At a glance 46: Reablement: a key role for occupational therapists

Published: October 2011

This briefing has been co-produced with the College of Occupational Therapists.

Key messages

Evidence from research and practice shows that occupational therapists have an important role in the delivery of reablement.
No single model exists for involving occupational therapists in reablement. Occupational therapists may be core team members or they could work collaboratively with a reablement service – an arrangement that could be aided through co-location.
The occupational therapist’s strengths in assessment and goal planning are integral to service users achieving personalised outcomes.
Rapid access to both occupational therapy skills and equipment is essential to avoid delays in people’s progress.
Occupational therapists have the skills and expertise to provide training to care workers delivering reablement.
Advice on rehabilitation techniques from occupational therapists can assist the continuous reablement process for people with complex conditions and is particularly valued by care workers at progress reviews.
Further evidence is required on the impact of occupational therapy involvement on service user outcomes within different models of delivery.

Introduction

This At a glance briefing summarises research and practice evidence about reablement and explains the contribution that occupational therapists make to reablement services. It provides four case study examples of the different ways that occupational therapists are supporting or leading existing reablement teams.

The focus of reablement is on restoring independent functioning rather than resolving health care issues. The objective is to help people do things for themselves rather than the conventional home care approach of doing things for people. Reablement is key because it appears to be welcomed by people receiving the service, and represents an investment that may produce savings.

Research on reablement has examined whether it is a better approach to supporting people than conventional home care. Key questions are whether greater outcomes can be achieved, and for whom, and whether savings can be made through investment in reablement.

Reablement is key because it appears to be welcomed by people receiving the service, and represents an investment that may produce savings.

The findings are broadly positive. An Australian study (Lewin 2010) found that, compared with home care, reablement delivers improvements in physical functioning. A UK study (Glendinning et al 2010) concluded that reablement was significantly associated with better health-related quality of life and social care outcomes compared with the use of conventional home care. The same study also concluded that there is a high probability that reablement is more cost effective than conventional home care and therefore worth investing in.

Reablement aims to maximise independence by removing environmental barriers and helping people to regain practical skills and confidence.
Rabiee and Glendinning 2011

Implications for occupational therapists

The wider prevention agenda and the development of specific reablement services provide real opportunities for occupational therapists. Their growing involvement has been recognised in the emerging evidence, by the Department of Health (Nicholson and Kerslake 2011) and in Welsh policy:

‘The role of occupational therapists in helping to deliver reablement services will be key.
Welsh Assembly Government 2011

Reablement aims to ‘maximise independence by removing environmental barriers and helping people to regain practical skills and confidence’ (Rabiee and Glendinning 2011). It therefore embodies the philosophy and practice of occupational therapy (College of Occupational Therapists 2010).

Due to its aim of restoring or regaining function, reablement requires enhanced competencies in assessment and goal setting (Social Services Improvement Agency 2011). Occupational therapists are able to use such skills, together with their knowledge of the medical, physical, emotional and cognitive impact of disability and injury, to ensure that reablement is tailored to an individual’s needs and potential for independence.

An implicit aim of reablement is to reduce the care hours required to support people at home, or to develop their independence so that they can remain in their own home (Francis et al 2011). While reduction in care hours is a key indicator of positive outcomes, it is also important to measure the difference that reablement makes to the service user’s occupational performance. Occupational goal setting can focus on finding ways to enable service users to prepare their own meals and manage their personal care, but also to regain their participation and social inclusion in meaningful activities (Mickel 2010). Occupational therapists can reliably measure improvement and outcomes using standardised techniques. Tools such as the Functional Analysis of Care Environments (FACE), and the Canadian Occupational Performance Measure (COPM), are commonly used in practice.

We know from the evidence on reablement that occupational therapy skills play an important role in its delivery. Lack of timely access to those skills can delay service provision and the potential progress of service users. Although evidence on the cost of occupational therapist involvement is limited, it indicates that reablement services employing occupational therapists do not appear to be any more expensive than those employing only social care staff (Glendinning et al 2010).

Consistent in the evidence on reablement is that occupational therapy skills play an important role in its delivery.

