Community learning disability teams: developments, composition and good practice: a review of the literature

How to improve sharing and application of knowledge in care and support for people with intellectual disabilities? A systematic review

BACKGROUND

To optimise care and support for people with intellectual disabilities (ID), sharing and application of knowledge is a precondition. In healthcare in general, there is a body of knowledge on bridging the 'know-do-gap'. However, it is not known to what extent the identified barriers and facilitators to knowledge sharing and application also hold for the care and support of people with ID, due to its specific characteristics including long-term care. Therefore, we conducted a systematic review to identify which organisational factors are enabling and/or disabling in stimulating the sharing and application of knowledge in the care and support of people with ID.

METHOD

A systematic review was conducted using five electronic databases of relevant articles published in English between January 2000 and December 2015. During each phase of selection and analysis a minimum of two independent reviewers assessed all articles according to PRISMA guidelines.

RESULTS

In total 2,256 articles were retrieved, of which 19 articles met our inclusion criteria. All organisational factors retrieved from these articles were categorised into three main clusters: (1) characteristics of the intervention (factors related to the tools and processes by which the method was implemented); (2) factors related to people (both at an individual and group level); and, (3) factors related to the organisational context (both material factors (office arrangements and ICT system, resources, time and organisation) and immaterial factors (training, staff, size of team)).

CONCLUSION

Overall analyses of the retrieved factors suggest that they are related to each other through the preconditional role of management (i.e., practice leadership) and the key role of professionals (i.e. (in)ability to fulfill new roles).

Sexuality issues and the voices of adults with intellectual disabilities: A systematic review of the literature

BACKGROUND

There is a growing and evolving research evidence base regarding sexuality issues and adults with intellectual disabilities. Individuals can face challenges, including the right to express their sexuality and to access necessary education and supports.

AIMS

This systematic review explores sexuality experiences, the views and opinions of adults with intellectual disabilities and highlights areas for future practice developments.

METHODS AND PROCEDURES

A comprehensive search of relevant databases from January 2006 to December 2016 was carried out. Included studies had to address specific criteria including: peer reviewed papers, the use of appropriate research methods, and focused exclusively on the individual views and opinions of people with an intellectual disability. The search of relevant databases yielded 230 hits. Following the application of explicit inclusion and exclusion criteria, 23 papers were deemed suitable for the review.

OUTCOMES AND RESULTS

The data were analysed and key themes were identified that included: autonomy v's risk of harm, knowledge and sexuality, relationships and intimacy, self-determination and taking control, and encouragement and supports.

CONCLUSIONS AND IMPLICATIONS

Adults with intellectual disabilities need education and support to express their sexuality and to meet individual needs.

The experiences and support needs of people with intellectual disabilities who identify as LGBT: A review of the literature

BACKGROUND

People who identify as lesbian, gay, bisexual and transgender (LGBT) can face many challenges in society including accessing education, care and support appropriate to individual needs. However, there is a growing and evolving evidence base about the specific needs of people with intellectual disabilities (ID) in this regard.

AIMS

The aim of this review was to explore the experiences of people with ID who identified as LGBT through an examination of studies that addressed their views and highlighted specific issues, concerns and service responses.

METHODS AND PROCEDURES

A comprehensive search of relevant databases from February 1995 to February 2015 was conducted. Studies were identified that met specific criteria that included: empirical peer reviewed studies, the use of recognised research methods and focused on people with ID whom identified as LGBT. The search yielded 161 papers in total. The search was narrowed and 37 papers were screened using rigorous inclusion and exclusion criteria. Finally, 14 papers were considered suitable for the review.

OUTCOMES AND RESULTS

The data were analysed and key themes identified that included accessing health services, gender and sexual identity, attitudes of people with ID regarding their LGBT status, and education, supports and therapeutic interventions.

CONCLUSIONS AND IMPLICATIONS

There is a need for service providers and carers to be more responsive to the concerns of people with ID who identify as LGBT to improve their health and well-being by reducing stigma and discrimination and by increasing awareness of their care and support needs. The implications are discussed in terms of policy, education, research and practice developments.

