The Effectiveness of the Older Prisoner Health and Social Care Assessment and Plan (OHSCAP): A Randomised Controlled Trial.

Background: The number of older prisoners is increasing rapidly (Cooney & Braggins, 2010). Between 2000 and 2010, the percentage of older prisoners in the UK increased by a striking 128% (Prison Reform Trust, 2011). Older prisoners have complex health and social needs (Fazel et al., 2001) which often remain unmet (Fazel et al., 2004). Older prisoner care is currently routinely uncoordinated. In a previous study (SDO 08/1809/230), the research team developed the Older prisoner Health and Social Care Assessment and Plan (OHSCAP) to systematically identify and address the health and social care needs of older prisoners, through better assessment, care planning and subsequent service delivery. This will result in a reduction in health and social care needs and improvements in health symptoms and social care problems. The intervention: The OHSCAP is a structured approach for better identification and management of the health and social care needs of older prisoners. It is a paper based tool consisting of an assessment, subsequent care planning and reviews. It is conducted by the Older Prisoner Lead (OPL, a prison officer). The information gathered in OHSCAP and subsequent care planning are shared across prison and healthcare departments via previously established computerised systems. Treatment as usual (TAU): TAU includes the standard non age- specific reception health assessment (Grubin et al. 2002) with further assessment and intervention following local procedures at each establishment. Identification of health and social needs, and care planning is generally inadequate (Shaw et al., 2009). Research Questions: 1. Does use of the OHSCAP, compared with treatment as usual, improve: a. proportion of met health and social care needs b. health related quality of life c. depression d. functional health and wellbeing and activities of daily living e. quality of health and social care planning f. cost effectiveness 2. What are the facilitators and barriers to the implementation and operation of the OHSCAP? Design: The research programme involves mixed methods and is divided into five key parts. Part 1: Training on the delivery of the intervention The OPLs at each of the four prisons will be provided with a one day training session on the delivery of the OHSCAP. Part 2: Randomised Controlled Trial Recruitment: We will seek informed consent from 504 men aged 50 and over, newly received into one of the four identified prisons if their known release date (convicted) or likely release date (unconvicted), is at least three months after their prison entry date. Release dates for unconvicted prisoners will be predicted using an algorithm developed for a previous study (Shaw et al., 2008). Randomisation will be undertaken by the Clinical Trials Unit. Participants will be randomised to receive the OHSCAP or TAU. The following outcome measures will be used at baseline and three months after prison entry. Primary outcome measure: The mean number of unmet health and social care needs at three months as measured by The Camberwell Assessment of Need Short Forensic Version (CANFOR-S) (Thomas et al., 2003) Secondary outcome measures: 1. Functional health and wellbeing and activities of daily as measured by The SF-36 (Ware et al., 1993) 2. Depression as measured by The Geriatric Depression Scale Short form (Sheikh & Yesavage, 1986) 3. Appropriate health and service usage as measured by The Client Service Receipt Inventory (CSRI; Beecham et al., 1992); 4. Health related quality of life as measured by The EQ-5D (Dolan et al., 1995) Analysis: The primary outcome will be analysed with a Mann-Whitney U test. A sensitivity analysis will be undertaken using the data for all randomised cases by assuming no change in the number of unmet needs from baseline for cases without the three month data. A regression analysis will be used to adjust for baseline characteristics. Similar approaches will be adopted for the secondary outcomes with the details depending on the distribution of the particular outcome. Part 3: Audit of care plans The care plans produced by the OPLs, in conjunction with the older prisoners, will be reviewed by two members of the research team using a bespoke proforma designed to assess the quality of the care planning. The team have developed similar proformas for other studies (Rahman et al., in preparation; Shaw et al., 2006). Descriptive statistics will be used to describe the type of referrals made and actions taken and quality of planning. Part 4: Qualitative interviews with prisoners and staff involved in the OHSCAP Semi-structured interviews will take place with prisoners who received the OHSCAP at three month follow-up, to gain an understanding of the barriers and facilitators to the intervention (aprox.30). A purposive sample of participants with a range of sentence length, offences and health status will be used. In addition, semi-structured interviews with the four OPLs will take place to understand and evaluate the OHSCAP process in practice. All interviews will be analysed thematically. A number of themes will be generated using aspects of constant comparative methods (Glaser, 1965) within the computer software NVivo (QSR International Pty Ltd., 2008). Part 5: Cost-effectiveness analysis The economic analysis will estimate the incremental cost-effectiveness of the OHSCAP compared to TAU to evaluate whether its implementation would likely represent a cost-effective use of resources at standard UK threshold values for health care. Resource utilisation will be collected using a combination of medical note review and patient questionnaire administered during the follow-up assessments. This patient questionnaire will be developed de novo from the annotated cost questionnaire (Thompson & Wordsworth, 2010). The effectiveness of the intervention will be assessed using the CANFOR-S and EQ-5D outcome measures. The incremental cost-effectiveness ratio per quality-adjusted life year gained, cost-effectiveness acceptability curves and net benefit statistics of the OHSCAP compared to TAU will be estimated.