Where reablement is delivered within an integrated team, the profession’s ability to transcend health and social care is invaluable.
Petch 2008

Delivering reablement – models of occupational therapy involvement

No single leading model for the delivery of reablement has yet been identified (Care Services Efficiency Delivery Programme 2007). ‘Intake’ and ‘hospital discharge only’ approaches are both common practice. Likewise, there is no dominant model for the involvement of occupational therapists.

An early UK study indicated the key role played by the reablement coordinator trained in occupational therapy (Kent 2000), while an Australian scheme differed as it included an occupational therapist, a physiotherapist and a nurse (although only one of these professionals would specifically work with the service user) (Lewin and Vandermeulen 2010). Where reablement is delivered within an integrated team, the profession’s ability to transcend health and social care is invaluable (Petch 2008).

Under the four headings below, we highlight different ways occupational therapists contribute to reablement teams: as core team members, as external to the team but working collaboratively, as trainers and as assessors.

Core team members

Occupational therapists may be core team members. In Wales, 73 per cent of local authorities have occupational therapists within their reablement services (Social Services Improvement Agency 2011). Of five sites investigated in England, two have occupational therapists as team members (Rabiee and Glendinning 2011). Where they are central to the reablement team, there is evidence that care workers value the close working relationships and regular advice available from occupational therapists (McLeod et al 2009).

Example: The core team member

The London Borough of Barking and Dagenham has an in-house reablement service led by an experienced occupational therapist. In addition, a dedicated occupational therapist and occupational therapy assistant are core members of the team, ensuring that reablement plans are person centred, have clear goals and are targeted to those who can benefit most. Specialist equipment is readily available when required and reablement workers have ready access to advice and guidance around different techniques and approaches, including case-by-case guidance to support them on areas such as energy conservation with regard to respiratory conditions; fatigue management; and moving and handling techniques.

Collaborative working

Where occupational therapists are not team members, they may contribute in response to fast-tracked referrals sent to outside teams. They may be co-located, in either the NHS or local authority social care services.

Example: Occupational therapists working collaboratively

Occupational therapists are not core members of the reablement service in the London Borough of Sutton. However, the reablement team managers see occupational therapy involvement as ‘critical’ to success. There are robust working relationships with the community-based occupational therapists as well as the hospital and rehabilitation teams. Support workers operate as ‘trusted assessors’ within boundaries set by the occupational therapists (particularly for moving and handling and home environment equipment). Joint working also takes place where there are any reservations about assessments or complex cases.

Providing training

The input of occupational therapists is highly valued for training care workers to assess for smaller pieces of equipment, thereby reducing some unnecessary delays (Glendinning et al). Indeed, even where they are team members, occupational therapists will not necessarily see every individual receiving reablement – in one study just 30 per cent of users had support from an occupational therapist (Jones 2009). The occupational therapists’ focus is often on supporting care workers in their direct support roles, giving essential training on assessment, goal setting and maintaining a ‘reabling ethos’ (Francis et al 2011).

Example: Occupational therapists as trainers

Occupational therapists can take a leadership role in facilitating the change needed for support staff to work in a new ‘reabling’ way. The five-day training programme in Worcestershire is planned and delivered by occupational therapists, physiotherapists and a nurse coordinator for both health and social care staff. It covers topics including promoting independence, personal and domestic activities of daily living, equipment fitting, cognition/ perception/dementia, normal movement, stroke and orthopaedic issues, mobility, transfers, moving and handling, exercise programmes, stairs, and walking aids. The nursing awareness day includes catheter and stoma care and putting on thrombo embolus deterrent (TED) stockings. To ensure that all assistants work to a required standard, qualified staff assess for their competence in each of the above areas through a combination of classroom teaching and shadowing.

Progress reviews

Service user progress against their goals is fundamental to reablement, but there will be occasions when anticipated progress is not achieved. In these cases occupational therapists can provide additional assessment and intervention, or advice to support workers (for example around supported risk-taking), to ensure that independence is maximised prior to discharge from the reablement service and/or there is provision of any ongoing care.

