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To study quality of care (as well as quality of life) in a cross-national research design requires the use of some pre-defined criteria on what is or what is not good quality. This is not easy as on the one hand, quality of care has been defined in many ways, and on the other, the quality of long-term care of older people is weakly defined. Further, the definitions of quality of care from the perspectives of the clients are rare (e.g. Baldock & Hadlow, 2002; Bowling, 1997), and same regards definitions of quality from a multi-professional perspective (Nies & Berman, 2004). Regarding the quality of long-term care of older people, homecare seems to lack quality definitions (e.g. Paljärvi, Rissanen, & Sinkkonen, 2003; Thomé, Dykes, & Rahm Hallberg, 2003), more often than nursing care and institutional care (e.g. Ranz, Zwygart-Stauffacher, & Popejoy, 1999). In health care, the definition given by Donabedian (1969, 1980) is a widely accepted framework to evaluate quality of care. According to this model, the quality of (health) care needs to be ensured in the three following aspects:Structure: the stable elements of the care system in a community that facilitate or inhibit the access to and provision of services. In health and welfare economics these factors are called inputs, meaning issues such as material resources and financial investments as well as societal goals given to the care.Process: the interaction between the client and a provider. Two dimensions are important here—the technical excellence of given care (appropriateness and skilfulness of the intervention) and interpersonal excellence (humanity and responsiveness to client preferences).Outcomes: results of care including clinical status, functional status, client satisfaction, and improved QoL of the client. These elements are reflected in the current definitions of the quality of care and in the methods of evaluating the quality, especially regarding health care. [ABSTRACT FROM AUTHOR]

In gerontology, there is a substantial and increasing body of theoretical and empirical research on quality of life (QoL) in old age, especially in psychology and health-related research. However, a specific focus on QoL of frail older persons or older persons with permanent need of external help is rare, and even more neglected is the role of care for their QoL. In addition, the question of how much the existing definitions really reflect the opinions of older people themselves has got too little attention (Bowling, Gabriel, Banister, & Sutton, 2002). These notions motivated the Care Keys research to search for a better understanding of the role of homecare and institutional care for the QoL of frail older persons. Applying the production of welfare approach (see Chapter 1), the aim was to produce information on the specific life situations of these older persons, and on the linkages between care and QoL. By providing a model of care-related QoL we aimed at a concept that would allow for the evaluation of care practices in view of their outcomes for frail older persons, thus supporting development of care practices as well as quality management of (long-term) care. Searching for a theoretical model of QoL of frail older persons we found suitable starting points, but also encountered unresolved issues and open questions. This situation prompted the Care Keys research to proceed in two directions. First, we selected concepts and instruments that were available in the literature, introduced some preliminary adaptations to the life circumstances of frail older persons receiving care, and investigated the relation of care quality to QoL as an outcome. Second, we took a closer look at the theoretical issues and their relevance for a concept of care-related QoL. While the empirical research is reported elsewhere (see Part III), the results of the theoretical reflections on QoL are presented and discussed in this chapter. [ABSTRACT FROM AUTHOR]

The discussion presented in this volume has been multifaceted, looking at quality of life (QoL) in care-dependent old people in many ways both theoretically and empirically. The main purpose has been to examine the relationship between long-term care and QoL in frail older persons from theoretical, empirical, methodological and practical perspectives. Our key questions were1.What are the determinants of QoL in older people receiving regular formal homecare or living in institutional settings?2.How does formal long-term care contribute to their QoL, and what are the features of a good quality and effective care from the perspectives of the clients and professional care?3.How does care management contribute to good client and professional outcomes, and how could quality management (QoM) be improved by evidence-based performance evaluation? For a number of reasons the project was quite complex and ambitious. From the outset of the project it was clear that there was a lack of knowledge and scarcity of research on QoL of care-dependent, frail older people. In addition, there was criticism presented in previous studies on the general concept of QoL as not being able to take the situations of frail older people properly into account. Specific models should be developed, so the suggestion in the literature, maybe even models specific for types of care and for the diverse client groups. Thus, there arose a need for the development of theoretical concepts and models, and our basic approach was to favor a unified and generic concept of QoL to be further specified by empirically tested indicators. [ABSTRACT FROM AUTHOR]

