An Evaluation of Day Support: A Community Rehabilitation Service?

Geraldine Fleming & Brian J Taylor

Abstract

Day support services are a neglected aspect of promoting the health and social wellbeing of vulnerable adults within the community. Recent policy developments highlight the need to make services more needs-centred and to promote social inclusion. Perceptions of day support provision were explored using quantitative and qualitative questionnaires with clients (54), family carers (7) and a range of health and social services staff (36) and other organisations (10) regarding day support services provided by one Health and Social Services Trust in Northern Ireland. These questionnaires were followed by focus groups to explore key themes. A theoretical framework to shape the evaluation was derived from the work of Maslow and Wolfensberger. A diverse and complex range of health and social care needs were met through day support provision. The engagement of service users seemed patchy in terms of both information provision and consultation. Publicly funded transport was widely regarded as key to accessibility of services. Younger clients did not find current provision attractive, and desired more flexible opening hours. The development of skills for, and support for transition to, employment seemed underdeveloped. For family carers, day support services provided respite that was much valued although clients were not always aware of their family carer's needs. Day support services have an important role within community care, but this is little recognised. Day support services need to be appraised within the context of meeting more complex health and social care needs in the community and emerging policy directions such as the management of risk and the desirability and cost-effectiveness of support for family carers.

Introduction

This study reports on an evaluation of publicly-funded day support services in one locality in Northern Ireland undertaken to inform planning to improve services for adults with physical and sensory disabilities. Day support services are a neglected aspect of promoting the health and social wellbeing of vulnerable adults within the community. Recent policy developments highlight the need to make services more needs-centred and to promote social inclusion, although this area of work lacks a theoretical framework to shape practice. Perceptions of day support services provided by one Health and Social Services Trust in Northern Ireland were explored with service users, family carers, a range of health and social services staff and staff from other organisations. The questionnaires were followed by focus groups to explore key themes.

Historical Context

Over the decades there has been a move to reshape day support from service responses based on diagnostic need to models focusing on enabling and empowering individuals to realise their potential as active participants in society (Carter, 1981; Clark, 2001). This client-centred and needs-led approach (Taylor & Devine, 1993) encompasses ideas of empowerment, user involvement and choice. More recent developments highlight the need to promote social inclusion and integration with the community and the transition to adulthood (Brown & Taylor, 2008). Pioneering outreach services such as enabling clients to access leisure, education and vocational activities in the community have served to extend day support beyond the centre walls and out into the community. Many clients accessing day support services have complex needs relating to physical need and social isolation, and are physically or mentally vulnerable.

Defining Day Support Services

One contemporary definition of day support services is:

Adult day services are community-based group programmes designed to meet the needs of functionally and cognitively impaired adults through an individual plan of care. These structured, comprehensive programmes provide a variety of health, social and other related support services in a protective setting during any part of a day, but less than 24-hour care. Adult day centres generally operate programmes during normal business hours five days a week. Some programs offer services in the evenings and on weekends.' (National Adult Day Services Association (USA), 16 December 2008, www.nadsa.org)

There are a range of models of day support (Tester, 1989; Gaugler & Zarit, 2001; Johnson, Sakaris, Tripp, Vroman & Wood, 2004). A contemporary outline of aims includes: physical care and shelter; preventing deterioration of physical and mental health; companionship and social stimulation; rehabilitation and the teaching of life skills and social skills; positive experiences and new achievements; promoting independence, social integration and employment; and providing respite for family carers (Clark, 2001).

Legal and Policy Context

In Northern Ireland the core role for statutory day support lies within the general duty to promote health and social welfare (Health and Personal Social Services (NI) Order, 1972) and forms part of a continuum of community based services to enable people to remain in their own homes wherever possible. The development of day support fits within the objectives of the community care policy initiative of the 1990s in the UK: to promote the development of domiciliary, day and respite services to enable people to live in their own homes whenever possible, and to ensure that service providers make practical support for family carers a high priority (Department of Health and Social Services, 1990). However mention of day support within government publications is generally limited, and the profile of day support is no more remarkable in the research literature (Social Services Inspectorate, 1992) despite the importance of day activity within other initiatives such as supported housing (Taylor & Neill, 2009).

Developing a Framework for the Evaluation

In order to create a structure for this study, the aims identified in the literature above were considered in the light of the basic human needs framework of Maslow (1943) and the precepts of 'normalisation' articulated by Wolfensberger (1983) to develop the following framework of four broad aims within which to conceptualise the evaluation:

  • meeting health and care needs;
  • developing and enriching lives;
  • promoting social inclusion; and
  • supporting family carers.

