Older people want to live at home for as long as possible and expect a system of care to enable this. This desire is also recognized in many national policies, where ageing in place with the support of informal caregivers is increasingly seen as a viable solution to institutional care. Despite this, refusal of such care at point of delivery can create further health issues for individuals as well as organizational challenges for care providers. This study aims to explore older people’s perceptions of why homecare is, or may be, refused. It builds on a quantitative study, where 18 per cent of instances of non-delivery of homecare in one major care provider in Scotland were categorized as ‘Service Refusal’. Data from a convenience sample of 17 people, aged 65 years and older, with experience of homecare, from the Greater Glasgow and Clyde area in Scotland, underwent framework analysis. In contrast to the quantitative study, this study uncovered an unexpected propensity for service acceptance; living at home was the presiding value and the main motivating factor to accept homecare, irrespective of its quality. This study provides a deeper understanding of the complexities of homecare from those who receive it, highlighting critical insights to inform governmental initiatives and homecare service providers. Allowing people to remain at home for as long as possible with appropriate and sustainable homecare should be central to national outcomes in Scotland, with the findings of this study also providing useful insights for homecare providers internationally.

As the population ages and the prevalence of dementia increases, caring for a relative living at home with dementia has become a reality for many families worldwide. Studies have shown that families are confronted with diverse difficulties as they try to address the challenges involved in providing care. By understanding how they manage daily life, formal service providers become better equipped to meet the diverse needs of these families. Learning how families live with memory loss and cognitive changes calls for an understanding of the shared context surrounding the person, including the collective of people, and their connections. With the research method of ethnographic case study, we followed eight families living at home with dementia for two years. All participants had been placed on a waiting list for a specialised dementia day care programme. The analysis presented here is based on three cases which reflect widely different experiences and situations. We describe how these families dealt with their daily living at home, if and how they made use of the formal support available and what approaches they found helpful for improving their lives. The results show how the persons living with dementia and their care-givers drew on the collective of their backgrounds, surroundings and available support. With diverse arrangements, families tried to find ways to make their daily lives work out. But constant re-arrangement was necessary. This knowledge could be a central learning point for formal service to build on. While systematic or routine procedures in service provision can be helpful, time and space must be provided for professionals to understand families' different practices, so that they can provide family-centred support.

UK policy discourse presents technology as a solution to challenges facing care services, including issues of quality and the mismatch between care workforce supply and demand. This discourse characterises technology as ‘transformative’, homogenous and wholly positive for care delivery, eliding the diversity of digital devices and systems and their varied uses. Our paper draws on data gathered through 34 interviews with care sector stakeholders and four in-depth case studies of UK homecare providers to comparatively analyse ‘storylines’ of technological solutions expressed by policy (macro-level), sector stakeholders (meso-level) and homecare managers and care workers (micro-level) alongside enacted experiences of technology-in-use. The ‘storylines’ presented by care sector stakeholders and homecare managers converged with those of the policy discourse, emphasising technology’s capacity to enhance quality and efficiency. Our case studies however highlighted several implications for care work and organisational practice in homecare provision: the technologies we observed sometimes produced additional tasks and responsibilities, undermining the efficiency and quality storylines. The experiences of care providers and workers engaging with technologies in homecare warrant further investigation and greater prominence to challenge a discourse which is at times overly simplistic and optimistic.

Little is known about risk management in homecare for people with dementia. We aimed to gain an understanding of the ways in which homecare workers assess and manage risk whilst caring for people with dementia in their own homes. We conducted a qualitative interview study with 17 homecare workers assisting people with dementia with their personal care. Interviews were face-to-face, semi-structured, recorded and transcribed verbatim. Analysis was inductive and thematic. A key theme of risk was identified, with three main sources: the client as a source of risk to the homecare worker, the clients' home and behaviours as a risk to the client, and the wider health and social care system as a risk to both clients and homecare workers. Three interrelated aspects of risk were found to influence homecare workers' decision making and actions: homecare workers' perception of the level of risk, their perceived ability to control the risk and their tolerability of risk. The higher the perceived risk, the stronger the action taken by the worker or agency to mitigate it and the greater the impact on the client. To support effective development of this workforce there is a need to devise training that incorporates the use of tacit knowledge and experiential learning. Risk management policies for homecare should acknowledge and utilise the expertise, experiences and values of homecare workers.