The aim of the Care Keys project was to make a contribution to the improvement of long-term care on the level of the theory of care and carerelated quality of life, on the level of empirical enquiry into the relationships between care and care outcomes, and on the level of practical instruments and tools for care quality management. The theoretical and empirical results have been described elsewhere in this book, and this chapter will briefly describe the practical outcomes of the research (additional information and prototypes of the tools are available on the project website http://www.carekeys.net). The main objective was to develop a set of "key indicators" that could be used to guide care quality management, and to take the first steps in developing instruments and tools for practitioners using these indicators. Combining a practical approach with the research objectives was motivated by two considerations. First, it is increasingly recognised that research has to look into the prospects and problems of dissemination and implementation of its results, if it wants to have an impact on practice. Simply to assume that good research results will find their way into care practice and to leave matters of implementation to educationalists or practitioners appears to be ineffective. At least the first steps towards practical implementation have to be taken by practice-oriented research to provide an "interface". Second, many of the partners in the Care Keys project were directly involved in social and health care services and were well aware of the pressing need for practical improvements within their own arenas. [ABSTRACT FROM AUTHOR]

Theoretical and empirical research on the effect of management strategies and service organisation on the quality of care and on the quality of life of clients is still developing. In view of the growing importance of the provision of care in an "ageing society" this state of the art should raise concern and induce enhanced research efforts. The Care Keys project tried to make a contribution to the theoretical and empirical issues, even addressing practical concerns by developing tools for quality management in long-term care. The theoretical framework for management has been presented elsewhere (Chapter 6), and the reader might like to refer to this discussion for more detail. The objectives for the following analyses focus on empirical issues. We will investigate the effects of elements of "good" management strategies on the quality of care and care outcomes for the client. Drawing on the theoretical background, the concept of management will be put into operational terms by a set of indicators, which may guide quality management. The aim is to demonstrate the empirical significance and impact of the indicators in order to provide at least preliminary empirical support both for the indicators and for the structure and comprehensiveness of the strategy employing them. The practical aim of developing a matrix of quality indicators into a tool for quality management will, thus, be supported by a first evidence base. The contribution will proceed in the following steps: first, the theoretical background will be sketched out. The aim is to clarify basic concepts of "good management" and to provide a model of management impacts as a basis for the empirical theses to be investigated. Second, the aim is to define and to structure the set of variables and to discuss some issues about the indicators, data and methods used in the following analyses. Third, the results of first analyses are shown focusing on the reconstruction of management styles from the data by cluster analysis, and the investigation of causal impacts by regression analyses. Finally, the results will be discussed and some conclusions drawn for further research. [ABSTRACT FROM AUTHOR]

Care managers constantly face the question of how best to utilise scarce resources and how to avoid waste of resources. This is especially emphasised in the phrase "increasing needs versus decreasing resources". However, it is also currently widely agreed that the cost containment does not mean "as cheap as possible" but "achieving the best possible outcomes on available resources". Therefore, simple productivity measures are insufficient, as service providers, purchasers, governments, clients and customers require value for money also in the terms of quality and effectiveness of interventions. Thus, efficiency is not only a matter of economics, but also involves doing the right things in the right way and in the right time. Central questions are: How effectively the care meets the client's needs? How efficiently the resources are used and would some alternative way of using them provide with better outcomes? To what extent the available resources are adequate to satisfy the assessed needs? How equal is the resource distribution among the needy groups? It is clear that to be able to answer to these questions is a matter of efficient care management, and moreover, it also helps the managers to defend their resources against cuts or to claim for new resources. Because resources are inevitably limited compared with needs, the use of the resources has to be considered carefully, but the allocation of care cannot be based only on principles of conventional economical efficiency but also on principles of quality and equity. For example Knapp defines efficiency as a combination of equity, economy and effectiveness (Knapp, 1984, 70-81; Vaarama, 1995). [ABSTRACT FROM AUTHOR]