This paper reports a service evaluation of statutory day support services using this framework within one locality in Northern Ireland where public bodies known as Health and Social Services Trusts deliver community health and social services as well as acute hospital services. These are almost entirely publicly-funded (Taylor, 1998). There are four statutory Day Centres operated by the Causeway Trust to serve the population of about 100,000 people in a predominantly rural area (Fleming & Taylor, 2007). Three of the centres are traditional social services day support, each providing a range of activities and meeting a wide range of needs including social and personal care, meals and respite for families. The fourth follows a vocational rehabilitation model of day support provision drawing more on the tradition of occupational therapy, and focusing more on productive work activity and constructive leisure activity.

Methods

This primarily qualitative service evaluation was carried out to inform the development of day support for adults with a physical disability or sensory impairment (Department of Health, Social Services and Personal Safety, 2002). Questionnaires were completed by clients (54), day support staff (15), social workers (10), occupational therapists (8), family carers (7) and managers of day centres (3). The term family carer refers here to family members who undertake (unpaid) caring for their blood relatives. Telephone interviews (10) were conducted with key external stakeholder organisations such as voluntary organisations and significant government agencies. These questionnaires and interviews were followed by focus groups with service users, family carers and staff groups to explore key themes. A summary of the sample and data collection tools is given in Table 1. Results of the study were discussed with staff who participated and with service managers as a form of validation.

Table 1: Participant groups and data gathering tools

Participant Groups

Data Collection Tool

A Self Completion Questionnaire

B Assisted Questionnaire

C Telephone Interview

D Focus Group

Service User

Option (or B)

Option (or A)

-

Yes

Day Centre Staff

Yes

-

-

Yes

Day Centre Manager

Yes

-

-

Yes

Physical Disability Social Worker

Yes

-

-

Yes

Social Worker for Children with Special Needs

Yes

-

-

Yes

Allied Health Professional

-

-

-

Yes

Family Carer

-

-

Yes

Yes

Other Organisation

-

-

Yes

-

Findings

Findings reported here reflect particularly the views of users of the day support services.

Meeting Health and Care Needs

A diverse and complex range of health and social care needs were met through the educational and leisure activities at the day centres. Members participated in a wide range of activities including money management, personal hygiene, information technology, literacy, numeracy, social skills and workplace skills. Thirty-two (59%) of members were aged 35-54 years, and 15 (28%) were 55-64 years. Nineteen (35%) of members had suffered a brain injury, of which 13 (68% of these) were male. Thirty-two (59%) of members participated for three days or less per week. Some members suggested more exercise facilities would be valuable, and more activities to promote mobility. Fifty-nine percent of clients had attended the centres for five years or less, suggesting considerable throughput.

Developing and Enriching Lives

The broad satisfaction with the service from many users and staff was reassuring. Forty-one (75%) clients were always or usually happy with the activities, although 20 (37%) said that they always or usually found the activities limited and repetitive. Where provision was perceived as suited to their needs, service users valued the service. Younger clients tended not to find current provision so attractive, and desired more flexible opening hours (Mrug & Wallander, 2002). Service users suggested that they would like a greater range of classes and leisure activities, including gardening and more social support groups.

Promoting Social Inclusion

Thirty-seven (69%) of service users did not use any other facilities; the others went to such as leisure centres (including gyms), ten-pin bowling, fishing, the public library and going out for meals. The development of skills for, and support for transition to, employment seemed underdeveloped (Taylor, McGilloway & Donnelly, 2004), and there were lessons to be learned from clients regarding the supports that they would find helpful. About half of the clients were familiar with their care plan, although a higher percentage felt that they were involved in the care review process. Forty-seven (74%) used the Trust buses to get to the Centres. This publicly-funded, customised transport was widely regarded as essential to accessibility of services. Although all centres had member committees, the quality of engagement of service users received mixed reviews and there was a desire for more written information by both clients and family carers (cf. Moriarty et al, 2007).

Supporting family carers

For family carers, day support services provided respite that was often seen as crucial in supporting their caring role. Clients were not always aware of their family carer's needs and the pressures that they felt. Informal contact with day support staff was widely regarded as a valuable part of communication in addressing ongoing minor issues and suiting care to needs. Communication with the centres was generally regarded as good by the family carers.

Discussion

Day support services had an important role in meeting health and social care needs and in supporting family carers, greater than seems to be recognised in public social policy discussions. The role of flexible day support services in promoting personal development tailored to individual needs and social inclusion requires consideration against the backdrop of chronic long-term care and rehabilitative needs, family support needs and the role of day support in maintaining clients within the community. It was interesting that despite the increasing focus on 'managing risk' within health and social services professions and organisations (Taylor & Donnelly, 2006), this was not a prominent theme in relation to the topics in this study. Our sense is that in general day support services operate at the lower end of the 'risk continuum'. Lower level preventive services, such as day support, have yet to establish their place in managing long term chronic conditions and in preventing the need for long term care and more expensive and intrusive services. The day support services effectively met needs and supported family carers, but need to demonstrate more clearly their role in rehabilitation and in delaying the need for more intensive (and expensive) services. Day support needs to find its role within the continuum of community care services as an effective preventive and rehabilitative service that meets needs, promotes inclusion and develops and enriches the lives of people with a disability.

