View in EDS HTML Full Text PDF Full Text

Adults with Intellectual Disabilities and Challenging Behaviour: The Costs and Outcomes of In- and Out-of-Area Placements

Saved in:
Bibliographic Details
Title: Adults with Intellectual Disabilities and Challenging Behaviour: The Costs and Outcomes of In- and Out-of-Area Placements
Language: English
Authors: Perry, J., Allen, D. G., Pimm, C., Meek, A., Lowe, K., Groves, S., Cohen, D., Felce, D.
Source: Journal of Intellectual Disability Research. Feb 2013 57(2):139-152.
Availability: Wiley-Blackwell. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8598; Fax: 781-388-8232; e-mail: cs-journals@wiley.com; Web site: http://www.wiley.com/WileyCDA/
Peer Reviewed: Y
Page Count: 14
Publication Date: 2013
Document Type: Journal Articles
Reports - Research
Descriptors: Foreign Countries, Adults, Late Adolescents, Comparative Analysis, Placement, Risk, Health Services, Costs, Individual Needs, Quality of Life, Outcomes of Treatment, Housing, Mental Retardation, Federal Legislation, Measures (Individuals), Rating Scales, Group Homes, Psychological Patterns, Questionnaires, Individual Characteristics, Tables (Data), Residential Programs, Residential Care
Geographic Terms: United Kingdom (Wales)
Assessment and Survey Identifiers: Adaptive Behavior Scale
DOI: 10.1111/j.1365-2788.2012.01558.x
ISSN: 0964-2633
Abstract: Background: People with severe challenging behaviour are vulnerable to exclusion from local services and removal to out-of-area placements if locally available supported accommodation is insufficient to meet their needs. There are concerns about the high costs and potentially poorer outcomes of out-of-area placements but relatively little is known about how costs and outcomes compare with provision for a similar population placed locally. Methods: Costs, quality of care and a wide range of quality of life outcomes for 38 people with intellectual disabilities and challenging behaviour living in-area and 38 similar people living out-of-area were compared. The two groups were matched as far as possible on risk factors for out-of-area placement. The out-of-area group represented two-thirds of the total number of people who originated from the territory served by the largest specialist health service in Wales and were placed in residential settings at least 10 miles beyond its boundaries. Results: There was a mixed pattern of quality of care and quality of outcome advantages between the two types of setting, although in-area placements had a greater number of advantages than out-of-area placements. Unexpectedly, out-of-area placements had lower total costs, accommodation costs and daytime activity costs. Conclusions: No overall conclusion could be reached about cost-effectiveness. A number of potential reasons for the differences in cost were identified. Although additional resources may be needed to provide in-area services for those currently placed out-of-area, government policy to provide comprehensively for those who want to live locally, irrespective of their needs, appears to be attainable. (Contains 4 tables.)
Abstractor: As Provided
Number of References: 39
Entry Date: 2014
Accession Number: EJ1012862
Database: ERIC
Full text is not displayed to guests.
FullText Links:
  – Type: pdflink
    Url: https://content.ebscohost.com/cds/retrieve?content=AQICAHj0k_4E0hTGH8RJwT4gCJyBsGNe_WN95AvKlDbXJGqwxwGP8FoyPivPsYfInfVCacdWAAAA4jCB3wYJKoZIhvcNAQcGoIHRMIHOAgEAMIHIBgkqhkiG9w0BBwEwHgYJYIZIAWUDBAEuMBEEDJKqTNzp-cWSiJiAVAIBEICBmrYD-o212j4BD_saAX8BvhXm1qy745clSG2z76COyl8Ap-9uSAj0ZKAehMtdVKlYW1AV_Vyalh4Sg4W4RkgIMyl-TA45Tq1tSZuVWtTbRSHBnWPpGHQin1wdlOZHJYY3aj7fhIJWnJH9Xk4hVkSmZl8C-FgvmBs9otqcVdeUpGc5c8i6EzyjxsEBO0ZA4deX6IHR5hnEt5C66B8=
Text:
  Availability: 1
  Value: <anid>AN0084622608;eul01feb.13;2018Jul09.14:14;v2.2.500</anid> <title id="AN0084622608-1">Adults with intellectual disabilities and challenging behaviour: the costs and outcomes of in- and out-of-area placements. </title> <p>Background  People with severe challenging behaviour are vulnerable to exclusion from local services and removal to out‐of‐area placements if locally available supported accommodation is insufficient to meet their needs. There are concerns about the high costs and potentially poorer outcomes of out‐of‐area placements but relatively little is known about how costs and outcomes compare with provision for a similar population placed locally. Methods  Costs, quality of care and a wide range of quality of life outcomes for 38 people with intellectual disabilities and challenging behaviour living in‐area and 38 similar people living out‐of‐area were compared. The two groups were matched as far as possible on risk factors for out‐of‐area placement. The out‐of‐area group represented two‐thirds of the total number of people who originated from the territory served by the largest specialist health service in Wales and were placed in residential settings at least 10 miles beyond its boundaries. Results  There was a mixed pattern of quality of care and quality of outcome advantages between the two types of setting, although in‐area placements had a greater number of advantages than out‐of‐area placements. Unexpectedly, out‐of‐area placements had lower total costs, accommodation costs and daytime activity costs. Conclusions  No overall conclusion could be reached about cost‐effectiveness. A number of potential reasons for the differences in cost were identified. Although additional resources may be needed to provide in‐area services for those currently placed out‐of‐area, government policy to provide comprehensively for those who want to live locally, irrespective of their needs, appears to be attainable.</p> <p>intellectual disability; placement; quality of life outcome; supported housing; costs</p> <p>People with severe challenging behaviour remain vulnerable to exclusion from local services. Emerson et al. (2008) showed that about one‐third of people with intellectual disabilities (ID) who were aged 18–64 years and in residential or nursing home accommodation commissioned by local authorities in 2006 were placed outside of the authority area and that this proportion had increased between 2003 and 2005. Predictors of out‐of‐area placement have been found to include: younger age, less severe ID, repeated self‐injury, significant challenging behaviour, autistic spectrum disorder, mental health problems and having been detained under the Mental Health Act (Allen et al. 2007; Hassiotis et al. 2008). While a minority of out‐of‐area placements are thought to have been made for positive reasons, the majority are believed to stem from a failure of authorities to commission or provide adequate local support arrangements to meet people's specialist needs, a belief accompanied by concerns about both the high costs and potentially poorer outcomes of such placements (Emerson et al. 2008). However, relatively little is known about how costs and outcomes compare with provision for a similar population placed locally.</p> <p>The concern about high cost follows from the expectation that specialist services will have more staff, more qualified staff and greater professional input, and that, in a seller's market, those providing for people with complex needs are able to set a charging structure that local commissioners have little option other than to accept. Hassiotis et al. (2008) reported that costs of out‐of‐area placements were significantly higher than those of in‐area placements in two of five boroughs studied. Pritchard & Roy (2006) reported that average care package costs for people placed out‐of‐area were one‐third higher than those for people placed locally.</p> <p>Research looking at the impact of placing people out‐of‐area on quality of care or quality of life outcome is equally limited. Goodman et al. (2006) reported low levels of individual assessment and planning among people in out‐of‐area placements and raised concern over the extent to which monitoring oversight by the placing authorities was maintained in practice. In a study that lacked control for potentially relevant participant characteristics, Beadle‐Brown et al. (2006) found that choice and community involvement among 30 people with ID placed out‐of‐area were inferior to those reported in selected published studies on local community services. In addition, Beadle‐Brown et al. (2009) reported that families of 30 people living out‐of‐area identified problems of poor quality care, as did community team professionals. However, care managers and family members generally reported satisfaction with placements.</p> <p>As evidence on the relative advantages and disadvantages of in‐ and out‐of‐area placements is limited, we sought to provide a case study from one locality comparing the costs and outcomes of these two ways of providing for people with ID and challenging behaviour. Sample identification was underpinned by an earlier survey of 901 people with challenging behaviour from the research territory (Lowe et al. 2007), 97 of whom were placed out of area. The aim was to follow up the latter group and select similar individuals from the larger number placed within area as a matched control group. Our approach to assessing costs followed the comprehensive costing approach recommended by Beecham & Knapp (1992). Our approach to assessing quality of life outcome followed the recommendations of an international consensus panel (Schalock et al. 2002) to reflect the multidimensional nature of the construct and to include both objective and subjective indicators. The latter is only possible among people with less severe ID who can respond to abstract concepts without response bias (i.e. reply ‘yes’ or ‘no’ to questions irrespective of meaning or select predetermined answers to questions on the basis of order rather than meaning). Objective indicators are recommended in service evaluation as subjective appraisal tends to be insensitive to environmental differences (Schalock & Felce 2004). Outcome dimensions were kept distinct in line with the conclusion of Emerson et al. (2000) that the empirical basis for delivering an overall quality index is extremely weak. Given the broad range of outcomes being assessed, the study was conceptualised as a costs and consequences analysis (Drummond et al. 2005).