Being dependent on homecare potentially threatens a person's integrity and autonomy, particularly when people are dependent on help to manage basic bodily functions that involve intimacy and nudity, making the person vulnerable despite being in his or her own home. As the population continues to age and live longer, more people are expected to be dependent on homecare. The aim of this study was to investigate the phenomenon of dependence on homecare among people ageing at home. Individual in-depth interviews were used to explore 15 Danish and Norwegian homecare receivers’ experiences of dependence on homecare. Interview records were transcribed and analysed in a hermeneutical phenomenological process described by van Manen. First and foremost, the experience of dependence on homecare is a question of adaption. The older people in this study struggled to get used to their deteriorating body and at the same time they continuously had to negotiate to get care in accordance with their values. Being dependent on care could be experienced as being reduced to a task or a problem to be solved though the participants had a significant need for undivided mental attention. The presence of homecare staff in the participants’ homes could entail a change where the participants experienced that they lost control over the surroundings. According to the voices of the older people in this study, future homecare should be accommodated in an organisational set-up that gives priority to stability and continuity in the relation between the homecare receiver and the homecare staff. Also it is significant that homecare staff do not have a task-oriented approach to their job and are sensitive to the values of the homecare receivers.

In the context of demographic aging, preventing autonomy loss is a major issue. Adapting care systems to help keep seniors at home is a daily challenge. “La Mutualité Française”, a national mutual insurance company, has implemented in one of its healthcare services an innovative program to strengthen well-being: “The Well-Being Autonomy Pole.” This program comprises five Prevention and Support Care components and hypothesizes that strengthening the well-being of elderly people already suffering from physical limitations would prevent their autonomy decline. The originality of this program is its focus on elderly people who have rarely been studied in terms of preventing autonomy loss, given their existing functional limitations. A first evaluation was carried out over three months to verify the methodological feasibility of an impact assessment and to provide preliminary results on the effectiveness of the program. Key findings suggest improved levels of self-esteem, physical well-being, psychological autonomy and decreased anxiety. Methodological limitations of this first feasibility assessment and perspectives for future research are discussed.

This article presents the results of a qualitative study on the contributions made by volunteers from a volunteer community organization to the home care of older adults living in a rural setting. In this study, the volunteer was considered as part of a social care system made up of a number of groups (the elderly themselves, those close to them, professional health providers, and volunteers). Results show that the lines delimiting the responsibilities of these various groups are neither clear nor precise. The place of the volunteer must take into account the nature of the participation of the other groups. How far the services offered by volunteers are used depends upon the characteristics that define their contributions and on the type of relationship they develop with a given older adult.

In 1999 Veterans Affairs Canada (VAC) implemented the Overseas Service Veterans (OSV) At Home Pilot Project in response to the problem that a growing number of clients were on waiting lists for beds in long-term care facilities. The At Home pilot offered certain clients on waiting lists, who met nursing-level care and military-service requirements, access to home care and treatment services for which they had previously been ineligible. A review of the pilot showed that a large majority of clients preferred to remain at home, with support, rather than accept a long-term care placement, even when a bed became available. The pilot has helped reduce waiting times for nursing home beds and may have important implications for reducing costs and the demand for long-term care beds.

This article describes and evaluates cash-for-care programmes for older people in four European countries, namely Home-Care Grants in Ireland, Direct Payments in the United Kingdom (England), Service Vouchers in Finland and Personal Budgets in The Netherlands. The purpose is to raise understanding of the background and reasons for the introduction of cash-for-care programmes and their impact on the countries' care regimes. It is argued that while the motives for introducing cash-for-care programmes in the four countries are similar, namely to promote choice and autonomy, to plug gaps in existing provision, to create jobs, and to promote efficiency, cost savings and domiciliary care, the relative importance of these goals varies. Current cash-for-care programmes have comparatively modest coverage as compared with direct service provision and provide no more than an optional, supplementary source of care in three of the studied countries. Cash-for-care schemes have not radically transformed the care regimes in Finland, The Netherlands or the United Kingdom. In Ireland, however, the restricted availability of alternative forms of formal service provision means that the expansion of cash-for-care might shift care provision significantly towards private provision and financing.