1. Care planning conversations in aged care facilities: piloting ASCOT
Ann-Marie Towers and Karn Nelson
Australian Association of Gerontology Conference, Canberra, November 2016

2. What is ASCOT? Social care related quality of life (SCRQoL)
Personal cleanliness and comfort
Food and drink
Personal safety
Accommodation cleanliness and comfort
Control over daily life
Social participation and involvement
Occupation
Dignity

3. Outcome states per domain
Ideal state:
The individual’s preferences and wishes in that domain are met.
No needs:
The individual’s needs are met in that domain but not in a way that is truly personalised (mustn’t grumble).
Some needs:
There are some unmet needs in that domain. They are sufficiently important or frequent to affect an individual’s quality of life but do not have a health implication
High needs:
There are high unmet needs in that domain. They are sufficiently severe or frequent to affect the person’s mental or physical health.

4. Range of instruments available
SCT4
INT4
CH3
Carers
Format
Self-completion questionnaire
Face to face interview
Mixed methods
Number of levels 4 3
Current SCRQoL
Yes
Expected SCRQoL
No**
Number of questions 9
 23
n/a
21 
Intended use
All services where service users able to self-complete a questionnaire
All services where service users able to participate in a face to face interview
Residential setting such as care or nursing homes
With carers of adults who are supported by social care services
Go through differences between the versions
Uses of the versions –
Costs and
** why the stars?

5. Using ASCOT in care homes
Researcher-led, using CH3 ( & new CH4)
Data collected by ASCOT team, feedback given to homes:
Useful for quality auditing and marketing purposes
Shared in newsletters and at relative and resident events.
Evidence for the regulator (Care Quality Commission) of commitment to quality.
But how to collect as part of routine care practice?
Integrate the domains into care planning?

6. Piloting ASCOT in care planning
Working with The Whiddon Group
Use INT4 to frame conversations
Enables us to estimate the impact of the service
Usually face-to-face interview
Adapted for care planning to include people with dementia.
INT4 questions without the filter questions (shorter) and with a notes/evidence section….

7. INT4 Tool ASCOT ASCOT Residential Care Client Interview Pilot
adult social care outcomes toolkit
ASCOT Residential Care Client Interview Pilot
Control over daily life
Which of the following statements best describes how much control you have over your daily life?
Interviewer prompt: By ‘control over daily life’ we mean having the choice to do things or have things done for you as you like and when you want. If needed, please prompt: When answering the question, think about your situation at the moment.
I have as much control over my daily life as I want
I have adequate control over my daily life
I have some control over my daily life but not enough
I have no control over my daily life
Please tick () one box
Now imagine that you didn’t have the support and services from (the care home) that you do now and no other help stepped in. In that situation, which of the following would best describe how you would spend your time?
Interviewer note: It is important that respondents do not base their answers on the assumption that any other help steps in; please emphasise this to interviewees. Reassure if necessary: Please be assured that this is purely imaginary and does not affect the services you receive in any way.
I would have as much control over my daily life as I want
I would have adequate control over my daily life
I would have some control over my daily life, but not enough
I would have no control over my daily life
Please tick () one box

8. Method 15 month trial, 4 services, new & existing clients
ASCOT team provided online training
Sharing:
INT4 ratings + evidence + demographic, functional and clinical data with ASCOT team.
Circle of care interviews to include RN, resident, member of staff and family member
6 monthly review by ASCOT team of ratings.
Compared to English research data (new CH4)
Current N = 58 (wave 2)

9. Profile of residents Wave 2 (n=58) UK (n=81) Mean age in years (SD)
85.03 (8.51)
84.35 (9.5)
N female
39 (63.4%)
59 (73%)
Mean No. ADLs need help (SD)
5.03 (3.44)
Not available yet
Mean MDSCPS (SD)
2.05 (1.38)
Short-term memory problems
39 (64%)
45 (56%)
ADLs 0 -10
MDSCPS 0 (intact)- 6 (v severe impairment) – most clients borderline intact or with mild cog impairment