</p> <hd id="AN0084622608-2">Methods</hd> <hd id="AN0084622608-3">Ethical approval</hd> <p>Ethical approval was obtained from the Research Ethics Committee for Wales.</p> <hd id="AN0084622608-4">Sample identification and recruitment</hd> <p>The research territory comprised the seven local authorities covered by the Abertawe Bro Morgannwg University Health Board Directorate of Learning Disabilities.</p> <hd id="AN0084622608-5">Out‐of‐area placement group</hd> <p>The prior survey of 97 people aged 16 years or over placed outside of the territory was updated by: (<reflink idref="bib1" id="ref1">1</reflink>) contacting provider organisations and asking about current placement; (<reflink idref="bib2" id="ref2">2</reflink>) following up the children who had become adults in a similar manner; (<reflink idref="bib3" id="ref3">3</reflink>) contacting local care managers for contact details when the original provider organisations no longer knew the whereabouts of individuals; and (<reflink idref="bib4" id="ref4">4</reflink>) asking local authority and the local health board finance officers about people in currently funded out‐of‐area placements. Two exclusion criteria were applied: (<reflink idref="bib1" id="ref5">1</reflink>) people in placements which they or their family had requested the authority to commission and (<reflink idref="bib2" id="ref6">2</reflink>) people in placements less than 10 miles outside of the research territory which might on this basis be considered as local to the individual and family.</p> <p>Figure 1 summarises recruitment. The potential out‐of‐area sample was increased to 133 by the addition of 18 children who were now adult and 18 adults newly placed out‐of‐area. However, this figure was reduced to 56 because 33 had moved to placements within the research territory, 18 were placed within the 10 mile exclusion zone, 11 could not be traced, 7 had died or were too ill to take part, 4 were considered not to have an ID or challenging behaviour, 2 were no longer funded by an authority within the territory, 1 had only just started residential college and 1 was deemed too vulnerable to take part by the local authority's protection of vulnerable adults team.</p> <p>People in the final potential sample or their personal consultees, in the case of people who did not have mental capacity, were informed about the study and asked to go through a consent procedure. At this point, three people with ID decided not to take part. One person with ID who agreed to the consent procedure subsequently refused consent. In addition, 14 people did not take part either because their personal consultee did not consent or the setting where they were living did not think they should take part. Twenty people with ID gave their consent. Eighteen personal consultees agreed to the identified person with ID taking part. This resulted in a final out‐of‐area sample of 38 people.</p> <hd id="AN0084622608-6">In‐area placement group</hd> <p>The in‐area group comprised 38 individuals from the original survey who were in out‐of‐family placements in‐area and who were matched as far as possible on the risk factors for out‐of‐area placement identified by Allen et al. (2007).</p> <hd id="AN0084622608-7">The consent procedure</hd> <p>After provision of a written description of the study, staff or family members were asked whether they thought that the potential participant would be able to understand sufficiently to give informed consent. For 40 of the 76 participants, consent was then sought directly from the individual. For the remainder, agreement was sought from a personal consultee, usually a close family member but in some cases a familiar member of staff, social worker or personal advocate.</p> <p>The consent procedure took place at a pre‐arranged time after staff had had an opportunity to consider the requirements of the study and discuss the possibility of taking part with the person concerned. Prior to gaining the individual's agreement to participate, the researcher introduced herself and explained why she was there and where she was from. Then, using specially prepared information sheets, the researcher described what the study would involve, asking questions throughout the process to ensure that the person understood and could retain the information.</p> <p>There were two versions of the information sheet used in the consent procedure, one in large font with pictures, and one without pictures but still with a clear, accessible format and language. In two cases, the information sheet was adapted following prior consultation with staff. Twenty people from each group were able to complete the consent procedure themselves and all but one agreed to take part in the research. Assent from a personal consultee was obtained for the remaining participants after a similar plain language explanation of the intended research, supported by an information sheet.</p> <hd id="AN0084622608-8">Measurement</hd> <hd id="AN0084622608-9">Participant characteristics</hd> <p>Information was collected on each participant's age, gender and ethnicity. In addition, information was collected on each participant's skills using the Adaptive Behavior Scale – Residential and Community 2nd edition (ABS) (Nihira et al. 1993), challenging behaviour using the Aberrant Behavior Checklist (ABC) (Aman & Singh 1986), social impairment – using the Autism Screening Questionnaire (Howlin 1996) and mental health status using the psychiatric assessment scale for adults with developmental disabilities (PAS‐ADD) checklist (Moss et al. 1998). Information was obtained on placement history, referral pathways and stability of residence and living companions in the preceding 3 years.</p> <hd id="AN0084622608-10">Setting descriptors</hd> <p>The Residential Services Setting Questionnaire (RSSQ) used by Emerson et al. (2000) was completed by interviewing the senior staff of the setting. This covered the size and location and homelikeness of the setting, the number and qualifications of staff and professional input. The mean number of staff hours per resident per week was calculated.</p> <hd id="AN0084622608-11">Resource inputs</hd> <p>Costs were assessed from a societal perspective to include costs to the caregiving agencies, the National Health Service (NHS), local authorities and families of residents. Data were collected on site‐specific staff and non‐staff costs and services provided independently of the residence: external daytime, hospital and community services. Site‐specific costs were collected by the RSSQ and a separate Setting Cost Questionnaire developed by the project team which obtained accounts data from providing agencies. As these costs were often not specific to individual residents, total weekly site costs were divided by the number of residents to provide a mean cost per person. Staff costs for study participants were adjusted based on staff estimates of the distribution of staffing to the individuals concerned. The frequency and extent of individual use of non‐accommodation services and of costs borne by families of residents were assessed using the Client Service Receipt Inventory (Knapp et al. 1992). Off‐site costs paid for by the site were excluded to avoid double counting. Service usage data were translated to cost data using 2008/9 unit costs. Some NHS costs were available for earlier financial years but not for 2008/9. These were uplifted using the NHS Hospital and Community Health index. Unit costs and their sources can be obtained from the authors.</p> <hd id="AN0084622608-12">Quality of care</hd> <p>Working methods were assessed using the Residential Services Working Practices Scale (RSWPS) (Felce et al. 1998), which covers five areas: planning for residents, assessment and teaching, arranging resident activities, supporting resident activities and staff training. For each area, the RSWPS includes a summary four‐point rating. These ratings were dichotomised so that the score signified the existence or non‐existence of the working practice in question. The Group Homes Management Scale (Raynes et al. 1994) was used to assess whether the setting was institutionally or individually oriented in relation to: ‘block treatment’, ‘depersonalisation’, ‘social distance’ and ‘rigidity of routine’. In addition, various aspects of the treatment and management of challenging behaviour were assessed following the approach of Robertson et al. (2005).