Cognitive impairment due to age-related dementia such as Alzheimer's disease will present considerable challenges to health and social care services as populations age worldwide. As well as expanding services to meet increased numbers of people with dementia, the challenge will also involve providing care that will ensure a good quality of life (QoL) for people who are vulnerable and dependent. Dementia also presents considerable challenges in terms of developing frameworks for evaluating the quality of care. The Care Keys approach emphasises the need to incorporate measures of QoL and well-being in the evaluation of care, while also ‘giving a voice' to the client by eliciting their views on their own well-being and satisfaction with the services they receive. However, this is problematic with cognitively impaired people who may be unable to comprehend questions, formulate coherent answers and articulate and communicate their views. This has often resulted in people with dementia being excluded from research into QoL (cf. Balcombe, Ferry, & Saweirs, 2001). Recent research on QoL in dementia has attempted to address this situation (Torrington, 2006), arguing that the views and responses of people with dementia should still be taken seriously. However, there are limits to this when the severity of the dementia may prevent meaningful verbal communication and, in these situations, alternative approaches are required. Unfortunately, approaches to assessing QoL for people with dementia remain conceptually and methodologically weak. A traditional biomedical perspective generally frames the experience of dementia in terms of cognitive decline and associated functional impairment. However, alternative perspectives suggest that QoL in dementia is more than just cognition (Banerjee et al., 2006) and that a wider perspective encompassing aspects of the person, context and care (Sixsmith & Gibson, 2006) need to be considered. As far as the concept of crQoL is concerned, a number of key theoretical and methodological issues need to be resolved. Firstly, are the concepts underlying the crQoL model appropriate to people with dementia? Secondly, are ideas of subjective well-being that have been developed particularly in respect to non-demented people, applicable to people with dementia? Finally, can care make a difference to the QoL of people with dementia? In this context, this chapter presents some of the results of work carried out within the Care Keys project that specifically addressed the needs of people with dementia. [ABSTRACT FROM AUTHOR]

It is generally accepted that most old people prefer to live independently in their own homes. However, institutional care in nursing or residential homes is often the only option available for frail and dependent people, who require higher levels of support. Moreover, social and demographic changes throughout Europe show a weakening of family and community networks, resulting in a reduction in informal support from family and friends to allow frail old people to remain at home. Care institutions provide adapted and safe environments and provide a range of care, such as support in everyday activities and medical procedures. In addition to these instrumental issues, increasing attention has also been paid to the general quality of life (QoL) of clients through facilitating social participation, leisure activities and, supporting clients' lifestyles, while trying to preserve individuals' autonomy and control. At the same time however, the individual has to conform to the social roles and rules prevalent in the institution. Among older people, this process can lead to "induced dependency" whereby the person undergoes psychological changes, loss of personal competence and even physical deterioration. Residents of care institutions commonly have serious limitations in their abilities to take care of themselves because of the illnesses or frailties of advanced age. These conditions and associated functional decline inevitably have an impact on QoL. As well as physical functioning, other factors such as psychological, social and emotional changes can have an impact on wellbeing and satisfaction with life. [ABSTRACT FROM AUTHOR]

The objective of enabling older people to live in their own homes as long as possible is a widely accepted guiding principle of old age policies in most western societies. "Ageing in place" is seen as a goal that accommodates the preferences of both older people themselves and society. Homecare (HC) is one of the key means to support older people who need regular external help to remain living at home. Underlying the provision of homecare, there is an implicit or explicit goal to enhance the general well-being of the clients. However, there is still little known, especially from the perspective of old people themselves, about the ways that different types of homecare and how they are organised and delivered can impact on the quality of life (QoL) of the clients. Although patterns of homecare provision may vary considerably between European countries, reflecting different approaches to provision within "mixed economies of care", services usually range from help for housekeeping and daily activities of living to nursing care at home, as well as social, emotional and psychological support to maintain independence and autonomy. During the last two decades, most European countries have introduced policies for prioritising or targeting client needs in order to allocate the available scarce resources to those in most need (e.g. Evers & Svetlik, 1993; Pacolet, Bouten, Lanoye, & Versieck, 1998). For example, in Finland, a shift from a publicly provided social model of home help towards a more medically orientated care at home is apparent, as well as a shift from public provision towards a more mixed economy, involving providers from both the public and private sectors (Vaarama & Noro, 2006). For "better targeting of care", eligibility for formal homecare is increasingly targeted on those people with highest needs in respect to personal daily activities (PADL—help with personal hygiene, going to the toilet, etc.), whereas those persons needing help in housekeeping and other instrumental daily activities (IADL) are increasingly likely to be cared for by families or to buy the services privately. Importantly, services that support the psycho-social and environmental and housing needs of clients tend to be ignored. [ABSTRACT FROM AUTHOR]

