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Published February 2020
This briefing is an overview of the role and principles of reablement in the social care sector. It is designed for those working in reablement or commissioning it, but may also be useful to carers and people receiving reablement.
As well as describing what the roles and principles of reablement are and the different models used to deliver it, the briefing illustrates the shift from traditional home care towards personalised, outcome-focused care and describes the principles of effective reablement.
Reablement is a strengths-based, person-centred approach that promotes and maximises independence and wellbeing. It aims to ensure positive change using user-defined goals and is designed to enable people to gain, or regain, their confidence, ability, and necessary skills to live as independently as possible, especially after an illness, deterioration in health or injury.
Reablement:
Reablement, which is generally provided in the person’s own home or care home, is a goal-focused intervention that involves intensive, time-limited assessment and therapeutic work over a period of up to six weeks (but possibly for a shorter period). It involves a process of identifying a person’s own strengths and abilities by focusing on what they can safely do instead of what they cannot do anymore.
Since 2010 the UK Government has substantially invested in reablement services through NHS funding. It is now set within the context of the Government’s broad prevention agenda, which aims to promote wellbeing and help reduce unnecessary hospital admissions, re-admissions and delayed discharges.
In England, reablement is seen as a core element of intermediate care that:
From this information, meaningful functional goals and outcomes are developed with the individual, to promote wellbeing, autonomy, independence and choice. It aims to ‘enable people to be and to do what they have reason to value’.
Reablement is a person-centred approach within health and social care that helps individuals to learn or re-learn the skills necessary to be able to engage in activities / occupations that are important to them.
Reablement: key issues for commissioners of adult social care (SCIE)
Reablement was further defined in a study funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research (HSDR) programme.
To restore previous self-care skills and abilities (or re-learn them in new ways) that enable people to be as independent as possible in the everyday activities that make up their daily lives (e.g. cleaning the house, shopping, or bathing and dressing themselves) rather than having someone (e.g. an informal or formal carer) do things ‘to’ them or ‘for’ them.
Reablement services for people at risk of needing social care: the MoRe mixed-method evaluation (NIHR and HSDR)
One of the key principles of reablement is to support people who are at risk of needing social care or an increased intensity of care to regain functioning, maintain life skills, rebuild their confidence and promote wellbeing.
Reablement is often considered an alternative to traditional homecare for:
It is a way of empowering people to do things for themselves rather than having things done for them, as in traditional homecare, which can lead to dependence on a care package.
The use of a reablement approach, and subsequent interventions, can ultimately result in reducing or preventing the need for traditional homecare. However, homecare still has its place following a period of reablement or when reablement is inappropriate, but the ethos of reablement needs to be continued.
| Traditional home care | Reablement |
|---|---|
| Often a long-term provision. | Usually a short-term intervention. |
| Means-tested. | Non-means-tested. |
| Usually uses a ‘doing for’ approach with little or no attempt to develop self-care skills. | Uses a ‘doing with’ approach, which involves supporting people to do things for themselves. |
| No goals are set. | Goals-orientated, which are co-produced with the person receiving reablement. |
The film begins with a brief introduction to reablement, which we see in operation with Jill Hunter, recently discharged from hospital following surgery. Jill lives in the Central Bedfordshire local authority. As well as seeing how reablement has improved Jill’s independence to the point she will soon require no support, we hear from the Operational Manager of Reablement Services about the significant cost savings that reablement has delivered. This is verified with data from research and practice across the UK, presented by experts Gerald Pilkington and Professor Caroline Glendinning. We also see how investment in a ‘step-down’ reablement unit has facilitated far more hospital discharges, making cost savings in the health sector.
Reablement services are delivered using different models. Which model used often depends on local needs such as population and demographics, as well as the existence of similar support services and the resources available.
Many reablement services are commissioned and provided by local authorities; however, in some cases, they are joint-funded by the local clinical commissioning group and the local authority.
Reablement should be offered as a first option for people being considered for home care if it can improve independence and wellbeing. For those already receiving home care, reablement should be considered as part of the review or re-assessment process.
Broadly, there are two categories of reablement service:
Intake and assessment services tend to operate a ‘de-selective’ model, where all those referred for home care undergo reablement unless it is agreed they will not benefit. For example, if someone has end of life care needs, they will be de-selected.