</p> <hd id="AN0084622608-13">Quality of life outcome</hd> <p>(<reflink idref="bib1" id="ref7">1</reflink>) The degree and independence of individual participation in domestic management was assessed by using the Index of Participation in Domestic Life (Raynes et al. 1994). It has 13 items relating to different domestic tasks and participation is scored on each as 0 indicating no participation, 1 indicating participation with help, or 2 indicating independent participation. (<reflink idref="bib2" id="ref8">2</reflink>) Independence in the community was assessed by using the Community Participation Inventory (Stancliffe & Keane 2000). This gauges the frequency of participation in 18 community events in the previous 3 months and the number of community places used without staff support. (<reflink idref="bib3" id="ref9">3</reflink>) Choice was assessed using the Choice Questionnaire (Stancliffe 1997). (<reflink idref="bib4" id="ref10">4</reflink>) The range and frequency of social and community activities was assessed by using the Index of Community Involvement (Raynes et al. 1994 as modified by Felce et al. 1998). This gauges the frequency of participation in 5 social and 10 community events in the previous month. (<reflink idref="bib5" id="ref11">5</reflink>) The size and nature of the participants' social networks were assessed by using the modified version of the Social Network Map (Emerson et al. 2000). (<reflink idref="bib6" id="ref12">6</reflink>) Sense of social isolation was assessed by the Loneliness Questionnaire (Chadsey‐Rusch et al. 1992). (<reflink idref="bib7" id="ref13">7</reflink>) Health was reflected in selected items from the Health Survey for England used by Emerson et al. (2000) and the Health Care Scale (Stancliffe & Keane 2000), which has a maximum score of 36 indicating better health care. (<reflink idref="bib8" id="ref14">8</reflink>) Participant safety was assessed using the Risks Scale (Emerson et al. 2000) and the Safety Inventory (Stancliffe & Keane 2000). (<reflink idref="bib9" id="ref15">9</reflink>) Lifestyle satisfaction was assessed using the Comprehensive Quality of Life Scale – Intellectual Disability (Cummins 1997) and the Lifestyle Satisfaction Scale (LSS) (Harner & Heal 1992). The former has seven domains and subjective measurement takes account of the importance that individuals attach to each area, as well as their satisfaction with each. It includes pre‐screening for competency to understand and respond to the scale items without response bias. The latter comprises 45 items which assess satisfaction in three areas.</p> <hd id="AN0084622608-14">Data collection</hd> <p>Case managers were asked about commissioning arrangements; service administrators were asked for financial information; service managers were interviewed about settings, staffing, staff training, working methods and routines; individual participants were interviewed for their subjective appraisals of outcome (provided they passed screening for response bias); and paid carers who knew the person well were consulted about objective information on participant characteristics and lifestyle outcome. Some agencies did not allow access to expenditure accounts. Where this was the case, costing was also approached from the perspective of the funding provided by commissioners.</p> <hd id="AN0084622608-15">Analysis</hd> <p>As far as possible, no assumptions of normality were made in testing for group differences as non‐parametric tests (Mann–Whitney U or χ<sups>2</sups>) were generally used. However, there was limited use of analysis of covariance to control for outstanding differences in participant characteristics. Costs were expressed per participant per week. For staff costs, RSSQ data were considered most appropriate as they were built up from the individual staff salaries and hours worked and hence better reflect resources consumed. Where staff hours were recorded on the RSSQ but salaries were not provided (in‐area = 19, out‐of‐area = 1), estimates based on relevant pay scale data were used. Where neither staff hours nor salaries were provided on the RSSQ (in‐area = 1, out‐of‐area = 0), staff costs were imputed using mean staff salaries and places occupied for the relevant group. Setting costs were taken from the Setting Cost Questionnaire. Where these were missing, but local authority or local health board cost data had been provided (in‐area = 2, out‐of‐area = 9), setting costs were determined by splitting these costs by the ratio of direct to indirect staff costs for the relevant area. Where data were missing altogether (in‐area = 4, out‐of‐area = 3), mean costs for the relevant area were imputed. Mean differences in staff and total accommodation costs and in grouped resource variables (daytime activities, hospital and community services) and in total costs were tested using non‐parametric bootstrapping (Efron & Tibshirani 1993) using S Plus software (version 2000) and 10 000 replications. Bootstrapping produces a confidence interval for the difference between the means. The difference between the means is assumed to be significant if the confidence interval does not contain zero.</p> <hd id="AN0084622608-16">Results</hd> <hd id="AN0084622608-17">Participant characteristics</hd> <p>In‐area participants were 23 men and 15 women and out‐of‐area participants were 25 men and 13 women. Mean ages were 46 years and 35 years respectively. All participants were White. The average lengths of time that in‐area and out‐of‐area participants had lived in their current setting were 97 months and 88 months respectively. Twenty‐one per cent of in‐area participants previously lived in group homes, 8% with their families, 61% in hospitals or hostels, and 8% in other forms of accommodation. The corresponding figures for out‐of‐area participants were 24% group homes, 11% family homes, 32% hospitals, 19% residential school or children's home, 3% respite care and 13% other. Three in‐area and eight out‐of‐area participants had had a change of address in the previous three years. Average turnover of living companions in the same period was significantly lower for in‐area participants (3.5) than for out‐of‐area participants (<reflink idref="bib8" id="ref16">8</reflink>) (z = −4.3, P < 0.001).</p> <p>Main reasons for in‐area placement were resettlement from hospital (n = 13), inadequacy of previous accommodation (n = 10) and moving to be closer to family (n = 6). Challenging behaviour was the principal reason for out‐of‐area placements (n = 13). Placement breakdown, moving on from temporary accommodation or residential special schooling, and moving because previous accommodation was inappropriate to need accounted for a further 17 placements.</p> <p>Mean total ABS scores for the in‐area and out‐of‐area groups were 176 and 190, SD 61.8 and 62.1 respectively. The difference was not significant (z = −1.01, P = 0.31) but that should not be taken to imply similarity. The greater ability of the out‐of‐area group is likely to be reflected in higher scores on the objective quality of life indicators (see Felce & Perry 2009). The distribution of the average of the ten ABS domain percentile ranks for each sample was similar (mean in‐area = 50.3, SD = 22.0, range 5.1–94.9; mean out‐of‐area = 56.1, SD = 22.8, range 4.7–91.3). There was a significant difference between groups on level of challenging behaviour; those living out‐of‐area had significantly lower ABC scores (mean in‐area = 35.1, SD = 29.2; mean out‐of‐area = 20.5, SD = 21.2; z = −2.77, P < 0.01). Such differences would be expected to bias the group comparison in favour of lower costs and higher scores on some objective quality of life indicators for the out‐of‐area group (see Felce et al. 2003, 2011). There was no significant difference between groups in the proportion of residents who achieved caseness for symptoms associated with mental illness on the PAS‐ADD checklist (28.9% in‐area and 15.8% out‐of‐area, χ<sups>2</sups> = 0.27, P = 0.14). The proportion of individuals who reached the criterion level associated with autistic spectrum disorders was similar (47.4% in‐area and 44.7% out‐of‐area).</p> <hd id="AN0084622608-18">Setting characteristics</hd> <p>The sample lived in 49 settings: 26 in‐area and 23 out‐of‐area. In‐area settings were significantly smaller (mean number of places 3.5, range = 1–12, SD = 2.21 compared to out‐of‐area mean 8.5, range = 1–24, SD = 6.4; z = −3.0, P < 0.01). Homelikeness ratings did not differ significantly. In‐area settings had significantly higher staffing (mean number of staff hours per resident per week = 134, SD = 92.9 compared to out‐of‐area mean = 56, SD = 35.4; z = −4.43, P < 0.001).</p> <hd id="AN0084622608-19">Costs and service use</hd> <hd id="AN0084622608-20">Costs</hd> <p>Total weekly costs, broken down between those associated with the provision of accommodation and those for use of off‐site day activities and hospital and community services, are shown in Table 1. Total, accommodation and non‐accommodation costs were significantly higher in‐area. This was mainly due to significantly higher direct staff costs (95% CI = £368 to £875) but costs of day activities were also substantially higher. The difference in accommodation costs remained significant even after an analysis of covariance was conducted to control for differences in ABC scores (d.f. = 1, F = 9.75, P < 0.01).</p> <p>1 Mean (SD) weekly costs of in‐area and out‐of‐area placements (£/week)</p> <p> <ephtml> <table><tr><th>Measure</th><th>In‐area</th><th>Out‐of‐area</th><th>Mean difference (95% CI)</th></tr><tr><th>Mean (SD)</th><th>Mean (SD)</th></tr><tr><td>Non‐accommodation costs</td><td>186.5 (173.8)</td><td>113.1 (141.2)</td><td>73.4 (6.0 to 147.5)*</td></tr><tr><td> Daytime activities</td><td>131.7 (152.3)</td><td>65.0 (127.0)</td><td>66.7 (7.2 to 132.7)*</td></tr><tr><td> Hospital‐based services</td><td>12.1 (31.9)</td><td>2.6 (6.7)</td><td>9.5 (3.0 to 28.6)*</td></tr><tr><td> Community‐based services</td><td>42.7 (43.6)</td><td>45.5 (74.3)</td><td>−2.8 (−39.0 to 18.2)</td></tr><tr><td>Accommodation costs</td><td>1689.6 (572.5)</td><td>1278.6 (471.3)</td><td>411.0 (229.9 to 757.0)*</td></tr><tr><td> Direct staffing</td><td>1206.5 (686.4)</td><td>650.4 (307.5)</td><td>556.1 (368.1 to 874.6)*</td></tr><tr><td> Non‐staff inputs (inc. administration and overheads)</td><td>480.1 (402.8)</td><td>628.3 (263.2)</td><td>−148.1 (−293.8 to 8.9)</td></tr><tr><td>Total costs</td><td>1876.1 (591.8)</td><td>1391.8 (462.6)</td><td>484.4 (297.4 to 810.8)*</td></tr></table> </ephtml> </p> <p>1 * Statistically significant.