Generic or specialist profession? Identifying social work in community learning disability teams

Purpose

– Social work is integral to community learning disability teams (CLDTs), however there is little research on how social workers discharge their statutory duties within them. The purpose of this paper is to report a study designed to describe what social workers do within a CLDT (anonymised as Maples). The question addressed is: what is the social work role in CLDTs and how is this accomplished?

Design/methodology/approach

– Ethnographic fieldwork was conducted in a CLDT in London during 2011/2012. This involved interviews of professionals and observations of “everyday” social work practice. Data were analysed using constructivist grounded theory.

Findings

– Social work practice in Maples could be categorised along five domains of practice, namely: case management, safeguarding, assessments, mental health practice, and duty. The accompanying professional activities within these domains are described in Table I, with a subsequent focus on the less researched domains of case management, assessment, and duty.

Originality/value

– This research is one of the few to delineate the professional activities of social workers within CLDT. By showing what professionals do, it has important implications for policy – example personalisation – and role effectiveness.

Organising healthcare services for persons with an intellectual disability

BACKGROUND

When compared to the general population, persons with an intellectual disability have lower life expectancy, higher morbidity, and more difficulty finding and obtaining healthcare. Organisational interventions are used to reconfigure the structure or delivery of healthcare services. This is the first update of the original review.

OBJECTIVES

To assess the effects of organisational interventions of healthcare services for the mental and physical health problems of persons with an intellectual disability.

SEARCH METHODS

For this update we searched CENTRAL, MEDLINE, EMBASE, CINAHL and other databases, from April 2006 to 4 September 2015. We checked reference lists of included studies and consulted experts in the field.

SELECTION CRITERIA

Randomised controlled trials of organisational interventions of healthcare services aimed at improving care of mental and physical health problems of adult persons with an intellectual disability.

DATA COLLECTION AND ANALYSIS

We employed standard methodological procedures as outlined in the Cochrane Handbook of Systematic Reviews of Interventions, in addition to specific guidance from the Cochrane Effective Practice and Organisation of Care (EPOC) Group.

MAIN RESULTS

We identified one new trial from the updated searches.Seven trials (347 participants) met the selection criteria. The interventions varied but had common components: interventions that increased the intensity and frequency of service delivery (4 trials, 200 participants), community-based specialist behaviour therapy (1 trial, 63 participants), and outreach treatment (1 trial, 50 participants). Another trial compared two active arms (traditional counselling and integrated intervention for bereavement, 34 participants).The included studies investigated interventions dealing with the mental health problems of persons with an intellectual disability; none focused on physical health problems. Four studies assessed the effect of organisational interventions on behavioural problems for persons with an intellectual disability, three assessed care giver burden, and three assessed the costs associated with the interventions. None of the included studies reported data on the effect of organisational interventions on adverse events. Most studies were assessed as having low risk of bias.It is uncertain whether interventions that increase the frequency and intensity of delivery or outreach treatment decrease behavioural problems for persons with an intellectual disability (two and one trials respectively, very low certainty evidence). Behavioural problems were slightly decreased by community-based specialist behavioural therapy (one trial, low certainty evidence). Increasing the frequency and intensity of service delivery probably makes little or no difference to care giver burden (MD 0.03, 95% CI -3.48 to 3.54, two trials, moderate certainty evidence). It is uncertain whether outreach treatment makes any difference for care giver burden (one trial, very low certainty evidence). There was very limited evidence regarding costs, with low to very low certainty evidence for the different interventions.

AUTHORS' CONCLUSIONS

There is very limited evidence on the organisation of healthcare services for persons with an intellectual disability. There are currently no well-designed studies focusing on organising the health services of persons with an intellectual disability and concurrent physical problems. There are very few studies of organisational interventions targeting mental health needs and the results of those that were found need corroboration. There is an urgent need for high-quality health services research to identify optimal health services for persons with an intellectual disability and concurrent physical problem.

Making reasonable and achievable adjustments: the contributions of learning disability liaison nurses in 'Getting it right' for people with learning disabilities receiving general hospitals care

AIMS

To examine the role of learning disability liaison nurses in facilitating reasonable and achievable adjustments to support access to general hospital services for people with learning disabilities.

