At a glance 56: Making the move to delivering reablement

Published: March 2012

This briefing has been co-produced with the United Kingdom Homecare Association (UKHCA).

Key messages

Reablement is a high priority for central and local government.
Evidence shows that reablement has positive outcomes for people who use services, providers and commissioners.
Reablement is not about ‘getting rid’ of home care, it is about helping people learn or relearn the skills they need for daily living – which they may have lost through the deterioration of their health and/or increased support needs – to help them gain more independence.
Home care managers need to build on their existing relationships with commissioners to maximise all opportunities for reablement.
There needs to be a significant shift in the culture of working – which some care workers will adapt to more easily than others – for reablement to happen.
It is crucial that people who provide reablement receive specialist training.
Flexibility is key to the success of reablement.
There needs to be an outcomesfocused approach to commissioning reablement.
Reablement highlights the importance of tailoring support to the individual.

Introduction

This At a glance briefing summarises research and practice evidence about reablement. It explains how to move from a traditional home care service to a new reablement service. However, it can also be used by service managers who want to continue to provide a traditional home care service but in a more ‘reabling’ way. This is particularly important when providing care to people who have ongoing needs after a period of reablement. If the long-term care provider cannot deliver support in a ‘reabling’ way the individual is likely to lose any progress made during reablement.

Reablement focuses on helping an individual gain independence and better functioning rather than resolving their healthcare issues. The aim is to help people do things for themselves rather than the traditional home care approach of doing things for them. Reablement is key because people receiving the service appear to welcome it, and it represents an investment that may produce savings.

Reablement focuses on helping an individual gain independence and better functioning rather than resolving their healthcare issues.

Research on reablement has examined whether it is a better way to support people than traditional home care. The key questions focus on whether reablement can achieve better outcomes, who would benefit from these outcomes, and if savings can be made through investment in reablement. The findings are broadly positive.

Reablement is not about ‘getting rid’ of home care; it is about supporting people to achieve outcomes relevant to their situation and to live as independently as possible.

An Australian study (1) found that – compared with traditional home care – reablement delivers improvements in physical functioning.
A United Kingdom (UK) study (2) concluded that reablement was significantly associated with better health-related quality of life and social care outcomes, compared with traditional home care. The same study also concluded that reablement is more cost effective than traditional home care and should be invested in.

Opportunity or threat?

Home care providers might see reablement as a potential business threat for a number of reasons:

It reduces the number of hours a carer is needed as the independence of an individual improves.
It moves away from traditional task-driven services where carers do things for people to doing things with them, so that in time they are able to do things for themselves.
Reablement requires more flexible planning with more responsive visits – these may last longer than traditional home care visits according to the different needs of each individual.

However, reablement is not about ‘getting rid’ of home care; it is about supporting people to achieve outcomes relevant to their situation and to live as independently as possible. Reablement helps to ensure that ongoing support – such as home care – is given to those with the greatest need.

Good, honest relationships between commissioners and providers are essential. This is because support packages – which include reablement (or more ‘reabling’ home care) – should be commissioned on the basis of outcomes achieved rather than hours provided. This is a clear departure from traditional commissioning arrangements and will require trust and transparency from both commissioner and provider to turn reablement from a threat to an opportunity.

Preparing meals independently

Mrs R was referred for three calls a day, for reablement with personal care and meal preparation. She has a visual impairment, osteoporosis and arthritis and uses a walking frame. She wanted to remain as independent as possible.

Following an assessment, reablement care workers encouraged her to participate as fully as she could with washing and dressing tasks, but realised early on in the reablement phase that this would be an ongoing need for her.

Mrs R had frozen foods delivered but struggled to heat these meals, as she could not read the instructions or see the microwave properly. She was also burning her lunch. The reablement workers:

moved the microwave closer to the window for additional light
attached large labels with the cooking times written on them to all her meals in the freezer (e.g. 7 minutes)
attached raised, florescent stickers to represent 5, 10 and 15 minutes on the microwave dial.

Mrs R was then able to prepare lunch independently. Following the six-week programme, Mrs R’s care package was reduced to two calls per day, to assist with her ongoing mobility needs.

What do I need to do as a home care manager?