</p> <hd id="AN0084622608-21">Use of off‐site services</hd> <p>The two groups did not differ significantly with respect to day activities except that more in‐area participants attended social clubs than out‐of‐area participants (32% compared to 8%) and attendance at day centres was a more common mode of provision among out‐of‐area participants (51% compared to 34% respectively). However, much out‐of‐area day activities was organised on‐site using accommodation staff. Hence, the additional costs of in‐area day activities were higher, as reported above. Proportions of each group using hospital‐ and community‐based services were broadly similar but higher proportions of in‐area participants received input from psychiatrists and clinical psychologists (χ<sups>2</sups> = 3.62 and 6.97, P < 0.05 and P < 0.01 respectively).</p> <hd id="AN0084622608-22">Visitor costs</hd> <p>Families and friends of participants living out‐of‐area had significantly greater costs when seeing their relatives or friends (mean = £8.3/week, SD = £12.7) than those in‐area (mean = £1.9/week, SD = £3.2; mean difference = −6.7, 95% bootstrapped 95% CI = −11.8 to −3.1).</p> <hd id="AN0084622608-23">Quality of care</hd> <hd id="AN0084622608-24">Working practices and setting management</hd> <p>In‐area and out‐of‐area settings were similar with respect to the majority of practices reflected by the RSWPS and GHMS (Table 2). There were significant differences in relation to the presence of: (<reflink idref="bib1" id="ref17">1</reflink>) procedures for behavioural assessment of residents and writing teaching programmes, and (<reflink idref="bib2" id="ref18">2</reflink>) induction training, regular in‐service training and supervision, which were both more common in in‐area settings. In addition, there was significantly greater staff distance between staff and residents in out‐of‐area settings.</p> <p>2 Working and management practices in in‐area and out‐of‐area placements</p> <p> <ephtml> <table><tr><th>Measure</th><th>In‐area</th><th>Out‐of‐area</th><th>Significance</th></tr><tr><th>Mean %</th><th>Mean %</th></tr><tr><td>Working practices†</td><td /><td /><td /></tr><tr><td> Individual planning</td><td>92</td><td>95</td><td>χ<sup>2</sup> = 0.17 NS</td></tr><tr><td> Behavioural assessment/teaching</td><td>80</td><td>43</td><td>χ<sup>2</sup> = 6.8*</td></tr><tr><td> Planning activities</td><td>60</td><td>77</td><td>χ<sup>2</sup> = 1.61 NS</td></tr><tr><td> Planning staff support</td><td>84</td><td>71</td><td>χ<sup>2</sup> = 1.06 NS</td></tr><tr><td> Staff training/supervision</td><td>100</td><td>65</td><td>χ<sup>2</sup> = 10.8**</td></tr><tr><td>Group Homes Management Scale‡</td><td /><td /><td /></tr><tr><td> Absence of rigid routines</td><td>88</td><td>87</td><td>z = −0.27 NS</td></tr><tr><td> Absence of block treatment</td><td>72</td><td>71</td><td>z = −0.21 NS</td></tr><tr><td> Absence of staff distance</td><td>80</td><td>73</td><td>z = −1.97*</td></tr><tr><td> Absence of depersonalisation</td><td>68</td><td>65</td><td>z = −0.53 NS</td></tr></table> </ephtml> </p> <ulist> <item>2 * P < 0.05, ** P < 0.01.</item> <item>3 † Percentage of settings with established approaches to a range of procedures.</item> <item>4 Group Homes Management Scale mean scores were converted to percentages where higher scores indicated working practices which were individually as opposed to institutionally oriented. The Group Homes Management Scale was not administered in the seven settings with a single resident.</item> <item>5 NS, non‐significant.</item> </ulist> <hd id="AN0084622608-25">Response to challenging behaviour</hd> <p>Setting types did not differ in extent and recency of staff training in managing challenging behaviour, which was almost total in both cases. Table 3 shows the proportion of participants for whom specific types of intervention were ‘usually’ adopted and types of intervention ‘usually’ and ‘sometimes’ used. There were no significant differences with respect to level of response to challenging behaviour or the use of the majority of types of intervention. However, physical restraint was used significantly more in out‐of‐area settings and sedation significantly more in‐area. Use of functional analysis was significantly more common in in‐area settings. Review of medication for mental health problems or challenging behaviour was conducted at least every quarter for significantly more in‐area participants (69% compared to 39%, χ<sups>2</sups> = 3.86, P < 0.05).</p> <p>3 Response to challenging behaviour in in‐area and out‐of‐area placements</p> <p> <ephtml> <table><tr><th>Measure</th><th>In‐area</th><th>Out‐of‐area</th><th>Significance</th></tr><tr><th>Mean %</th><th>Mean %</th></tr><tr><td>Usual intervention</td><td /><td /><td /></tr><tr><td> No intervention, behaviour ceases spontaneously</td><td>8</td><td>8</td><td>χ<sup>2</sup> = 0.001 NS</td></tr><tr><td> No intervention, behaviour is tolerated or accepted</td><td>5</td><td>3</td><td>χ<sup>2</sup> = 0.38 NS</td></tr><tr><td> Ignored as part of an agreed programme</td><td>14</td><td>5</td><td>χ<sup>2</sup> = 1.51 NS</td></tr><tr><td> Verbal response</td><td>62</td><td>76</td><td>χ<sup>2</sup> = 1.77 NS</td></tr><tr><td> Physical intervention – one staff member</td><td>5</td><td>3</td><td>χ<sup>2</sup> = 0.38 NS</td></tr><tr><td> Physical intervention – >one staff member</td><td>3</td><td>3</td><td>χ<sup>2</sup> = 0.00 NS</td></tr><tr><td> Other</td><td>3</td><td>2</td><td>χ<sup>2</sup> = 1.04 NS</td></tr><tr><td>Type of intervention needed ‘usually’ or ‘sometimes’</td><td /><td /><td /></tr><tr><td> Physical restraint</td><td>8</td><td>29</td><td>χ<sup>2</sup> = 5.4*</td></tr><tr><td> Seclusion</td><td>49</td><td>29</td><td>χ<sup>2</sup> = 3.07 NS</td></tr><tr><td> Sedation</td><td>32</td><td>8</td><td>χ<sup>2</sup> = 7.1**</td></tr><tr><td> Other techniques</td><td>79</td><td>61</td><td>χ<sup>2</sup> = 2.54 NS</td></tr><tr><td> Functional analysis</td><td>97</td><td>79</td><td>χ<sup>2</sup> = 5.98*</td></tr><tr><td> Written programmes</td><td>100</td><td>100</td><td>NA</td></tr><tr><td> Medication</td><td>100</td><td>100</td><td>NA</td></tr></table> </ephtml> </p> <ulist> <item>6 * P < 0.05, ** P < 0.01.</item> <item>7 NS, non‐significant; NA, no statistics computed because variable is a constant.</item> </ulist> <hd id="AN0084622608-26">Quality of life outcome</hd> <p>Table 4 shows scores on various objective and subjective quality of life outcome measures. There were no significant differences in household participation or choice. Both groups participated in a similar variety of community activities, although the frequency of participation for those living in‐area was significantly greater (37 compared to 25 per month, z = −3.0, P < 0.01). There were no significant differences between groups on any aspect of the Index of Community Integration or in the composition of social networks. There were non‐significant trends towards more frequent visits to and from family among the in‐area group. Visits from friends occurred significantly more often among in‐area participants (2.8 compared to 0.3, z = −2.12, P < 0.05). Despite an indication of lower reported loneliness in‐area, the difference between the groups was not significant.</p> <p>4 Quality of life outcomes in in‐area and out‐of‐area placements</p> <p> <ephtml> <table><tr><th>Measure</th><th>In‐area</th><th>Out‐of‐area</th><th>Significance</th></tr><tr><th>Mean (SD)</th><th>Mean (SD)</th></tr><tr><td>Participation in domestic life (% max)</td><td>44.3 (21.6)</td><td>40.8 (18.0)</td><td>z = −1.24 NS</td></tr><tr><td>Community Participation Inventory</td><td /><td /><td /></tr><tr><td> Variety of activities (max = 18)</td><td>8.0 (2.5)</td><td>7.6 (4.3)</td><td>z = −0.57 NS</td></tr><tr><td> No. of activities in last month</td><td>37.0 (21.1)</td><td>24.9 (19.7)</td><td>z = −3.0**</td></tr><tr><td> Activities done independently (max = 18)</td><td>0.4 (1.5)</td><td>0.7 (2.3)</td><td>z = −0.76 NS</td></tr><tr><td>Choice Questionnaire</td><td>44.9 (15.2)</td><td>49.2 (14.7)</td><td>z = −1.25 NS</td></tr><tr><td>Index of Community Integration</td><td /><td /><td /></tr><tr><td> Variety of social activities (max = 5)</td><td>1.5 (0.9)</td><td>1.5 (1.3)</td><td>z = −0.37 NS</td></tr><tr><td> No. of social activities in last month</td><td>4.4 (2.9)</td><td>3.8 (3.7)</td><td>z = −1.08 NS</td></tr><tr><td> Variety of community activities (max = 10)</td><td>4.9 (1.7)</td><td>5.1 (3.5)</td><td>z = −0.38 NS</td></tr><tr><td> No. of community activities in last month</td><td>15.1 (6.3)</td><td>12.1 (6.8)</td><td>z = −1.78 NS</td></tr><tr><td>Social networks</td><td /><td /><td /></tr><tr><td> With family members (%)</td><td>78.9</td><td>78.9</td><td>NA</td></tr><tr><td> With friends (%)</td><td>100</td><td>100</td><td>NA</td></tr><tr><td> With friends without intellectual disability (%)</td><td>31.6</td><td>15.8</td><td>χ<sup>2</sup> = 2.05 NS</td></tr><tr><td> Visits to family in last 3 months</td><td>3.9 (6.0)</td><td>1.4 (1.9)</td><td>z = −0.51 NS</td></tr><tr><td> Visits from family in last 3 months</td><td>4.1 (6.4)</td><td>2.0 (3.0)</td><td>z = −0.27 NS</td></tr><tr><td> Visits to friends in last 3 months</td><td>0.4 (1.1)</td><td>0.5 (1.2)</td><td>z = −0.38 NS</td></tr><tr><td> Visits from friends in last 3 months</td><td>2.8 (1.2)</td><td>0.3 (1.1)</td><td>z = −2.12*</td></tr><tr><td>Loneliness scale†</td><td>80.4 (12.8)</td><td>67.3 (27.5)</td><td>z = −1.00 NS</td></tr><tr><td>Body mass index</td><td /><td /><td /></tr><tr><td> Underweight (%)</td><td>5.7</td><td>5.4</td><td>χ<sup>2</sup> = 0.00 NS</td></tr><tr><td> Overweight but not obese (%)</td><td>22.9</td><td>29.7</td><td>χ<sup>2</sup> = 0.44 NS</td></tr><tr><td> Obese (%)</td><td>34.3</td><td>29.7</td><td>χ<sup>2</sup> = 0.17 NS</td></tr><tr><td>Exercise</td><td /><td /><td /></tr><tr><td> Bouts of moderate/vigorous exercise last month</td><td>6.4</td><td>11.5</td><td>z = −2.4*‡</td></tr><tr><td> Proportion inactive (%)§</td><td>86</td><td>60</td><td>χ<sup>2</sup> = 6.17*</td></tr><tr><td>Health checks (% receiving)</td><td /><td /><td /></tr><tr><td> General health check in last year</td><td>97</td><td>89</td><td>χ<sup>2</sup> = 2.02 NS</td></tr><tr><td> Blood pressure check in last year</td><td>100</td><td>100</td><td>NA</td></tr><tr><td> Visited dentist in last year</td><td>94</td><td>92</td><td>χ<sup>2</sup> = 0.11 NS</td></tr><tr><td> Vision check in last 2 years</td><td>63</td><td>90</td><td>χ<sup>2</sup> = 7.3*</td></tr><tr><td> Hearing check in last 2 years</td><td>13</td><td>29</td><td>χ<sup>2</sup> = 2.85 NS</td></tr><tr><td>Health Care Scale (% max)</td><td>91</td><td>92</td><td>z = −0.83 NS</td></tr><tr><td> Health care subtotal</td><td>95</td><td>95</td><td>z = −0.68 NS</td></tr><tr><td> Lifestyle subtotal</td><td>86</td><td>89</td><td>z = −0.66 NS</td></tr><tr><td>Risks (%)</td><td /><td /><td /></tr><tr><td> Perceived to be at risk¶</td><td>74</td><td>71</td><td>χ<sup>2</sup> = 0.07 NS</td></tr><tr><td> Major accident in last year††</td><td>32</td><td>18</td><td>χ<sup>2</sup> = 1.75 NS</td></tr><tr><td> Victim of abuse in last 5 years</td><td>11</td><td>5</td><td>χ<sup>2</sup> = 0.72 NS</td></tr><tr><td> Victim of crime‡‡</td><td>26</td><td>11</td><td>χ<sup>2</sup> = 3.15 NS</td></tr><tr><td>Safety Inventory (% max)§§</td><td>91 (7.7)</td><td>89 (10.5)</td><td>z = −0.53 NS</td></tr></table> </ephtml> </p> <ulist> <item>8 * P < 0.05, ** P < 0.01.</item> <item>9 † n = 19 in‐area, n = 14 out‐of‐area, scores are presented as a percentage of the total possible and reversed so that higher scores indicate lower loneliness.</item> <item>10 Type of placement ceased to be significant when the effect of age was taken into account using a general linear model with age as a covariate (r2 = 0.06, F1,66 = 0.3, P = 0.58).</item> <item>11 Fewer than 12 bouts of moderate or vigorous exercise in the preceding four weeks (see Emerson 2005).</item> <item>12 Risk of accidents, exploitation or abuse.</item> <item>13 Requiring a visit to a casualty unit.</item> <item>14 Since start of residence in current home.</item> <item>15 n = 19 in‐area, n = 16 out‐of‐area.</item> <item>16 NS, non‐significant; NA, no statistics computed because variable is a constant.</item> </ulist> <p>There were no significant differences in the proportions of participants who were underweight, overweight but not obese, or obese. In‐area participants undertook activities involving moderate or vigorous physical exercise significantly less frequently than out‐of‐area participants (mean = 6.4, SD = 9.8 compared to mean = 11.5, SD = 12.0; z = −2.4, P < 0.05). However, type of placement ceased to be significant when the effect of age was taken into account using a general linear model with age as a covariate (r<sups>2</sups> = 0.06, F<subs>1,66</subs> = 0.3, P = 0.58). Using 12 bouts of moderate or vigorous exercise in the preceding 4 weeks as a definition of inactivity (Emerson 2005), significantly more in‐area participants were inactive (86% compared to 60%, χ<sups>2</sups> = 6.17, P < 0.05, control for age not possible because inactivity is a nominal variable).</p> <p>There were no significant differences between setting types in terms of receipt of health‐related services apart from significantly fewer in‐area participants having had a sight test in the previous 2 years (63% compared to 90%, χ<sups>2</sups> = 7.3, P < 0.05). There were no significant differences between the two groups on the Health Care Scale and its subscales. Nor were there significant differences on the Risks Scale or Safety Inventory.</p> <p>None of the 19 in‐area participants and 18 out‐of‐area participants who were able to respond to questions which tested for response bias showed evidence of such bias. However, one in‐area participant chose not to complete the Comprehensive Quality of Life satisfaction scale, and two out‐of‐area participants did not meet other criteria required to complete the assessment. Satisfaction with the seven sub‐domains all approached the scale maximum in both groups. There were no significant between‐group differences. The LSS incorporates a subscale which is designed to assess acquiescence when questions are asked in the format used in the broader scale. The LSS was administered to the same 37 participants. However, seven in‐area participants and six out‐of‐area participants scored above the ‘no‐response bias’ threshold on the LSS acquiescence scale (i.e. the tendency to reply ‘yes’ to questions irrespective of meaning). Among the remainder there were no significant differences between groups on the domain scores relating to home and community and satisfaction with friends, free time, recreation and leisure. (Analysis of the LSS items about employment was not performed because so few of the sample were employed.)</p> <hd id="AN0084622608-27">Discussion</hd> <hd id="AN0084622608-28">Summary of findings and limitations of the study</hd> <p>This was a total population study of adults with ID and challenging behaviour who originated from the territory served by the largest NHS specialist health service in Wales and were placed in residential settings at least 10 miles beyond its boundaries compared to a selected group of similar adults accommodated in out‐of‐family placements in‐area. Both types of placement had advantages and disadvantages making an overall conclusion about cost‐effectiveness not possible. Advantages of in‐area placement were: (<reflink idref="bib1" id="ref19">1</reflink>) settings were smaller; (<reflink idref="bib2" id="ref20">2</reflink>) staffing per person was higher; (<reflink idref="bib3" id="ref21">3</reflink>) staff induction training and regular in‐service training and supervision were more common; (<reflink idref="bib4" id="ref22">4</reflink>) contact from specialist psychiatrists and clinical psychologists was greater; (<reflink idref="bib5" id="ref23">5</reflink>) procedures for behavioural assessment and writing teaching programmes were more common as was functional analysis of challenging behaviour; (<reflink idref="bib6" id="ref24">6</reflink>) staff distance between staff and residents was less; (<reflink idref="bib7" id="ref25">7</reflink>) physical restraint was less frequent; (<reflink idref="bib8" id="ref26">8</reflink>) review of medication prescribed for mental health problems or challenging behaviour was more frequent; (<reflink idref="bib9" id="ref27">9</reflink>) turnover of living companions in the previous 3 years was lower; (<reflink idref="bib10" id="ref28">10</reflink>) attendance at daytime social clubs was more common; (<reflink idref="bib11" id="ref29">11</reflink>) community activities were undertaken more frequently; (<reflink idref="bib12" id="ref30">12</reflink>) visits from friends were more frequent; and (<reflink idref="bib13" id="ref31">13</reflink>) costs of maintaining contact for families and friends were lower. The advantages of out‐of‐area placement were: (<reflink idref="bib1" id="ref32">1</reflink>) total costs were lower; (<reflink idref="bib2" id="ref33">2</reflink>) accommodation costs, daytime activity costs and costs of hospital services were lower; (<reflink idref="bib3" id="ref34">3</reflink>) day centre attendance was more common; (<reflink idref="bib4" id="ref35">4</reflink>) sedation was less frequent; and (<reflink idref="bib5" id="ref36">5</reflink>) more people had had their sight tested in the previous 2 years.</p> <p>These results need to be interpreted with caution because of limitations in the research design. First, it is a study from one area of the UK and we do not know whether its findings are generalisable. Second, despite being a two‐thirds sample of those living significantly out‐of‐area, the achieved sample is smaller than had been anticipated primarily because of the numbers of people who had been moved back into area since the original survey. The resulting small sample size means that there is a greater risk of Type 2 error, namely the failure to identify actual differences between the groups because of a lack of power. Areas where differences were relatively large but non‐significant were: social networks containing friends without ID (in‐area 31.6%, out‐of‐area 15.8%), mean frequency of visits to and from family per month (in‐area 3.9 and 4.1 respectively, out‐of‐area 1.4 and 2.0), score on the loneliness scale (in‐area 80.4%, out‐of‐area 67.3%), the use of seclusion (in‐area 49%, out‐of‐area 29%) and satisfaction with recreational activities (in‐area 31%, out‐of‐area 82%). Some of these differences may have been revealed as significant with a larger sample.