In comparison, hospital discharge services usually operate on a more selective basis. They support only those people who are judged likely to benefit from reablement. For example, discharge from hospital of someone who lacks confidence in their abilities following a fall which resulted in injury.
In recent years some of the hospital discharge services have broadened their role and evolved into a ‘de-selective’ model – and, similarly, some intake and assessment services have become more selective (perhaps due to financial pressures).
The service I manage works with the hospital social work team – the hospital has two very busy elderly care wards including an assessment unit. Our focus is to try and reduce the length of stay in the acute setting to avoid delayed discharges and to prevent elderly patients picking up hospital-acquired infections. We use reablement to support these wards and this means we only accept service users with reablement potential (selective model) based on criteria we have set – i.e. those that we think can return to their maximum functional capacity within six weeks of reablement.
Hospital service manager
The chosen model should reflect the shift towards prevention, wellbeing and person-centred, outcome-focused care that is strengths based.
Figure 1 Shows the move from generic care towards person-centred, strengths-based care.
Generic Personal circumstances are not considered. Institutional The same care is provided for all people. Deficit-based A focus on what a person cannot do. Input-focused Measures progress by how many tasks someone has completed. Risk averse Unsupportive by playing it safe.
Personalised People have a choice and control over their care plan. Independence-orientated Supports people to maintain daily activitues and connect with communities, families and friends. Strengths-based Draws on a person’s strengths and assets. Outcome-focused What goals the person is working towards. Risk aware Willing to prepare for potential risks.
South Tyneside – Adult Social Care provides an example of how a reablement approach, which emphasises the promotion of independence, can be integrated into service delivery. It has removed the traditional ‘assessment for services’ approach and created a new culture where practice is based on the three conversations model. The ‘three conversations model’ provides a set of tools to enable the committed, principled and skilled workforce to have conversations based on what people want to tell them, not what they want to ask them. The South Tyneside approach encourages people to make the best use of support from their own community, including family and friends, and voluntary organisations. South Tyneside has developed a model to ensure that people can get the right level and type of support at the right time to help prevent, reduce or delay the need for ongoing support, and maximise peoples’ independence. Source: South Tyneside
Reablement can be used with a variety of different people including those with physical disabilities, dementia and learning disabilities. Whilst a referral to reablement should be based on an individual’s needs rather than medical diagnosis, there are some authorities that use the selective approach and only target people who are most likely to benefit, by regaining physical function and improving their independence. For this reason, people with certain conditions, such as dementia, tend not to be offered reablement. This group of people may be offered reablement depending on their individual circumstances, in authorities which operate a de-selective approach.
The Government’s policy for those people living with dementia is to support them to live well by keeping them actively engaged in their daily life for as long as possible. This can be achieved through a coordinated, personalised reablement approach, incorporated into their routine care, drawing on the person’s strengths and considering their declining abilities.
There needs to be attention to staff training to ensure they have adequate knowledge of assessment and how to build on the remaining ability of the person with dementia.
A reablement approach can also be successful when used with people living with a learning disability.
The Imagine Act Succeed (IAS) reablement service in Oldham supports adults with a learning disability. It works in more person-centred ways to further independence, community connections and self-reliance. The emphasis of the service is to build on the person’s own resilience and independence. A key role for staff is to enable people not only to maintain existing friendships and relationships, but also to support the development of new social networks in the community. Source: Imagine Act Succeed (IAS)
Another principle of reablement, which ensures an effective service, is having a reliable team. This is dependent on having the right structure, roles and a fully competent team of people who understand and operate within the ethos of reablement. Research has shown that staff skills and knowledge of reablement principles are regarded as key to successful reablement.
The reablement team often consists of reablement assessors, reablement support workers and occupational therapists. However, in some areas, other disciplines such as physiotherapy may also be included.
Reablement assessors or occupational therapists will carry out the assessment process, which involves measuring the person’s base line in all aspects of activities of daily living. The support plan will then be developed along with the person who uses services in the hospital or at home and identifies the outcomes they would like to achieve.
Evidence from research and practice suggests that the most successful reablement teams have occupational therapy input. There is no single agreed way of involving occupational therapists. They could contribute to the reablement team in different ways:
Occupational therapists may not be part of a reablement team, but they may be co-located so their expertise is easily accessible to reablement workers.
The basis of the whole adult care service in Coventry is to help people to gain or regain their independence.