This section aims to help home care managers who are considering transforming their current service into a reablement team.

If you are a locally based service provider you will have established links with social services colleagues and you are likely to communicate with them on a daily basis. This will help to ensure that negotiations about setting up a service are conducted with the right people around the table. It will also help you understand the long-term goals of your local council.

As a home care manager developing a reablement strategy, you should consider the following points:

What are your local council’s strategic objectives?
Does the council still have an in-house home care team?
If so, how does the council use its in-house team? Are they providing traditional services or do they deliver the reablement service?
Do they have other services such as rapid discharge, admission avoidance – in other words, do they provide services that may duplicate one another and could be merged or dovetailed?
If the council has a reablement service, is it working? What outcomes are achieved? Do you receive a lot of referrals for individuals who have been on the scheme and still need significant care or have been re-admitted to hospital despite reablement?
Is the council currently implementing ‘critical’ or ‘substantial’ eligibility criteria for reablement?
Will they apply Fair Access to Care (FACS) criteria at the beginning or end of the reablement intervention, or both?
How will you monitor the outcomes of any reablement service you provide?
How will you make sure that your intervention is timely and that you point people in the right direction for other services?

Making the move to reablement

Here are some issues to consider – whether you are developing a reablement team from an existing home care service, creating a completely new service, or just trying to ensure your home care service provides more ‘reabling’ support.

Traditionally home care has been task-driven, with care workers given a list of tasks to do on behalf of the person using the service during a time-limited visit. This support is often over an extended period of time, which allows the care worker to enhance their job satisfaction as they build a relationship with the person using the service.

Reablement requires a significant culture change. Care workers will need to stand back and encourage people to regain or relearn the ability to do things for themselves. They also need to discuss and agree goals with the person using the service and break them down into achievable targets. Reablement care workers must also be responsive to the changing needs of an individual – communicating effectively so that they reduce the amount of support they give as an individual gains independence or give more support if an individual’s progress is slow.

This marked difference in the way support is provided probably explains research findings that staff with less experience in traditional home care adapted more easily to reablement. Researchers observed that many frontline staff with long histories of working as traditional ‘home helps’ or care workers faced a big challenge in learning to stand back instead of intervening when a person was struggling with a task such as dressing or washing.

It is clear that setting up a reablement service will involve reviewing existing care worker teams, providing reablement training and possibly recruiting additional care workers to respond to changing demands. Each service will also need to identify a branch coordinator to act as facilitator. The overall skill mix of the team should also be considered. Although care workers are the foundation of a reablement team, nurses, physiotherapists and especially occupational therapists make important contributions, and decisions will need to be made about how to involve them.

Care workers in the private and voluntary sectors are generally employed on zero hour contracts. A number of different models of reablement operate where care workers are only paid for ‘contact time’ (the period spent in the home of the person using the service). The summary below outlines the main advantages and disadvantages of both models of the service.

Payment by contact time or ‘zero-hours contracts’ are suitable if you need to commission specific tasks at a specific time. They are inflexible and – particularly in the context of reablement – carry risks, as there is no real incentive for the care worker to reduce the time they spend with a person using the service, as they would be reducing potential earnings.

Set contracted hours offer the employee greater stability. There is also less risk of the person using the service being rushed into having tasks done for them. This may be more suitable for reablement, but more costly. If reablement is commissioned in a haphazard and disorganised way, it could mean that the unit cost increases and staff are underutilised. It can also mean that a worker is paid for contracted hours when there is no longer any demand, or where the service has ceased.

Whichever model of employment is chosen, the key to a successful service is flexibility.

It is essential that a reablement service has enough skilled care workers to be flexible and promptly meet people’s needs.

It is essential that a reablement service has enough skilled care workers to be flexible and promptly meet people’s needs. The service might also need additional care staff to ensure continuity of care and to allow care workers the time to stand back and support people, rather than doing tasks for them. (1)

Training for reablement

Some councils set NVQ level 2 as the minimum qualification for reablement care workers. However, there is a consensus that care workers need specific training to understand the principles of delivering a reablement service. Care teams should also be highly trained in assessment and monitoring. There is currently no single, accredited training programme for reablement care workers. Individual councils have developed training manuals and programmes that they may be willing to share, and the North East Improvement and Efficiency Partnership (NE IEP) has published a guide to reablement for frontline staff. (3)

Training on the delivery of reablement services should:

provide staff with an understanding of the concept of reablement and the knowledge they need as a starting point in the ‘reabling’ process
explain the social and medical models of disability
ensure that staff are familiar with and can respond appropriately to common medical conditions
give staff the tools to identify, agree, monitor and record the outcomes achieved.