</p> <p>Third, evaluation of quality of care, quality of life outcomes and costs is necessarily multifaceted. This inevitably gives rise to the use of multiple statistical tests in examining differences and an increased risk of making Type 1 error (accepting as ‘real’ differences that are not). It is possible to restrict the alpha level to compensate for the number of tests made. However, this runs the risk of exacerbating the risk of Type 2 error and making full allowance for multiple testing may not be justified. Had alpha levels been restricted to below 0.01, a number of differences between the groups would no longer be considered significant. These differences should be treated with caution. However, despite such caution, one could still conclude that out‐of‐area placements were less costly but in‐area placements were associated with a greater number of other advantages.</p> <p>Fourth, as recipients of residential services are not randomised to service model, the nature of provision is likely to reflect their characteristics. This raises the possibility that any difference in outcome found may be due to differences in participant characteristics rather than the consequence of the service model. Hence, the attempt was made to select in‐area participants who were similar to the out‐of‐area group. However, matching in practice was complex and imperfect. Previous research has shown that level of adaptive behaviour and to a lesser extent level of challenging behaviour affect the objective indicators of outcome used in this study, with lower adaptive behaviour and higher challenging behaviour being associated with poorer outcome (see Felce & Perry 2009). In addition, studies that have related resource inputs to service‐user characteristics have generally found that a proportion of the variance in either staffing levels or costs between settings is associated with variation in the adaptive behaviour, challenging behaviour and other characteristics of service users (see Felce et al. 2003). In this study, in‐area participants had non‐significantly lower adaptive behaviour and significantly higher levels of challenging behaviour than out‐of‐area participants. One might have expected the quality differences in favour of in‐area placements to have been more pronounced and cost differences to have been less had matching been more exact.</p> <hd id="AN0084622608-29">Consistency with existing literature</hd> <p>The finding of lower cost in out‐of‐area placements differs from other recent studies and from the general perception that such placements may be associated with high‐cost care packages (see Emerson et al. 2008). Hassiotis et al. (2008) focused on recipients of high‐cost care packages (over £70 000 per annum) and found that expenditure out‐of‐area was higher. However, their results cannot be directly compared to the total population approach taken here as they did not consider the full range of placements. Our study showed that out‐of‐area placements do include low‐cost as well as high‐cost arrangements. For example, two out‐of‐area participants were in adult family placements, which incurred particularly low costs. Pritchard & Roy (2006) also demonstrated that in‐area and out‐of‐area placements span a range of care package costs. They found no difference in the distributions of care package costs for people with severe ID placed in‐area or out‐of‐area but a higher proportion of out‐of‐area costs for people defined as having complex mental health needs tended towards the upper end of the range compared to those accommodated in‐area. One possibility underlying the higher cost of in‐area settings in the current study is that the specialist health service within the territory had developed in‐area provision for adults with complex health needs deemed to require ‘continuing health care’. A higher proportion of the high care package costs associated with these service users may, therefore, have been in the in‐area sample than might be generally typical. Moreover, the fact that the extent of out‐of‐area placement from this territory has reduced in recent years, with more people having been moved back in‐area than new people placed out‐of‐area, gives rise to the additional possibility that average out‐of‐area costs may have been reduced by systematic targeting of people in high‐cost placements for relocation.</p> <p>The higher costs of in‐area settings were associated with higher staff input per participant and smaller group sizes. Findings of higher costs and higher staff input are consistent with previous research that has compared small group homes to larger, more traditional settings and there are grounds for believing that costs may be inversely related to setting size within small scale provision, specifically within the size range 1–5. (Felce & Emerson 2005). Most of the in‐area settings in the present study were within this size range, whereas most of the out‐of‐area settings were larger (mean size = 8.5).</p> <p>That aspects of the quality of care and quality of life outcome were superior for in‐area participants is consistent with previous research that has compared small, staffed community housing with larger, more traditional settings. Studies have generally found advantages in material standards, personal development, choice and participation in household and community activities (Emerson & Hatton 1996; Emerson et al. 2000; Felce 2000). However, certain quality of life outcomes have appeared relatively intransigent to change, particularly those concerned with broadening social relationships. Moreover, other outcomes, such as those concerned with risk of abuse or unhealthy lifestyle, have been found to be associated with more independent community living. In general, residential settings are complex environments and research suggests that the relationships between resource inputs, service models, service processes and outcomes are equally complex (Felce & Perry 2009). Therefore, the absence of significant differences across all outcome indicators between the setting types in this study, or even the majority, is not surprising.</p> <p>In‐area settings had higher staffing levels per person and this might be expected to underpin superior outcome. However, part of the complexity referred to above is the general absence of a straightforward link between higher costs or higher staffing and improved quality of life outcome (Felce & Emerson 2005). For example, staffing levels have been variously found to be unrelated to the frequency of community activities, positively related to the frequency of community activities among people with more severe ID and negatively related to the frequency of community activities among people able enough to live with only partial staff support. Moreover, higher staff‐to‐service user ratios have been associated with service users exercising less choice, participating less in the domestic routine of the household and being less independent when using community amenities (Stancliffe 1997; Felce et al. 2000, 2008; Stancliffe & Keane 2000; Robertson et al. 2001).</p> <hd id="AN0084622608-30">Policy implications</hd> <p>One of the key policy objectives set out in the new 3‐year strategy for people with ID in England is that people should have ‘. . . an informed choice about where, and with whom, they live’ (Department of Health 2009, p. 21). A capacity to provide comprehensive local services is a prerequisite for this, because it is only then that a decision to move out‐of‐area would not be enforced by an absence of suitable local provision. A similar position has been recently stated by the Welsh Assembly Government (2007). Findings concerning quality of service delivery and working methods in‐area in this study would suggest that service providers in‐area are as well equipped to meet the needs of this group of people as those out‐of‐area. People with a similar complexity and degree of need as those placed out‐of‐area were being served as well in‐area. The policy to provide comprehensively for those who want to live locally, irrespective of their needs, appears therefore to be attainable. It is not possible to reach a cost‐effectiveness conclusion about the alternative options studied here, but the results indicate that additional resources may be required to provide for those currently placed out‐of‐area. However, that might be justified not only in relation to achieving improved quality of care and quality of life outcomes but also in terms of the ethics of placing vulnerable people away from their home areas and families, through no choice of their own.