For those who approach the council for help (whatever their age), where it appears, they are likely to have care and support needs as a result of a physical impairment or old age frailty, the process will start for them with an assessment with an occupational therapist. Further to this, the occupational therapist and the individual will identify the goals they might be able to achieve, to gain greater independence as well as the support needs that are required at that time.
After the goals are set, the person is referred to the domiciliary care providers (in the independent sector), who support the person in meeting the agreed goals by using reablement approach. During the process there are weekly meetings with either an occupational therapist or a named social worker and, where appropriate, either these people or an occupational therapy aide will undertake direct work to assist or support staff to meet the pre-agreed goals.
An evaluation of the service has shown there are comparatively low numbers of people in receipt of longer-term support. All three community providers consistently achieve a two-thirds success rate in assisting people in a way that they do not require longer-term support. The evaluation also demonstrates how the approach can help people either to gain complete independence (with some managed risks) or to limit the care and support needs they have.
Source: Coventry Reablement Service
Reablement support workers are often local authority homecare staff who have received additional training to adopt an enablement approach.
When I worked as a home carer, I was often involved in preparing meals for people. Now I work in reablement and my role is to support people in re-learning to prepare meals for themselves after an accident or illness.
Reablement support worker
Support workers will follow the support plan and work daily with the person receiving the reablement service. Their focus is on observing, guiding and encouraging the person who uses services to do things themselves, to rebuild confidence and improve skills that may have been lost.
The elements of effective reablement include:
One of the core principles of reablement is the creation of a realistic support plan. This follows a functional assessment that measures the person’s baseline in all aspects of daily living and involves the person who uses services in identifying the outcomes or goals they would like to achieve.
It is important that the focus is on activities or occupation that the person identifies as important. The person would be asked, ‘What are the most important activities in your life right now?’
Goals can range from very small improvements to more complicated activities to help them recover skills, confidence and independence. They are likely to relate to:
There is a need to review a person’s progress almost daily in order to maintain improvement – revisit goals and amend as necessary. If all goals have been achieved, reablement doesn’t need to continue for the full six weeks (or the full-time period allowed locally).
Reablement is often seen as a service that provides adaptations and equipment as a means of support. However, it can also help users connect back to their community and take ownership of key areas of their lives.
The methods used can be split into two categories:
Click on the methods below to see an example of how you would implement it.
Following a fall, set small achievable targets to build confidence – such as walking for a short distance, first in the safety of the home and build on this to walking outdoors to the gate and then down to the end of the road.
To increase the motivation to achieve this, the individual may focus on a place they wish to walk to.
When putting on a shirt or blouse, always put the weaker arm or the arm with the least amount of movement into the sleeve first.
Advise sitting to carry out an activity such as preparing vegetables rather than standing to do this.
Organise the timing of activities to avoid unnecessary trips, for example limiting the need to go constantly up and down stairs.
Personal alarms, sensors for epilepsy or falls, medication dispensers with reminder alarms or ‘Just Checking’, which is an activity monitoring system that shows a person’s day-to-day capabilities and where they need support.
Social prescribing link worker.
Support the development of new social networks in the community or re-establish and maintaining existing ones.
Taking risks can be essential to an individual’s progress when re-learning a task or taking part in a chosen activity as part of reablement. Risk aversion often prevents people from living their lives freely and can create a perception of ‘I can’t’ or can increase anxiety if someone else is worried for them.
The role of workers within the reablement team is ‘to enable people to overcome the barriers that prevent them from doing the activities that matter to them; to take opportunities and not to see risk as another barrier’. It is often the occupational therapist that is involved in the risk assessment and reablement. This is to improve an individual’s abilities in a safe way and ‘avoid a focus on what cannot be done in favour of what can be done with greater certainty, accountability and transparency’.
This film focuses on ‘falls prevention’ programmes. This type of preventive support can be described as ‘early intervention’. Early intervention aims to identify people at risk and halt or slow down any deterioration and actively seek to improve their situation. Interventions include screening and case finding to identify individuals at risk of specific health conditions or events (such as stroke or falls) or those who have existing low level social care needs.
The film introduces us to a number of people who describe how they are benefitting from the falls prevention service and the exercise classes. People who were initially experiencing reduced mobility or had previously fallen reflect on how their physical ability has improved and their confidence has grown. As well as the exercises classes, physiotherapists work with the individuals to improve the home environment so that they can achieve mutually agreed outcomes, such as washing themselves, moving around the house safely and reduced anxiety. For some, this means a reduction in the need for ongoing care.
