Role and principles of reablement

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.

Key messages

Reablement:

leads to improved health and wellbeing
uses a strengths-based, person-centred approach
may be appropriate to support timely discharge from hospital or enable an individual to remain living at home if, due to illness or disability, they have increasing difficulty with daily life activities
is non-means-tested, where the person will qualify for reablement if they meet the eligibility criteria, regardless of income or capital
is time limited, where short-term support is provided, usually for up to six weeks, but possibly for a shorter period depending on progress
focus should be on achieving outcomes rather than completing care tasks
goals or outcomes should have meaning to the individual and be aimed at promoting wellbeing, autonomy, independence and choice
plan should be determined by both the long- and short-term outcomes the person has identified
aims to help reduce or eliminate the need for future care services.

What is 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:

promotes faster recovery from illness
prevents unnecessary acute hospital admissions and premature admissions to long-term care
supports timely discharge from hospital
maximises independent living and reduces or eliminates the need for an ongoing care package.

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.

Home care and reablement

Reablement is often considered an alternative to traditional homecare for:

individuals returning home from hospital or other inpatient care setting following a period of illness; or
individuals where there is evidence of declining independence or ability to cope with everyday living due to deteriorating health.

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.

Table 1: The differences between traditional home care and reablement

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 business case for reablement

The reablement service

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.

Models of delivery

Broadly, there are two categories of reablement service:

Intake and assessment service: support a wide range of users including hospital and community referrals.
Hospital discharge service: primarily support people on discharge from hospital.

Intake and assessment 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.

Hospital discharge service

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

Reflecting the shift

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.

Who is reablement for?

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.

Reablement for people living with dementia

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.

Reablement for people with a learning disability

A reablement approach can also be successful when used with people living with a learning disability.

The reablement team

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

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.

Occupational therapists

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:

as trainers of reablement workers
as assessors before and after a period of reablement
as reablement team managers.

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.

Reablement support workers

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.

Elements of effective reablement

The elements of effective reablement include:

individual assessment and person-centred goal setting to improve confidence and wellbeing
interventions to enable engagement in meaningful activities and occupational performance (the ability to desire, recall, plan and perform the required activities, tasks and roles of living). This engagement is achieved through goal setting with the individual receiving reablement
supporting and enabling risk management and risk-taking to maximise independence and choice
an ‘outcome focus’ to appropriately minimise the ongoing support required.

Assessment and goal setting in reablement

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:

activities of daily living tasks, such as getting washed and dressed, preparing a drink, light snack or meal
mobility, such as moving safely around their home or outdoors
enabling participation in social engagement, such as building confidence to take transport to their chosen activity in the community.

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 interventions

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:

Restorative: the learning or re-learning of skills or behaviours, improving confidence and increasing motivation.
Compensatory: finding a way around a functional difficulty, including adapting the environment and/or using assistive technology, telecare and/or equipment.

Click on the methods below to see an example of how you would implement it.

Managing risk and choice through reablement

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’.

Reablement: maintaining independence

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:

help people to have choice and control over their lives
recognise that making a choice can involve some risk
respect people’s rights and those of their family and carers
help people understand their responsibilities and the implications of their choices, including any risks
acknowledge that there will always be some risk, and that trying to remove it altogether can outweigh the quality of life benefits for the person
continue existing arrangements for safeguarding people.

Outcomes of reablement

The most widely reported outcomes of reablement are:

a reduction in the need for ongoing support
a significant improvement in peoples’ wellbeing, particularly in terms of restoring their ability to perform usual activities
an increase in their perceived quality of life compared to conventional home care services.

For the outcomes of reablement to be sustained, subsequent providers and informal carers need to continue the reablement ethos.

Reablement for users, carers and families

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: The roles of carers and families in reablement

Measuring the value of reablement

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:

comparing an individual’s functional status at the beginning and end of a reablement period through appropriate outcome measures, such as COPM (Canadian Occupational Performance Model), Barthel Index or NEADL (Nottingham Extended Activity of Daily Living)
quality of life questionnaires
Service outcomes, such as:
- reduction in traditional care home hours
- unplanned hospital admissions
- percentage of people able to remain living at home
- percentage of people requiring long-term support or admission to long-term care
- lasting benefit – the percentage of people no longer requiring a service up to 12 months post-reablement.
cost effectiveness – the cost of interventions vs usual care costs and health service utilisation.

Research has shown that successful reablement can result in:

a reduction in ongoing care support or avoid the need for any long-term care support
a significant improvement in the person’s wellbeing, particularly in terms of independence
an increase in their perceived quality of life.

Reablement: The business case II

SCIE Support

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:

a webinar produced in partnership with The British Red Cross looking at the latest evidence in reablement, along with examples of leading practice
a suite of resources, including guidance and a range of films for professionals, carers and families on the topic of reablement.