Hearing dogs for people with severe and profound hearing loss: a wait-list design randomised controlled trial investigating their effectiveness and cost-effectiveness

Abstract Background Hearing loss increases the risk of poor outcomes across a range of life domains. Where hearing loss is severe or profound, audiological interventions and rehabilitation have limited impact. Hearing dogs offer an alternative, or additional, intervention. They live permanently with recipients, providing sound support and companionship. Methods A single-centre, randomised controlled trial (RCT) evaluated the impacts of a hearing dog on mental well-being, anxiety, depression, problems associated with hearing loss (responding to sounds, fearfulness/social isolation), and perceived dependency on others. Participants were applicants to the UK charity ‘Hearing Dogs for Deaf People’. Eligibility criteria were as follows: first-time applicant; applying for a hearing dog (as opposed to other support provided by the charity). Participants were randomised 1:1 to the following: receive a hearing dog sooner than usual [HD], or within the usual application timeframe (wait-list [WL] comparator). The primary outcome was mental well-being (Short Warwick-Edinburgh Mental Well-Being Scale) 6 months (T1) after HD received a hearing dog. The cost-effectiveness analysis took a health and social care perspective. Results In total, 165 participants were randomised (HD n = 83, WL n = 82). A total of 112 (67.9%) were included in the primary analysis (HD n = 55, WL n = 57). At T1, mental well-being was significantly higher in the HD arm (adjusted mean difference 2.53, 95% CI 1.27 to 3.79, p < 0.001). Significant improvements in anxiety, depression, functioning, fearfulness/social isolation, and perceived dependency, favouring the HD arm, were also observed. On average, HD participants had used fewer statutory health and social care resources. In a scenario whereby costs of provision were borne by the public sector, hearing dogs do not appear to be value for money. If the public sector made a partial contribution, it is possible that hearing dogs would be cost-effective from a public sector perspective. Conclusions Hearing dogs appear to benefit recipients across a number of life domains, at least in the short term. Within the current funding model (costs entirely borne by the charity), hearing dogs are cost-effective from the public sector perspective. Whilst it would not be cost-effective to fully fund the provision of hearing dogs by the public sector, a partial contribution could be explored. Trial registration The trial was retrospectively registered with the International Standard Randomised Controlled Trial Number (ISRCTN) registry on 28.1.2019: ISRCTN36452009

Reablement services for people at risk of needing social care: the MoRe mixed-methods evaluation.

Background Reablement is an intensive, time-limited intervention for people at risk of needing social care or increased intensity of care. Differing from homecare, it seeks to restore functioning and self-care skills. In England, it as a core element of intermediate care. The existing evidence base is limited. Aims Describe reablement services in England and develop a service model typology; Conduct a mixed method comparative evaluation of service models investigating outcomes, factors impacting outcomes, costs and cost-effectiveness, and user and practitioner experiences; Investigate specialist reablement services/practices for people with dementia. Methods Work package 1 (WP1), taking place in 2015, surveyed reablement services in England. Data were collected on organisational characteristics, service delivery and practice, and service costs and caseload. Work package 2 (WP2) was an observational study of three reablement services, each representing a different service model. Data collected included: health- (EQ-5D-5L) and social care-related (ASCOT SCT-4) quality of life, practitioner (Barthel Index) and self-reported (NEADL scale) functioning, individual and service characteristics, and resource use. It was collected on entry into reablement (n=186), at discharge (n=128) and, for those reaching the timepoint within the study timeline, six months post-discharge (n=64). Interviews with staff and service users explored experiences of delivering or receiving reablement and its perceived impacts. Work package 3 (WP3) interviewed staff in eight reablement services to investigate experiences of reabling people with dementia. Results 201 services, located in 139 Local Authorities took part in the survey. Services varied in their organisational base, relationship with other intermediate care services, use of out-sourced providers, skill mix, and scope of reablement input. These characteristics influenced aspects of service delivery and practice. Average cost per case was £1,728. Lower than expected sample sizes meant a comparison of service models in WP2 was not possible. Findings are preliminary. At T1, significant improvements in mean score on outcome measures except self-reported functioning were observed. Further improvements were observed at T2, but only significant for self-reported functioning. There was some evidence that individual (e.g. engagement, mental health) and service (e.g. service structure) characteristics were associated with T1 outcomes and resource use. Staff views on factors affecting outcomes typically aligned with, or offered possible explanations for, these associations. However, it was not possible to establish the significance of these findings in terms of practice or commissioning decisions. Service users expressed satisfaction with reablement and identified two core impacts: regained independence and, during reablement, companionship. Staff participating in WP3 believed people with dementia can benefit from reablement, but objectives may differ and expectations for regained independence inappropriate. Furthermore, practice (e.g. duration of home visits) should be adjusted and staff adequately trained. Conclusions The study contributes to our understanding of reablement, and what impacts on outcomes and costs. Staff believe reablement can be appropriate for people with dementia. Findings will be of interest to commissioners and service managers. Future research should further investigate factors impacting on outcomes, and reabling people with dementia