In addition to the benefits described by the individuals in this film, we hear from the rehabilitation and falls specialist at the Cambridgeshire Falls Prevention Scheme about some of the ‘service outcomes’. By maintaining people’s independence, the service aims to reduce packages of care, most notably by preventing the need for expensive residential care. Professor Julien Forder also explains that this kind of early intervention service is likely to reduce hospital admissions, meaning a positive outcome for individuals and the public purse.
Risk is dynamic and may fluctuate – for example, a small task such as making a cup of tea may suddenly place an older person recovering from a broken hip at an increased risk of falling.
Independence, choice and risk: a guide to best practice in supported decision making (Department of Health)
In the quote from the Department of Health, the apparent risk should not stop the older person from trying to make a cup of tea. A reablement assessment allows the risk to be managed and the person to achieve their goal.
In the guide it goes on to say that people supporting users of reablement services must:
The most widely reported outcomes of reablement are:
For the outcomes of reablement to be sustained, subsequent providers and informal carers need to continue the reablement ethos.
People using reablement services, as well as their families and carers, appear to welcome reablement. Research has shown that those receiving reablement valued the person-centred approach, which focused on what they would like to do to maintain their independence and was flexible to their changing needs and priorities. They felt that the daily contact with support workers helped them to re-kindle and re-connect their interest in everyday life.
Reablement can help families balance caring, paid work and other responsibilities by enabling people to gain or regain their confidence, ability, and necessary skills to live as independently as possible, especially after an illness, deterioration in health or injury. This can reduce the need for support and care from friends and family and lessen the strain on family relationships.
Families and friends need to have a clear understanding of reablement, need to be fully committed to the process and contribute to its successful implementation. Support is available from local services and other organisations such as SCIE to help families and carers become more familiar.
This is particularly important as the period of reablement comes to an end, because there can be anxiety regarding managing alone or transferring to a long-term care service. This can be overcome, in part, by managing expectations about the reablement experience. Everyone needs to be familiar with the ethos of reablement and its boundaries in terms of its nature and length of support.
Reablement is a strengths-based, person-centred approach that promotes and maximises independence and wellbeing.
The film introduces Jill Hunter who was recently discharged from hospital with limited mobility, following major surgery. Jill lives alone and was determined to return to her independent lifestyle. To enable this, Central Bedfordshire adult social care services commissioned their reablement team to work with Jill. We hear from two community reablement workers about the incredible transition people like Jill can make from initially requiring intensive support to being completely independent. We also hear how crucially important it is for families to ‘buy into’ the reablement ethos and contribute to its success. In turn, Emily Holzhausen (Carers UK) describes how reablement teams must respect and involve families, recognising their role as part of the whole support circle.
There is significant interest in the value of reablement and measuring its success. The approach used to measure the success of reablement depends on the local context and policies of the local authority. It is also likely to depend on the category of the reablement service (intake and assessment or hospital discharge) and the model (selective or de-selective).
For example, if a ‘de-selective’ model is used (normally seen in intake and assessment services), there will be a notable difference in the number of people who achieve full independence compared with a selection model (often hospital discharge schemes) where people are chosen for their reablement potential.
The value of reablement can be measured through:
Research has shown that successful reablement can result in:
In the London Borough of Tower Hamlets 63 per cent of people using an occupational therapy-led reablement service had their reablement cases closed without needing further support.
It provides a multidisciplinary, short-term reablement service to all adults over 18 in the borough who may have lost confidence, skills or independence following an accident, ill health, a disability or a stay in hospital. The service aims to enable people to re-learn life skills, to rebuild their confidence, to facilitate and consolidate their existing abilities and build on their own resources to enable and promote a healthy lifestyle that is relevant to the individual. This can lead to a reduction or absence in long-term support needed, thereby reducing long-term costs.
SCIE is a leading provider of reablement resources and support. We offer training and consultancy to support the review and embedding of a reablement approach in local care and support systems.
Work with us to explore the potential of reablement as a genuinely preventative form of care.
Our consultancy support can be tailored to local needs, budgets and timescales. Get in touch to find out more.
We also offer an e-learning course on reablement for staff working with people receiving care services, as well as bespoke classroom training.
Further information and resources include:
