Title: Enabling older people to engage effectively with community social care: developing a theory of change for specialist mental health support worker activities
Funder: Department of Health and Social Care

Abstract: Background As the number of older people with social care needs grows, so will the number who have problems engaging with care services for reasons linked to mental health problems or cognitive impairment. These engagement problems manifest in different ways. People may withdraw or avoid care workers, may display extreme apathy, or otherwise there may be assertive actions such as shouting or physical acts to repel care. Often this leads to a collapse of care arrangements, and a referral to secondary community mental health teams. The applicants' prior research highlighted the potentially vital role of specialist mental health support workers in helping engagement with social care. However, in common with assistant-grade staff across the care system, their activities lack an evidence-base. Without this understanding, practice varies locally without converging on &quot;what works&quot;. Aims and Objectives The research aims to develop a theory of change for mental health support worker activities to improve the engagement of older people with their social care. This will define key active components of their work and associated mechanisms of change, as well as understanding the important facilitators and barriers that influence outcomes. The end-point will be a handbook describing the theory of change in a practice-accessible format, with illustrative case-studies drawn from the research. Methods A three-stage research design is proposed. Stage 1 comprises a scoping review, which will synthesise existing (theoretical and empirical) literature that offers insight into engagement problems with community care. The synthesis will be interpreted by an expert workshop to interactively develop an outline, formative theory of change. This will propose how improved engagement can be achieved, and through what steps, and what change is required between each. Stage 2 comprises qualitative interviews and focus groups in four areas of England. In-depth interviews with 10-12 informal carers and social care providers will examine how engagement difficulties arise, and their perceptions of how support workers are able to assist. A further 22-24 interviews with support workers in mental health teams will examine their activities, focusing on key aspects of the outline theory of change identified at Stage 1. Finally, two focus groups with mental health professionals will examine wider facilitators and barriers to support worker outcomes. Stage 3 will design and develop a handbook for support workers. This will be a learning resource detailing how support workers can help older people to engage with social care, using illustrative practice examples and prompting for reflection on their own skills and capability. A consultation group with support workers will consider how practice change could be implemented in the long-term, such as through a training intervention in a future research project. Anticipated Impact and Dissemination The handbook will be complemented with targeted dissemination activity, through Skills for Care platform ('Learn from Others'), outputs in the British Journal for Healthcare Assistants and a presentation at a support worker-focused annual conference, amongst others. Longer-term impact activity will be oriented to new research seeking to embed learning in practice, such as through a novel training intervention.

Lay abstract: Many older people who need social care support at home (e.g. help with meals or personal care) have dementia, depression, anxiety and/or other mental health difficulties. For some, these problems mean that they cannot easily engage with social care. For example, they may avoid the people who try to give the care, or respond defensively in physical or verbal ways. The causes are complex. In part, it may be because they interpret the care as an intrusion or threat, or because they no longer recognise, or are not motivated to act on, their own support needs. It may also be because social care staff lack the skills and confidence to tailor their care for this group. Whatever the cause, we know that this can lead to the breakdown of social care and that, without this, older people are at severe risk of self-neglect, growing health problems and admission to hospital. A group of informal carers we consulted said these problems can also cause serious distress to the whole family. These difficulties sometimes trigger a referral to community mental health teams. These are specialist teams with mental health expertise, usually spanning both health and social care needs. An earlier study suggested that assistant-grade staff in these teams, known as support workers, are most valuable in helping people to engage with their social care. However, it is not clear what the key 'ingredients' of their work are, nor how they bring about improvements in people's engagement with social care. What is it about their work this is most helpful, how do these activities work, and what helps or hinders their success? This study has three research stages. The first stage will review past studies of similar issues to give us a better understanding about what might work and how. The next stage will interview informal carers, social care providers, support workers and mental health professionals to achieve an in-depth understanding of how support workers help. Finally we will design a handbook describing the learning that support workers (and their supervisors) can use to improve the quality of care they provide to older people. This handbook will be shared through important NHS and social care networks, through conferences, and also promoted through an article in a journal dedicated to support worker issues. This research would be the first step in a longer programme of work to improve support worker skills, and to help people to access the social care that they need.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS;7.3 MANAGEMENT AND DECISION MAKING;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE;MENTAL HEALTH