Example: Making a difference

Eric is 79 years old, has Parkinson’s, mild arthritis and is a diabetic. On discharge home from hospital following a fractured neck of femur, he had a care package of three visits daily. He was assessed by an occupational therapist from the West Sussex Reablement Service on the day after discharge and a subsequent programme of graded activities was delivered by reablement assistants. Good progress was achieved in the first month and Eric managed to get dressed/ undressed on his own and make himself a hot drink and microwave meals. His confidence grew and following regular reviews by the assistants and occupational therapist the care package was gradually reduced. Eric still had difficulty with bathing but agreed to strip-wash until his bathroom was further adapted. Eric was discharged from reablement with only an evening visit as he remained unable to lift his affected leg into bed.

Developing the evidence base

Research on reablement has so far failed to compare the effectiveness and cost-effectiveness of services that employ occupational therapists as core team members with those that do not. This is an important area for further research.

In planning and delivering reablement, a strong priority should be placed on the involvement of occupational therapy in order to achieve optimum outcomes for service users.
SCIE 2010

Summary

In planning and delivering reablement, a strong priority should be placed on the involvement of occupational therapy (SCIE 2010) in order to achieve optimum outcomes for service users. Whatever model of involvement is established, it is crucial that occupational therapists’ expertise can be rapidly accessed (Glendinning et al 2010).

Their [occupational therapists’] role is to provide professional, expert advice to team staff, particularly in developing the skills and confidence of home care organisers to set the individual goal plans for each service user. The OTs [occupational therapists] also work directly with those service users with the most complex needs.
McLeod et al 2009

References

Care Services Efficiency Delivery Programme (2007) Homecare re-ablement workstream: Discussion document HRA 002, London: Department of Health.
College of Occupational Therapists (2010) Position statement: Reablement: The added value of occupational therapists, London: College of Occupational Therapists.
Francis, J., Fisher, M. and Rutter, D. (2011) ‘Reablement: a cost-effective route to better outcomes’, Research Briefing 36, London: Social Care Institute for Excellence.
Glendinning, C., Jones, K., Baxter, K., Rabiee, P., Curtis, L.A., Wilde, A., Arksey, H. and Forder, J.E. (2010) Home care re-ablement services: Investigating the longer-term impacts (prospective longitudinal study), York and Canterbury: Social Policy Research Unit and Personal Social Services Research Unit.
Jones, K.C. (2009) Investigating the longer term impact of home care re-ablement services: The short-term outcomes and costs of home care re-ablement services: Interim report: Working Paper number DHR 2378, York and Canterbury: Social Policy Research Unit and Personal Social Services Research Unit.
Kent, J., Payne, C., Stewart, M. and Unell, J. (2000) External evaluation of the home care re-ablement pilot project, Leicester: De Montfort University.
Lewin, G. (2010) Submission to Inquiry into caring for older Australians, Canberra: Caring for Older Australians Productivity Commission.
Lewin, G. and Vandermeulen, S. (2010) ‘A non-randomised controlled trial of the Home Independence Program (HIP): an Australian restorative programme for older home-care clients’, Health & Social Care in the Community, vol 18, no 1, pp 91–99.
McLeod, B., Mair, M. and RP&M Associates Ltd (2009) Evaluation of City of Edinburgh Council Home Care Re-Ablement Service, Edinburgh: Scottish Government Social Research.
Mickel, A. (2010) ‘Rethinking reablement’, Occupational Therapy News, vol 18, no 11, pp 36–37.
Nicholson, D. and Kerslake, B. (2011) £162m additional winter pressures to primary care trusts, letter, London: Department of Health.
Petch, A. (2008) ‘Reablement and the role of the occupational therapist’, Journal of Integrated Care, vol 16, no 2, pp 38–39.
Rabiee, P. and Glendinning, C. (2011) ‘Organisation and delivery of home care re-ablement: what makes a difference?’, Health and Social Care in the Community, vol 19, no 5, pp 495–503.
Social Care Institute for Excellence (2010) Reablement: Emerging practice messages, London: Social Care Institute for Excellence
Social Services Improvement Agency (2011) Demonstrating improvement from reablement: Phase 1 overview report, Cardiff: Social Services Improvement Agency.
Welsh Assembly Government (2011) Sustainable social services for Wales: A framework for action, Cardiff: Welsh Assembly Government.

Acknowledgements