Service support to people in Wales with severe intellectual disability and the most severe challenging behaviours: processes, outcomes and costs.
Small community homes give better lives and lower costs for adults with severe ID and challenging behavior, but extra spending inside the same setting does not boost results.
01Research in Context
What this study did
Clarke et al. (1998) tracked adults in Wales who had severe intellectual disability and the most dangerous challenging behavior. They compared three living setups: small staffed houses in the community, ordinary family homes with light support, and traditional hospital-style units.
The team looked at process scores, quality-of-life signs, and costs for each setting.
What they found
Community houses beat the other two options on almost every measure. Family homes did better than hospital units but not as well as community houses.
Spending more money inside the same setting type did not create better results.
How this fits with other research
Shearn et al. (1997) saw the same pattern one year earlier in Northern Ireland: community care cost less than hospitals, yet higher spending inside community care did not lift outcomes.
Lakin et al. (2008) repeated the cost finding in US Medicaid data. HCBS cost about half of ICF/MR per person per year, matching the Welsh savings.
Coffey et al. (2020) and Jessel et al. (2018) show how to cut the challenging behavior itself once the right housing is in place. IISCA-driven FCT gave 90% problem-behavior reduction in 25 outpatients. The Welsh survey maps where to place adults; the later studies give tools to treat the behavior after placement.
Why it matters
If you help adults with severe ID and challenging behavior, push for small community houses first. They win on safety, choice, and cost. Once the placement is set, add a brief IISCA and FCT to shrink the behavior further. Do not assume a bigger budget inside the same setting will do extra good—shift funds to getting the right house and the right clinical support.
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02At a glance
03Original abstract
A survey of people with severe intellectual disability and the most severe challenging behaviour in Wales identified five adults living in family homes, 17 in new specialist community housing and 19 in traditional services. With the omission of two people from the latter group and with a restricted collection of data for people living in the family home, the present study explored service input, outcome and costs across the three setting types. Process and outcome indicators for the family home group, who received little service input, were better than those for the traditional service group, although less good than those for the community house group. The specialist community home model produced significant gains over the traditional services in virtually all areas. Across the residential data set as a whole, there was no association between staff:resident ratios and severity of disability or between costs and severity of disability. This was largely true of the service types separately. There was a relationship between costs and service quality. However, this association was underpinned by gross differences between community houses and traditional settings. Costs, processes and outcomes ceased to be related when the two residential types were considered separately. Although higher costs of new community services compared to traditional services may be set against improved outcomes, high costs within the former could not be related to benefit. Outcome indicators were generally related to each other, suggesting that high quality in one sense was matched by high quality in other senses. Outcome was significantly associated with the ability of residents. Outcome indicators also tended to be related to observed staff performance, which was independent of resident ability. Therefore, outcome may be considered as dually determined by differences in resident ability and in what staff did.
Journal of intellectual disability research : JIDR, 1998 · doi:10.1046/j.1365-2788.1998.00153.x