DESIGN

Mixed methods study involving four health boards in Scotland with established Learning Disability Liaison Nurses (LDLN) Services. Quantitative data of all liaison nursing referrals over 18 months and qualitative data collected from stakeholders with experience of using the liaison services within the previous 3-6 months.

METHODS

Six liaison nurses collected quantitative data of 323 referrals and activity between September 2008-March 2010. Interviews and focus groups were held with 85 participants included adults with learning disabilities (n = 5), carers (n = 16), primary care (n = 39), general hospital (n = 19) and liaison nurses (n = 6).

RESULTS/FINDINGS

Facilitating reasonable and achievable adjustments was an important element of the LDLNs' role and focussed on access to information; adjustments to care; appropriate environment of care; ensuring equitable care; identifying patient need; meeting patient needs; and specialist tools/resources.

CONCLUSION

Ensuring that reasonable adjustments are made in the general hospital setting promotes person-centred care and equal health outcomes for people with a learning disability. This view accords with 'Getting it right' charter produced by the UK Charity Mencap which argues that healthcare professionals need support, encouragement and guidance to make reasonable adjustments for this group. LDLNs have an important and increasing role to play in advising on and establishing adjustments that are both reasonable and achievable.

The health role of local area coordinators in Scotland: a mixed methods study

The study set out to explore whether local area coordinators (LACs) and their managers view the health role of LACs as an essential component of their work and identify the health-related activities undertaken by LACs in Scotland. A mixed methods cross-sectional phenomenological study involving local authority service managers (n = 25) and LACs (n = 40) was adopted. Quantitative data from LACs were obtained using online and postal questionnaires. Qualitative data from local authority service managers and LACs were collected using one-to-one interviews and focus groups. Thematic analysis was undertaken of the qualitative data. The results indicate that there is a need to develop further the wider public health role of LACs to incorporate health-related activities focused on broader community-based outcomes such as empowerment and community integration. By adopting a public health role, LACs will be able to contribute to the reduction of health inequalities in people with learning disabilities.

Mental health services for people with intellectual disabilities

PURPOSE OF REVIEW

This review summarizes recent research into psychiatric services for adults with intellectual disabilities, with a particular focus on inpatient care.

RECENT FINDINGS

People with intellectual disability appear to be admitted with more severe problems and receive more interventions than those without intellectual disability when admitted to general psychiatric units. Qualitative research has shown poor standards of care on some general psychiatric inpatient units. Studies of supported generic inpatient units have reported successful outcomes, supported by qualitative studies of satisfaction. Length of stay for people with intellectual disability is not consistently longer on specialist than general psychiatric units. Delayed discharge and restrictive practices, however, still need addressing. The important components of community mental health services have been evaluated from the points of view of psychiatrists, patients and carers. Emergency provision of psychiatric assessment and care remains a problem in some centres.

SUMMARY

There have been few randomized controlled trials in this field; however, uncontrolled comparisons and service evaluations suggest positive outcomes in specialist services. Qualitative work has made important contributions to understanding the patients' and carers' experiences. Further work should focus on the measurements of outcome and satisfaction.

Hospitalisation rates for ambulatory care sensitive conditions for persons with and without an intellectual disability--a population perspective

BACKGROUND

There is evidence that persons with an intellectual disability (ID) face barriers to primary care; however, this has not been extensively studied at the population level. Rates of hospitalisation for ambulatory care sensitive conditions are used as an indicator of access to, and quality of, primary care. The objective of the study was to compare hospitalisation rates for ambulatory care sensitive conditions between persons with and without an ID in a publicly insured population.

METHODS

Persons with an ID were identified among the general population of a Canadian province between 1999 and 2003. Using a list of conditions applicable to persons with an ID, rates of hospitalisations for ambulatory care sensitive conditions for persons with and without an ID were calculated and compared. Regression models were used to adjust for age, sex and place of residence. Hospitalisation rates for specific conditions were also compared, controlling for differences in disease prevalence where possible.