Staff will also need additional management supervision to support their training and promote the idea of reablement. This will help them to review people’s care and support plans and their goals and outcomes. This increased management input does have an impact on the cost of a reablement service. It is however fundamental to its success. The home care manager will need to factor the cost of staff supervision into the business and implementation plan. This includes the higher manager to staff ratio and the time of the manager and care workers.

A new approach to commissioning

We have described how service providers and commissioners should see reablement as a business opportunity rather than a threat. Nevertheless it does require a new approach to commissioning that is specifically outcomes focused.

The intensive support that people receive should help them to maximise their independence, meaning they need less or no ongoing support. During each successful reablement programme, care workers are likely to have reduced hours as the person either moves into ongoing home care or requires no further support. Service providers should open negotiations with commissioners to develop services that focus on individuals’ outcomes and offer incentives for the provider (based on these outcomes). At the same time incentives to extend the reablement period should be reduced. An example of how this can work in practice is outlined in the box opposite.

How you select the people to take part in a reablement programme is likely to affect how successful a service appears to be, especially in terms of ‘care hours reduced’. Home care managers need to understand the criteria that commissioners use to assess people’s suitability for reablement. Some models of reablement call for everyone needing social care to undergo a period of reablement lasting up to six weeks.

Outcomes-based commissioning

The reablement contract outlines payment to the provider based on the employment of a number of staff each working under a fixed-hours contract. The commissioner pays staff wages through the provider and also pays a commission on top. That commission can be reduced or increased depending on the outcomes achieved by the person using the service. This is monitored by the commissioning department.

Monitoring when people leave the reablement service also gives commissioners the opportunity to record and compare results with similar local authorities.

Some commissioners will use the Fair Access to Care (FACS) criteria to assess eligibility, some will use the criteria to assess eligibility and again at the end, and others will only assess at the end. Some models support people who use services with mental health problems, dementia or end of life care needs, while others exclude them. If you are going to pay home care providers according to outcomes achieved, it is essential that the outcomes achieved are relatively measured against the baseline needs of the person using the service. This is an area that home care managers will need to discuss with their commissioners. It is also an area that should be reviewed regularly as part of service delivery to ensure that inclusive and non-discriminatory care and support is offered.

What do care workers need to do differently?

Most of this At a glance briefing has provided hints and advice to service managers but a reablement service will be a very different place for care workers to operate in.

As a care worker, reablement will require a change in the way you approach your work. The time frame of up to six weeks should mean that people do not become dependent on the care worker. At the same time care workers will need to develop trust and quickly form a professional relationship with the person. They will need to stand back and give encouragement and support, and then use all the skills taught in training to provide ongoing assessment to monitor progress.

Care workers need to understand that a one-sizefits- all approach will not work in reablement. They need training and support to develop person-centred, outcomes-focused care plans that will help people to achieve their goals. It will be essential for care workers to work as a team – communicating any changes, and recognising and reporting any limitations in people’s ability or progress. If a care package needs to be reduced or even stopped, care workers need to understand the importance of feeding this back to a branch coordinator. They should not be afraid of losing care hours as a result. Commissioners need to have confidence in the openness and flexibility a service has to offer and care workers play a crucial role in this.

Reablement is rewarding. People using the service can regain skills they may have lost and develop confidence. Care workers have the opportunity to see someone fulfil their goals, which will give greater job satisfaction.

Further information

Lewin, G. (2010) Submission to inquiry into caring for older Australians, Canberra: Caring for Older Australians Productivity Commission.
Glendinning, C. et al. (2010) Home care re-ablement services: investigating the longer-term impacts (prospective longitudinal study), York/Canterbury: SPRU, PSSRU.
North East Improvement and Efficiency Partnership (NE IEP) (2011) Key products from the adult social care programme