Ageing Europe faces a challenge of providing good care for older persons. Until recently there have been no universal standards for long-term care in the European Union (EU). Many national and European surveys indicate that health and social care for older people is primarily biomedically oriented and evaluates quality of care using health-related outcome measures (Carver, Chapman, Thomas, Stadnyk, & Rockwood, 1999; Garratt, Ruta, Abdalla, Buckingham, & Russell, 1993; Smit, 2000). Alternatively, recent research in the field of long-term care has clearly shown that quality of life (QoL) is a primary and meaningful outcome marker of care (Kane et al., 2003; Noelker & Harel, 2001). QoL can be evaluated using objective or subjective variables and indices (Lawton, 1991), but there is a growing consensus that the conceptualization and measurement of QoL in long-term care should be based primarily or exclusively on the resident's subjective assessment of his or her QoL (Kane et al., 2003). It is now recognized that QoL extends beyond a strict medical discourse into areas as psychology, environmental studies, social work and so on (Smith, 2000). For people who need help in everyday life, the quality of care can significantly influence their QoL (see Chapter 5). Research of QoL in long-term care is usually limited to one country, one care type or even one institution, and there is lack of comparative studies in this field. The main aim of the present study was to compare QoL of older people receiving long-term care—clients of home-based or institutional care-in different regions of EU: Estonia, United Kingdom, Sweden, Finland and Germany. Estonia is a "new" EU member and other four countries are "old" members. During the study Estonia had been a member of EU less than 2 years while others more than 10 years. Estonia differed from other project countries in several socio-economic areas. The mean life expectancy in Estonia was significantly lower (Estonia 71.8, UK 84.1, Sweden 86.3, Finland 81.4, Germany 82.3 years) (List of countries by life expectancy, 2005), general life satisfaction and happiness were poorer, security and state of repair of houses were more problematic and people were less satisfied with their homes, social life and health services (InfobaseEUROPE Database Record No. 7530, 2004). [ABSTRACT FROM AUTHOR]

Quality management (QM) is not just a recent strategy for management tasks such as resource management, personnel management, marketing management, risk management, knowledge management or innovation management, but it has become part of a quality movement. It is currently a firm element of scientific and public discussion on quality standards and a widely accepted requirement in the provision of social and health care services. For example, Total Quality Management (TQM) has become a comprehensive management philosophy, and an approach to management encompassing all tasks within a single framework. Although the concepts and strategies of TQM are proliferating, the discussion of central concepts of quality is still proceeding without a general agreement of terms and ideas, any agreed theoretical framework or consistent body of empirical findings. The TQM approach has been developed in the manufacturing industry, transformed for use with commercial services and has in the last 10 or 15 years become pervasive within public administrations and the health care and social services (Evers, Haverinen, Leichsenring, & Wistow, 1997; Görres, 1999; Øvretveit, 1998; Peterander & Speck, 2004). The movement has generated institutions and organisations on national and international levels that define quality for different realms of production, develop systematic standards, strategies and methods for quality development and certify their successful implementation. The certification of QM procedures can also be utilised in the competition in the marketplace for consumers. Quality becomes itself a product (certification) and a sales pitch, but at the same time the independently attested quality of products and service also provides consumer protection, since the consumer often has to rely on evaluations that he or she is not in a position to make himself or herself. Clearly, not all producers compete in the marketplace with similar levels of quality; it may be only the best quality for a given low price. Therefore, it is important to keep in mind that QM does not necessarily strive for the highest quality, but for a quality standard for given costs or prices. Moreover, since quality has a price, clients may have preferences for certain levels of quality, considering the trade-off between care outcomes and other consumption alternatives (Cangialose, Cary, Hoffmann, & Ballard, 1977). [ABSTRACT FROM AUTHOR]