Understanding and supporting user engagement in reablement

Main issue analysed and its relevance Existing evidence indicates that a number of person-centred factors reablement outcomes. These include service user understanding and expectations of the intervention, motivation, and acceptance of the need for help. Some person-centred factors are, potentially, amenable to change by the practitioners involved. Thus, aspects of service design and delivery are also implicated. In addition, and contributed to by both service user and practitioner, is the quality of the so-called ‘therapeutic alliance’. All these factors are components of the construct ‘intervention engagement’. However, despite reablement requiring active participation by the service user, the construct of engagement has not been investigated within this context. This paper reports findings from a study which begins to address this evidence gap. Methdology An observational study of individuals (n=186) receiving reablement in England, followed up for 6 months post-intervention. Four models of service delivery were represented. A measure of engagement, developed and evaluated by the research team, was included within a battery of measures. A nested qualitiative study investigated the views and experiences of service users, reablement staff, and senior practitioners. Together, these data have allowed us to: i) test and understand whether and how user engagement impacts on reablement outcomes; and ii) the ways that aspects of service design and delivery may moderate or mediate this association. Main findings expected from the analysis A first round of analysis of the quantitative data has found an association between user engagement and a range of outcome domains and that user engagement differed between service delivery models. Qualitative data offers some explanations for these findings. This paper will synthesise these findings and report further analyses looking at the involvement of mental health, and the association between engagement and longer-term outcomes. Finally, we will reflect on the study’s contribution to theory. We are interested in the fact that much writing on engagement is concerned with the relationship between user and worker yet, in reablement, multiple workers may be involved

The SHAPE project: Supporting adults with High-functioning Autism and asPerger syndromE. Mapping and evaluating Specialist Autism Team service models

BACKGR0UNDNICE recommends each locality has a ‘Specialist Autism Team’ (SAT): an autism-specialist, community-based, multi-disciplinary service responsible for developing, coordinating and delivering care and support. It recommended this novel delivery model was evaluated. OBJECTIVES• identify services fulfilling NICE’s description of a SAT;• describe practitioner and user experiences;• investigate outcomes;• identify factors associated with outcomes;• estimate costs and investigate cost-effectiveness.DESIGNStage 1: desk-based research and survey to identify SATs. .Stage 2: • mixed methods observational study of cohort of SAT users, followed for up to two years from assessment appointment. Users either referred for ‘diagnosis and support’ (D&S) or, if already diagnosed, ‘support only’ (SO))• nested qualitative study of senior practitioners. • exploratory comparison of D&S group with a cohort accessing a diagnostic assessment service (‘diagnosis only’ (DO)). Setting (Stage 2)Nine SATs; three also provided a regional diagnostic assessment service (used to recruit DO cohort). Participants (Stage 2)• SAT cohort: n 252 (D&S =164, SO=88). • DO cohort: n=56. Thirty-seven participants (across both cohorts) recruited to the qualitative evaluation and eleven practitioners to the nested qualitative study. Main outcome measuresWHOQOL-BREF Psychological Domain, GHQ-12.Data sources Self-reported outcomes, qualitative interviews with users, and focus groups with practitioners.RESULTSStage 1Eighteen SATs were identified, all for autistic adults without LD. Services varied in their characteristics. Resources available, commissioner specifications and clinical opinion determined service design. Stage 2: Staff reported increasing referral rates without commensurate increases in funding. They called for an expansion of SATs’ consultation/supervision function and resource for low-intensity, on-going support. For the SAT cohort, there was evidence of prevention of deterioration in outcomes and positive benefit for the D&S group. Users of services with more professions involved were likely to experience better outcomes; however, this may not be considered cost-effective. Some service characteristics were not associated with outcomes, suggesting different structural/organisational models are acceptable. Findings suggests one-to-one work for mental health problems was cost-effective and an episodic approach to delivering care plans more cost-effective than managed care. Qualitative findings generally align with quantitative findings; however, users consistently connected a managed-care approach to supporting improvement in outcomes.For the DO cohort, no changes in mental health outcomes at T3 were observed. Interviews, comparing D&S and DO individuals, suggests extended psychoeducation post-diagnosis impacts immediate and longer-term adjustment. LIMITATIONSSample size prohibited investigating association between some service characteristics and outcomes. Comparison of DO cohort and D&S group under-powered. Economic evaluation limited by incomplete costs data.CONCLUSIONSThe study provides first evidence on the implementation of SATs. There is some evidence of benefit for this model of care. Service characteristics which may affect outcomes, costs and cost-effectiveness were identified. Finding suggest extended psychoeducation post-diagnosis is a critical element of SAT provision. FUTURE WORKWe recommend:• comparative evaluation of SATs vs diagnostic-only provision • evaluation of models of providing consultation/supervision and low-intensity support