</p> <ref id="AN0084622608-31"> <title>References</title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext>Allen D. G., Lowe K., Moore K. & Brophy S. ( 2007 ) Predictors, costs and characteristics of out‐of‐area placement for people with intellectual disability and challenging behaviour. Journal of Intellectual Disability Research 51, 409 – 16. </bibtext> </blist> <blist> <bibl id="bib2" idref="ref2" type="bt">2</bibl> <bibtext>Aman M. G. & Singh N. N. ( 1986 ) The Aberrant Behavior Checklist. Slosson Educational Publications, New York. </bibtext> </blist> <blist> <bibl id="bib3" idref="ref3" type="bt">3</bibl> <bibtext>Beadle‐Brown J., Mansell J., Whelton B., Hutchinson A. & Skidmore C. ( 2006 ) People with learning disabilities in ‘out‐of‐area’ residential placements: 2. Resaons for and effects of placement. Journal of Intellectual Disability Research 50, 845 – 56. </bibtext> </blist> <blist> <bibl id="bib4" idref="ref4" type="bt">4</bibl> <bibtext>Beadle‐Brown J., Mansell J., Whelton B. & Hutchinson A. ( 2009 ) People with learning disabilities in ‘out‐of‐area’ residential placements: views of families, managers and specialists. British Journal of Developmental Disabilities 55, 15 – 31. </bibtext> </blist> <blist> <bibl id="bib5" idref="ref11" type="bt">5</bibl> <bibtext>Beecham J. & Knapp M. ( 1992 ) Costing psychiatric interventions. In: Measuring Mental Health Needs (eds G. Thornicroft, C. Brewin & J. Wing ), pp. 163 – 83. Gaskell, London. </bibtext> </blist> <blist> <bibl id="bib6" idref="ref12" type="bt">6</bibl> <bibtext>Chadsey‐Rusch J., Destefano L., O'Reilly M., Gonzalez P. & Collet‐Klingenberg D. ( 1992 ) Assessing the loneliness of workers with mental retardation. Mental Retardation 30, 85 – 92. </bibtext> </blist> <blist> <bibl id="bib7" idref="ref13" type="bt">7</bibl> <bibtext>Cummins R. A. ( 1997 ) The Comprehensive Quality of Life Scale: Intellectual Disability, 5th edn. Deakin University, Melbourne. </bibtext> </blist> <blist> <bibl id="bib8" idref="ref14" type="bt">8</bibl> <bibtext>Department of Health ( 2009 ) Valuing People Now: A New Three‐Year Strategy for People with Learning Disabilities. Department of Health, London. </bibtext> </blist> <blist> <bibl id="bib9" idref="ref15" type="bt">9</bibl> <bibtext>Drummond M., Sculpher M., Torrance G., O'Brien B. & Stoddart G. ( 2005 ) Methods for the Economic Evaluation of Programmes in Health Care, 3rd edn. Oxford University Press, Oxford. </bibtext> </blist> <blist> <bibl id="bib10" idref="ref28" type="bt">10</bibl> <bibtext>Efron B. & Tibshirani R. ( 1993 ) An Introduction to the Bootstrap. Chapman and Hall, New York. </bibtext> </blist> <blist> <bibl id="bib11" idref="ref29" type="bt">11</bibl> <bibtext>Emerson E. ( 2005 ) Underweight, obesity and exercise among adults with intellectual disabilities in supported accommodation in Northern England. Journal of Intellectual Disability Research 49, 134 – 43. </bibtext> </blist> <blist> <bibl id="bib12" idref="ref30" type="bt">12</bibl> <bibtext>Emerson E. & Hatton C. ( 1996 ) Deinstitutionalization in the UK and Ireland: outcomes for service users. Journal of Intellectual & Developmental Disability 21, 17 – 37. </bibtext> </blist> <blist> <bibl id="bib13" idref="ref31" type="bt">13</bibl> <bibtext>Emerson E., Robertson J., Gregory N., Hatton C., Kessissoglou S., Hallam A. et al. ( 2000 ) Quality and costs of community‐based residential supports, village communities, and residential campuses in the UK. American Journal of Mental Retardation 105, 81 – 102. </bibtext> </blist> <blist> <bibl id="bib14" type="bt">14</bibl> <bibtext>Emerson E., Robertson J., Dorr H., Russell P., Spencer K., Davies I. et al. ( 2008 ) Commissioning Person‐Centred, Cost‐Effective, Local Support for People with Learning Disabilities. Social Care Institute for Excellence, London. </bibtext> </blist> <blist> <bibl id="bib15" type="bt">15</bibl> <bibtext>Felce D. ( 2000 ) Quality of Life in Supported Housing in the Community: A Review of Research. Centre for Evidence‐based Social Care, University of Exeter, Exeter. </bibtext> </blist> <blist> <bibl id="bib16" type="bt">16</bibl> <bibtext>Felce D. & Emerson E. ( 2005 ) Community living: costs, outcomes and economies of scale. Findings from UK research. In: Costs and Outcomes of Community Services for People with Intellectual Disabilities (eds R. Stancliffe & C. Lakin ), pp. 45 – 62. Paul H Brookes Publishing Co., Baltimore. </bibtext> </blist> <blist> <bibl id="bib17" type="bt">17</bibl> <bibtext>Felce D. & Perry J. ( 2009 ) Living with support in the community: factors associated with quality‐of‐life outcome. In: Handbook of Developmental Disabilities (eds S. L. Odom, R. H. Horner, M. E. Snell & J. Blacher ), pp. 410 – 28. Guilford Press, New York. </bibtext> </blist> <blist> <bibl id="bib18" type="bt">18</bibl> <bibtext>Felce D., Lowe K., Perry J., Jones E., Hallam A. & Beecham J. ( 1998 ) Service support to people with severe intellectual disabilities and the most severe challenging behaviours in Wales: processes, outcomes and costs. Journal of Intellectual Disability Research 42, 390 – 408. </bibtext> </blist> <blist> <bibl id="bib19" type="bt">19</bibl> <bibtext>Felce D., Lowe K., Beecham J. & Hallam A. ( 2000 ) Exploring the relationships between costs and quality of services for adults with severe intellectual disabilities and the most severe challenging behaviours in Wales: a multivariate regression analysis. Journal of Intellectual and Developmental Disability 25, 307 – 26. </bibtext> </blist> <blist> <bibl id="bib20" type="bt">20</bibl> <bibtext>Felce D., Jones E., Lowe K. & Perry J. ( 2003 ) Rational resourcing and productivity: relationships among staff input, resident characteristics and group home quality. American Journal on Mental Retardation 108, 161 – 72. </bibtext> </blist> <blist> <bibl id="bib21" type="bt">21</bibl> <bibtext>Felce D., Perry J., Romeo R., Robertson J., Meek A., Emerson E. et al. ( 2008 ) Outcomes and costs of community living: semi‐independent living and fully staffed group homes. American Journal of Mental Retardation 113, 87 – 101. </bibtext> </blist> <blist> <bibl id="bib22" type="bt">22</bibl> <bibtext>Felce D., Perry J., Lowe K. & Jones E. ( 2011 ) The impact of autism or severe challenging behaviour on lifestyle outcome in community housing. Journal of Applied Research in Intellectual Disabilities 24, 1 – 17. </bibtext> </blist> <blist> <bibl id="bib23" type="bt">23</bibl> <bibtext>Goodman N., Nix J. & Ritchie F. ( 2006 ) Out of area, out of sight: review of out‐of‐area placement arrangements made by social services and health for people with learning disabilities from the West Midlands. Tizard Learning Disability Review 11, 35 – 43. </bibtext> </blist> <blist> <bibl id="bib24" type="bt">24</bibl> <bibtext>Harner C. J. & Heal L. W. ( 1992 ) The Multifaceted Lifestyle Satisfaction Scale (MLSS): psychometric properties of an interview schedule for assessing personal satisfaction of adults with limited intelligence. Research in Developmental Disabilities 14, 221 – 36. </bibtext> </blist> <blist> <bibl id="bib25" type="bt">25</bibl> <bibtext>Hassiotis A., Parkes C., Jones L., Fitzgerald B. & Romeo R. ( 2008 ) Individual characteristics and service expenditure on challenging behaviour for adults with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities 21, 438 – 45. </bibtext> </blist> <blist> <bibl id="bib26" type="bt">26</bibl> <bibtext>Howlin P. ( 1996 ) Autism Screening Questionnaire. St George's Medical School, London. </bibtext> </blist> <blist> <bibl id="bib27" type="bt">27</bibl> <bibtext>Knapp M., Cambridge P., Thomason C., Beecham J., Allen C. & Darton R. ( 1992 ) Care in the Community: Challenge and Demonstration. Ashgate, Aldershot. </bibtext> </blist> <blist> <bibl id="bib28" type="bt">28</bibl> <bibtext>Lowe K., Allen D., Jones E., Brophy S., Moore K. & James W. ( 2007 ) Challenging behaviours: prevalence and topographies. Journal of Intellectual Disability Research 51, 625 – 36. </bibtext> </blist> <blist> <bibl id="bib29" type="bt">29</bibl> <bibtext>Moss S. C., Prosser H., Costello H., Simpson N., Patel P., Rowe S. et al. ( 1998 ) Reliability and validity of the PAS‐ADD Checklist for detecting psychiatric disorders in adults with intellectual disabilities. Journal of Intellectual Disability Research 42, 173 – 83. </bibtext> </blist> <blist> <bibl id="bib30" type="bt">30</bibl> <bibtext>Nihira K., Leland H. & Lambert N. ( 1993 ) AAMR Adaptive Behaviour Scale – Residential and Community, 2nd edn. Pro‐Ed, Austin, TX. </bibtext> </blist> <blist> <bibl id="bib31" type="bt">31</bibl> <bibtext>Pritchard A. & Roy A. ( 2006 ) Reversing the export of people with learning disabilities and complex health needs. British Journal of Learning Disabilities 34, 88 – 93. </bibtext> </blist> <blist> <bibl id="bib32" type="bt">32</bibl> <bibtext>Raynes N., Wright K., Shiell A. & Pettipher C. ( 1994 ) The Cost and Quality of Community Residential Care. David Fulton, London. </bibtext> </blist> <blist> <bibl id="bib33" type="bt">33</bibl> <bibtext>Robertson J., Emerson E., Hatton C., Gregory N., Kessissoglou S., Hallam A. et al. ( 2001 ) Environmental opportunities and supports for exercising self‐determination in community‐based residential settings. Research in Developmental Disabilities 22, 486 – 502. </bibtext> </blist> <blist> <bibl id="bib34" type="bt">34</bibl> <bibtext>Robertson J., Emerson E., Pinkney L., Caesar E., Felce D., Meek A. et al. ( 2005 ) Treatment and management of challenging behaviours in congregate and non‐congregate community‐based supported accommodation. Journal of Intellectual Disability Research 49, 63 – 72. </bibtext> </blist> <blist> <bibl id="bib35" type="bt">35</bibl> <bibtext>Schalock R. & Felce D. ( 2004 ) Quality of life and subjective well‐being; Conceptual and measurement issues. In: International Handbook of Applied Research in Intellectual Disabilities (eds E. Emerson, C. Hatton, T. Thompson & T. Parmenter ), pp. 261 – 79. Wiley, Chichester. </bibtext> </blist> <blist> <bibl id="bib36" type="bt">36</bibl> <bibtext>Schalock R. L., Brown I., Brown R., Cummins R. A., Felce D., Matikka L. et al. ( 2002 ) Conceptualization, measurement, and application of quality of life for persons with intellectual disabilities: report of an international panel of experts. Mental Retardation 40, 457 – 70. </bibtext> </blist> <blist> <bibl id="bib37" type="bt">37</bibl> <bibtext>Stancliffe R. ( 1997 ) Community living‐unit size, staff presence, and residents' choice‐making. Mental Retardation 35, 1 – 9. </bibtext> </blist> <blist> <bibl id="bib38" type="bt">38</bibl> <bibtext>Stancliffe R. & Keane S. ( 2000 ) Outcomes and costs of community living: a matched comparison of group homes and semi‐independent living. Journal of Intellectual and Developmental Disability 25, 281 – 305. </bibtext> </blist> <blist> <bibl id="bib39" type="bt">39</bibl> <bibtext>Welsh Assembly Government ( 2007 ) Statement of Policy and Practice for Adults with a Learning Disability. Welsh Assembly Government, Cardiff. </bibtext> </blist> </ref> <p>Graph: 1 Recruitment of out‐of‐area sample.</p> <p>Graph: image%5fn/jir1558%5ff1.gif</p> <aug> <p>By J. Perry; D. G. Allen; C. Pimm; A. Meek; K. Lowe; S. Groves; D. Cohen and D. Felce</p> </aug>