RESULTS

Persons with an ID were consistently hospitalised for ambulatory care sensitive conditions at a higher rate than persons without an ID. Between 1999 and 2003 the adjusted rate ratio (RR) was 6.1 [95% confidence interval (CI) = 5.6, 6.7]. Rate ratios were highest when comparing persons with, to persons without, an ID between the ages of 30-39 (RR = 13.1; 95% CI = 10.6, 16.2) and among urban area dwellers (RR = 7.0; 95% CI = 6.2, 7.9). Hospitalisation rates for epilepsy and schizophrenic disorders were, respectively, 54 and 15 times higher for persons with compared with persons without an ID. Rate ratios for diabetes and asthma remained significant after controlling for the population prevalence of these diseases.

CONCLUSIONS

The large discrepancy in rates of hospitalisation between persons with and without an ID is an indicator of inadequate primary care for this vulnerable population. Decreasing the number of ambulatory care sensitive condition hospitalisations through specialised outpatient programmes for persons with an ID would potentially lead to better health, improved quality of life and cost savings. Future research should include potentially important factors such as disease severity, socio-economic variables and measures of health service organisation in the analysis. International comparisons of ambulatory care sensitive condition hospitalisation rates could point to the benefits and limitations of the health service policy directions adopted by different countries.

Workforce development and challenging behaviour: training staff to treat, to manage or to cope?

Staff working directly with adults' challenging behaviours in learning disability services need to be very good at what they do. They also need to want to do the job. A theory-practice gap exists, however, between what is known about effective, evidence-based approaches and whether and how these are used in person-centred community services. Many frontline staff working with people with the most serious challenging behaviours do not have the skills to implement programmes to change behaviour. This discussion article reviews workforce development in the context of clinical and service guidelines and asks whether the legitimate purview of frontline staff is treating challenging behaviour, managing it or simply coping with it on a daily basis, whilst maintaining the best quality of life possible for service users.

Followers or leaders? What is the role for social care practitioners in annual health checks for adults with learning disabilities?

The promotion of health checks for adults with learning disabilities in England is government policy based on the need to address lack of access to healthcare services and poor health outcomes for this group of citizens. This article reports the findings of a scoping review of the literature carried out in 2009 to explore the implications of a national system of health checks for the work of practitioners in social care services. The review found little in the research literature relevant to social care practice and concluded that there is a need to consider the possible roles of social care staff in initiating health checks; their possible involvement in decision making around issues of consent; social care practice in recording and implementing the recommendations of such checks; possible roles as escorts, chaperones and supporters with communications; and the presence of regulatory scrutiny of their participation in this activity.

Organising health care services for persons with an intellectual disability

BACKGROUND

When compared to the general population, persons with an intellectual disability have lower life expectancy, higher morbidity, higher rates of unmet health needs, and more difficulty finding and getting health care. Organisational interventions are used to reconfigure the structure or delivery of health care services and may prove useful to decrease the noted disparities.

OBJECTIVES

To assess the effects of organisational interventions for the mental and physical health problems of persons with an intellectual disability.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register (no year restriction), MEDLINE, EMBASE, CINAHL, other databases from January 1990 to April 2006 reference lists of included studies, and we consulted experts in the field.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series of organisational interventions aimed at improving care of mental and physical health problems of adult persons with an intellectual disability.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed study quality. Missing data were requested from authors of included studies.

MAIN RESULTS

Eight studies met the selection criteria: six were randomised controlled trials, one was a controlled before and after study, and one was an interrupted time series. In general the studies were of acceptable methodological quality. The included studies investigated interventions dealing with the mental health problems of persons with an intellectual disability, none focused on physical health problems. Three of the studies identified effective organisational interventions and five showed no evidence of effect. Only two studies were similar enough to analyse using a meta-analysis. In the pooled analyses 25 participants received assertive community treatment and 25 received standard community treatment. Results from measures of function, caregiver burden and quality of life were non-significant.

AUTHORS' CONCLUSIONS

There are currently no well designed studies focusing on organising the health services of persons with an intellectual disability and concurrent physical problems. There are very few studies of organisational interventions targeting mental health needs and the results of those that were found need corroboration. There is an urgent need for high quality health services research to identify optimal health services for persons with an intellectual disability and concurrent physical problem.