In order to elaborate the instruments, test the Care Keys methodology and build models, it was necessary to have different databases, covering all relevant client groups in all participant countries and containing measurements of all variables that might influence the crQoL of clients. The first databases were developed to test and pilot the various instruments for final data collection (see Chapter 2). After the instrumentation was finalised, national data collection took place during November 2004-March 2005, using common tools and a common data collection procedure. The national data sets were then combined to create a pooled database for empirical research that covered all the areas necessary for checking hypotheses and model building. The Care Keys pooled database (CKPD) contained data on about 1,500 clients from 5 European countries, with an average more than 500 measured variables per case. The structure of data was quite complicated, with the data being drawn from interviews with clients, caregivers (in some cases also relatives), extracted from the care documentation and from managers of services. The overall response rate was moderate, mainly because of the health of clients and lack of information within care documentation. The following data processing tasks were required to create the pooled database:1.Merging national data sets, cleaning, handling missing values, making imputations (where necessary and possible).2.Exploratory analysis of data (on national and integrated, conditionally European level) to find the leading tendencies and estimate the distributions of variables, checking working hypotheses.3.Compressing the data, calculating new variables (indexes).4.Finding key-indicators with the aim of optimising the list of variables that would be measured in future.5.Measuring dependencies and building models describing the factors influencing quality of life (QoL).6.Creating meta-models to follow the multilevel structure of factors influencing the QoL of clients via quality of care (QoC) and other factors. Mainly classical multivariate statistical methods were used in the data analysis, using the SPSS and SAS packages. [ABSTRACT FROM AUTHOR]

Research on care-related quality of life (crQoL) focuses mainly on the interaction between the quality of care (QoC) and the quality of life (QoL). However, the conditions for a good QoC are also important, that is the resources, structures and processes which facilitate good care outcomes. For comprehensive evaluation of care-related QoL, all the perspectives that have been included in the multi-dimensional and multi-actoral evaluation model developed in the Care Keys project are important. Hence, the instrumentation of the research carried out within Care Keys was designed to cover all the different elements within the meta-model and quality matrix that guided the project:1.Subjective QoL in old persons receiving home care or care in institutional settings, and determinants of it.2.Objective (assessed) QoL in old persons, and determinants of it.3.QoL in old persons with dementia.4.Subjective QoC in old persons using home care or care in institutional settings, and determinants of it.5.Professional quality of home care and care in institutional settings, and determinants of it.6.Quality management of home care and care in institutional settings, and determinants of it. It followed from this, firstly, that instruments were needed for carrying out interviews with clients to access their subjective perceptions about their QoL and the QoC they received. Secondly, instruments had to describe the QoL as professionally assessed and documented including professional (e.g. clinical) care outcomes. Thirdly, instruments were required for the evaluation of the QoL of older persons with dementia, who may be unable to provide the information themselves. Fourthly, a standardised instrument was needed for the collection of information on professional QoC, covering key components within the meta-model. Fifthly, an instrument was required to collect all the information needed from the perspective of management. Besides quality management information, the instrument also had to collect information at the organisational level on such issues as material resources, costs and organisational structures for quality management. The information sources for this information were the care managers at different management levels. [ABSTRACT FROM AUTHOR]

Initially, there were four major research objectives in the Care Keys research:1.What are the determinants of quality of life (QoL) of care-dependent old people; and what is the role of care in the production of it?2.What are the determinants of quality of care from the perspectives of the clients and professional carers, and how are they inter-related?3.How should care be managed to provide positive care outcomes?4.Development of a Toolkit, comprising models and instrumentation for evaluating care outcomes within applied research and care management practice. Care Keys has focused on older people who require help to cope with many aspects of daily life and are often dependent on care provided to them, either at home or in institutional settings, such as nursing homes. For many of these people, the possibilities, choices and opportunities in their everyday lives are more limited because of increasing frailty and loss of independence, with an inevitable impact on their QoL. The aim of the research was to find out how long-term care (LTC) provided to people in their homes or institutional settings impacts on their QoL and how LTC could be improved to support and enhance the well-being of the clients. A particular emphasis was on the "voice" of the clients. An initial literature review revealed that this type of research approach was rare, and the availability of appropriate models and instruments appropriate for use within Care Keys was very limited. Therefore, two further research tasks were defined:1.To develop a theoretical model of care-related quality of life (crQoL) that also includes concepts of quality of care and management of quality of care.2.To select, develop and validate instrumentation for research on crQoL. Hence, the Care Keys project involved both theoretical and empirical research. This chapter outlines the general theoretical framework of the Care Keys research, and in Part II, the results of our theoretical research are discussed. [ABSTRACT FROM AUTHOR]