Header DbId: eric
DbLabel: ERIC
An: EJ1012862
AccessLevel: 3
PubType: Academic Journal
PubTypeId: academicJournal
PreciseRelevancyScore: 0
IllustrationInfo
Items – Name: Title
  Label: Title
  Group: Ti
  Data: Adults with Intellectual Disabilities and Challenging Behaviour: The Costs and Outcomes of In- and Out-of-Area Placements
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Perry%2C+J%2E%22">Perry, J.</searchLink><br /><searchLink fieldCode="AR" term="%22Allen%2C+D%2E+G%2E%22">Allen, D. G.</searchLink><br /><searchLink fieldCode="AR" term="%22Pimm%2C+C%2E%22">Pimm, C.</searchLink><br /><searchLink fieldCode="AR" term="%22Meek%2C+A%2E%22">Meek, A.</searchLink><br /><searchLink fieldCode="AR" term="%22Lowe%2C+K%2E%22">Lowe, K.</searchLink><br /><searchLink fieldCode="AR" term="%22Groves%2C+S%2E%22">Groves, S.</searchLink><br /><searchLink fieldCode="AR" term="%22Cohen%2C+D%2E%22">Cohen, D.</searchLink><br /><searchLink fieldCode="AR" term="%22Felce%2C+D%2E%22">Felce, D.</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Journal+of+Intellectual+Disability+Research%22"><i>Journal of Intellectual Disability Research</i></searchLink>. Feb 2013 57(2):139-152.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: Wiley-Blackwell. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8598; Fax: 781-388-8232; e-mail: cs-journals@wiley.com; Web site: http://www.wiley.com/WileyCDA/
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 14
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2013
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Adults%22">Adults</searchLink><br /><searchLink fieldCode="DE" term="%22Late+Adolescents%22">Late Adolescents</searchLink><br /><searchLink fieldCode="DE" term="%22Comparative+Analysis%22">Comparative Analysis</searchLink><br /><searchLink fieldCode="DE" term="%22Placement%22">Placement</searchLink><br /><searchLink fieldCode="DE" term="%22Risk%22">Risk</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Services%22">Health Services</searchLink><br /><searchLink fieldCode="DE" term="%22Costs%22">Costs</searchLink><br /><searchLink fieldCode="DE" term="%22Individual+Needs%22">Individual Needs</searchLink><br /><searchLink fieldCode="DE" term="%22Quality+of+Life%22">Quality of Life</searchLink><br /><searchLink fieldCode="DE" term="%22Outcomes+of+Treatment%22">Outcomes of Treatment</searchLink><br /><searchLink fieldCode="DE" term="%22Housing%22">Housing</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Retardation%22">Mental Retardation</searchLink><br /><searchLink fieldCode="DE" term="%22Federal+Legislation%22">Federal Legislation</searchLink><br /><searchLink fieldCode="DE" term="%22Measures+%28Individuals%29%22">Measures (Individuals)</searchLink><br /><searchLink fieldCode="DE" term="%22Rating+Scales%22">Rating Scales</searchLink><br /><searchLink fieldCode="DE" term="%22Group+Homes%22">Group Homes</searchLink><br /><searchLink fieldCode="DE" term="%22Psychological+Patterns%22">Psychological Patterns</searchLink><br /><searchLink fieldCode="DE" term="%22Questionnaires%22">Questionnaires</searchLink><br /><searchLink fieldCode="DE" term="%22Individual+Characteristics%22">Individual Characteristics</searchLink><br /><searchLink fieldCode="DE" term="%22Tables+%28Data%29%22">Tables (Data)</searchLink><br /><searchLink fieldCode="DE" term="%22Residential+Programs%22">Residential Programs</searchLink><br /><searchLink fieldCode="DE" term="%22Residential+Care%22">Residential Care</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22United+Kingdom+%28Wales%29%22">United Kingdom (Wales)</searchLink>
– Name: SubjectThesaurus
  Label: Assessment and Survey Identifiers
  Group: Su
  Data: <searchLink fieldCode="SU" term="%22Adaptive+Behavior+Scale%22">Adaptive Behavior Scale</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1111/j.1365-2788.2012.01558.x
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0964-2633
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Background: People with severe challenging behaviour are vulnerable to exclusion from local services and removal to out-of-area placements if locally available supported accommodation is insufficient to meet their needs. There are concerns about the high costs and potentially poorer outcomes of out-of-area placements but relatively little is known about how costs and outcomes compare with provision for a similar population placed locally. Methods: Costs, quality of care and a wide range of quality of life outcomes for 38 people with intellectual disabilities and challenging behaviour living in-area and 38 similar people living out-of-area were compared. The two groups were matched as far as possible on risk factors for out-of-area placement. The out-of-area group represented two-thirds of the total number of people who originated from the territory served by the largest specialist health service in Wales and were placed in residential settings at least 10 miles beyond its boundaries. Results: There was a mixed pattern of quality of care and quality of outcome advantages between the two types of setting, although in-area placements had a greater number of advantages than out-of-area placements. Unexpectedly, out-of-area placements had lower total costs, accommodation costs and daytime activity costs. Conclusions: No overall conclusion could be reached about cost-effectiveness. A number of potential reasons for the differences in cost were identified. Although additional resources may be needed to provide in-area services for those currently placed out-of-area, government policy to provide comprehensively for those who want to live locally, irrespective of their needs, appears to be attainable. (Contains 4 tables.)
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: Ref
  Label: Number of References
  Group: RefInfo
  Data: 39
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2014
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1012862
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1012862
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1111/j.1365-2788.2012.01558.x
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 14
        StartPage: 139
    Subjects:
      – SubjectFull: Foreign Countries
        Type: general
      – SubjectFull: Adults
        Type: general
      – SubjectFull: Late Adolescents
        Type: general
      – SubjectFull: Comparative Analysis
        Type: general
      – SubjectFull: Placement
        Type: general
      – SubjectFull: Risk
        Type: general
      – SubjectFull: Health Services
        Type: general
      – SubjectFull: Costs
        Type: general
      – SubjectFull: Individual Needs
        Type: general
      – SubjectFull: Quality of Life
        Type: general
      – SubjectFull: Outcomes of Treatment
        Type: general
      – SubjectFull: Housing
        Type: general
      – SubjectFull: Mental Retardation
        Type: general
      – SubjectFull: Federal Legislation
        Type: general
      – SubjectFull: Measures (Individuals)
        Type: general
      – SubjectFull: Rating Scales
        Type: general
      – SubjectFull: Group Homes
        Type: general
      – SubjectFull: Psychological Patterns
        Type: general
      – SubjectFull: Questionnaires
        Type: general
      – SubjectFull: Individual Characteristics
        Type: general
      – SubjectFull: Tables (Data)
        Type: general
      – SubjectFull: Residential Programs
        Type: general
      – SubjectFull: Residential Care
        Type: general
      – SubjectFull: United Kingdom (Wales)
        Type: general
      – SubjectFull: Adaptive Behavior Scale
        Type: general
    Titles:
      – TitleFull: Adults with Intellectual Disabilities and Challenging Behaviour: The Costs and Outcomes of In- and Out-of-Area Placements
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Perry, J.
      – PersonEntity:
          Name:
            NameFull: Allen, D. G.
      – PersonEntity:
          Name:
            NameFull: Pimm, C.
      – PersonEntity:
          Name:
            NameFull: Meek, A.
      – PersonEntity:
          Name:
            NameFull: Lowe, K.
      – PersonEntity:
          Name:
            NameFull: Groves, S.
      – PersonEntity:
          Name:
            NameFull: Cohen, D.
      – PersonEntity:
          Name:
            NameFull: Felce, D.
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 02
              Type: published
              Y: 2013
          Identifiers:
            – Type: issn-print
              Value: 0964-2633
          Numbering:
            – Type: volume
              Value: 57
            – Type: issue
              Value: 2
          Titles:
            – TitleFull: Journal of Intellectual Disability Research
              Type: main
ResultId 1