and benefits of gerontology services in different countries and, related to this, the bias derived from a predominance of literature about NHs. Regarding the Model, although it does include the most widely used services by people in situations of dependency or at risk of suffering them, future research should explore the possibility of extending the Model by incorporating other services like Telecare, not included here because it poses less difficulty for allocation and has a higher rate of coverage and consensus in access criteria. Likewise, the Model could contemplate combining various services, as it currently only assigns the service which is considered as ideal and therefore, the first choice. Finally, work must be continued on the analysis of the Model, both in its statistical goodness of fit and in its validation for a future implementation. 4. References Aditya, B.S.; Sharma, J. C. ; Allen, S. 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