References

Brown, C. & Taylor, B.J. (2008) Literature Review of Evaluations of Transition Schemes for Younger People with a Physical Disability or Sensory Impairment Ballymena, Northern Ireland: Cedar Foundation.

Carter, J. (1981). Day Services for Adults: Somewhere to Go. London: Allen & Unwin.

Clark, C. (2001). The Transformation of Day Care. In C. Clark (ed.) (2001) Adult Day Services and Social Inclusion: Better Days. London: Jessica Kingsley Publishers.

Department of Health and Social Services (1990). People First: Community Care in Northern Ireland in the 1990s. Belfast: HMSO.

Department of Health, Social Services and Public Safety (2002). Effectiveness Evaluation: Health and Social Care. Belfast: DHSSPS.

Fleming, G. & Taylor, B. J. (2007). Battle on the home care front: Perceptions of Home Care Workers of factors influencing staff retention. Health & Social Care in the Community, 15 (1), 67-76.

Gaugler, J. E. & Zarit, S. H. (2001). The effectiveness of adult day services for disabled older people. Journal of Aging & Social Policy, 12 (2), 23-47.

Health and Personal Social Services (NI) Order 1972.

Johnson, J., Sakaris, J., Tripp, D., Vroman, K. & Wood, S. (2004). The role of social work in adult day services. Journal of Social Work in Long-Term Care, 3 (1), 3-13.

Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50, 370-396.

Moriarty, J., Rapaport, P., Beresford, P., Branfield, F., Forrest, V., Manthorpe, J., Martineau, S., Cornes, M., Butt, J., Iliffe, S., Taylor, B. & Keady, J. (2007) Practice Guide 11: The Participation of Adult Service Users, Including Older People, in Developing Social Care, London: Social Care Institute for Excellence

Mrug, S. & Wallander, J. L. (2002). Self-concept of young people with physical disabilities: Does integration play a role? International Journal of Disability, Development and Education, 49 (3), 267-280.

National Adult Day Services Association (USA). Definition of Adult Day Services www.nadsa.org. (accessed 16 December 2008)

Social Services Inspectorate (1992). A Review of Literature 1986-1991 on Day Care Services for Adults. London: HMSO.

Taylor, B. J. & Devine, T. (1993). Assessing Needs and Planning Care in Social Work. Hampshire: Ashgate.

Taylor, B. J. & Donnelly, M. (2006). Risks to home care workers: Professional perspectives, Health, Risk & Society, 8 (3), 239-256.

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Taylor, B.J. & Neill, A. (2009) 'Sheltered housing and care for older people: Perspective of tenants and scheme managers', Quality in Ageing: Policy, Practice and Research 10(4): 18-28

Tester, S. (1989). Caring by Day: A Study of Day Care Centres for Older People. London: Centre for Policy and Ageing.

Wolfensberger, W. (1983). Social role valorisation: A proposed new term for the principle of normalisation. Mental Retardation, 21 (6), 234-239.

Acknowledgements

The support of the Chief Executive, Directors, managers, staff, day centre members and their family carers in the former Causeway Health and Social Services Trust (now part of the Northern Health and Social Care Trust) is gratefully acknowledged.

Contributors:

Geraldine Fleming MSc RSW

Email: geraldine.fleming@northerntrust.hscni.net

Corresponding Author: Brian J Taylor PhD RSW, University of Ulster, Room 21C13 Dalriada, Shore Road, Newtownabbey, Country Antrim BT37 0QB, Northern Ireland, UK

Email: bj.taylor@ulster.ac.uk

Northern Health & Social Care Trust and University of Ulster, both Northern Ireland, UK

Authors' Biographies:

Geraldine Fleming is Assistant Director of Physical Health and Disability Services in the Northern Health and Social Care Trust, Northern Ireland, with responsibility for statutory services to adults with a physical or sensory disability, community development and adult day support.

Brian Taylor is Senior Lecturer in Social Work at the University of Ulster, Northern Ireland and has undertaken a range of research and evaluation work regarding health and social care services for adults with a disability and older people.

 

International Journal of Disability, Community & Rehabilitation
Volume 9, No. 1
www.ijdcr.ca
ISSN 1703-3381