10. Mean ASCOT scores: Whiddon & UK
Mean scores
English data (n=106)
Whiddon all (n=58)
Site 1 (n=14)
Site 2 (n=15)
Site 3 (n=14)
Site 4 (n=15)
Current SCRQoL (SD)
.78 (.16)
0.82 (0.16)
.75 (.17)
.90 (.09)
.84 (.14)
.79 (.19)
Expected SCRQoL (SD)
.09 (.18)
0.25 (0.28)
.33 (.19)
.00 (.11)
.27 (.28)
.40 (.19)
Gain (SD)
.69 (.21)
0.57 (0.31)
.42 (.19)
.90 (.15)
.57 (.27)
.39 (.29)
SCRQoL scores are weighted combination of all domains
Range from 1.00 (best) to (state worse than death)
Gain is the difference between the two scores and estimates impact of service
General population in the UK has an SCRQoL score of 0.86 (Netten et al. 2012)
*English data comes from emerging findings from a new NIHR School for Social Care Research (SSCR) funded study and has been chosen for comparability purposes (similar population using 4 outcome states)

11. Cobweb plots comparison
Time 2 Whiddon (n=58)
English research data (n=106)

12. Reliability of ratings
About 42% of ratings had no supporting statements.
Most statements were for current, not expected.
Difficult to condense conversations down to few sentences evidencing ratings.
Sometimes statements do not match ratings
Find a better way to moderate/validate ratings in future.
Implications for how these ratings are used…

13. Trial success criteria
Improves quality of care planning for everyone
A user friendly tool – Ease of use for RNs, good structure for evaluating client wellbeing and conversations with client and families/reps.
Enables continuous improvement at service and system level
Integration in current care planning and Time costs – Realistic view of likely additional RN time costs
Sustainability

14. Early findings Potential benefits to care planning
Identity: RNs and care/leisure staff understanding residents at a deeper level
Independence: Providing opportunity to raise concerns about choice and control eg don’t like my room, my husband is too controlling
Dignity: Picking up on little things that mean a lot. Residents feeling more empowered and cared for – a structure for a discussion, not a ‘whinge’
Positive and purposeful: Ongoing and better information about interests, meaningful events and celebrations
Meaningful relationships: More opportunity to discuss relationship dynamics and needs – couples
Health & wellness: Picking up on clinical details that were missed at admissions stage. Providing residents with an opportunity to discuss emotional and social needs – eg psychological issues, pearls, fear of storms
Service Issue: Has already picked up on a service issue around food in Site 3

15. ASCOT Sustainability in care planning?
Feedback from semi-structured interviews at T1 and 2
Extra RN time – 20/30 minute interviews. 15 minutes data entry. Plus time to organise Circle of Care interviews.
A deceptively simple and easy tool to use – a good structure for care planning conversations.
Circle of Care interviews add value, but hard to set up. Where possible. Of particular value when resident has dementia.
Easily integrates in normal care planning. But would suggest 6 monthly follow ups and 12 monthly formal Annual Care Planning.

16. Implications for use by providers
Adds value to care planning as a consistent structure for a wellbeing conversation. Residents and families in particular have appreciated this.
Potentially adds value to more holistic view of quality – at service and system level.
For care planning, it needs to be integrated in our systems.
In residential care, does the expected question need to be asked more than once? Could you measure social gain against one expected benchmark for each resident?
Methodology – may need to review Circle of Care
Who conducts – need for distance?
Accuracy/reliability of ratings when reconciling different perspectives – review training?

17. Disclaimer
The English comparison data in this presentation came from an on-going study of care home residents in England funded by the NIHR School for Social Care Research.
This presentation reports on independent research funded by the NIHR School for Social Care Research. The views expressed in this presentation are those of the authors and not necessarily those of the NIHR School for Social Care Research or the Department of Health/NIHR.