Maximising the potential of reablement

Outcome measurement – what does successful reablement look like?

Overview

Research evidence demonstrates that reablement improves wellbeing and independence, prolongs people’s ability to live at home and removes or reduces the need for commissioned care hours (in comparison with standard home care) [7, 10-11]. Research evidence is less convincing about savings to health care [7] although evidence from practice shows that reablement facilitates earlier hospital discharge and reduces hospital readmissions.

Measuring the outcomes of reablement

However we measure the outcomes of reablement, it is crucial to understand that ‘successful reablement’ looks different for different people. It may be relative to people’s abilities at the start of the service and will depend on other variables, including their motivation to make progress and the goals they wish to set.

Service outcomes such as ‘care hours required at the end of the service’ are a common measure of the success of reablement and are intended to illustrate the extent to which a person has regained independence. One local authority, which takes this approach, uses ‘the number of hours provided in week two of reablement’ as a proxy for the number of care hours the person would have needed had they not used reablement.

Case study: independence in meal preparation

Mrs Derbyshire 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 that this would be an ongoing need for her.

Mrs Derbyshire 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 (e.g. ‘7 minutes’) to all her meals in the freezer
attached raised, florescent stickers to represent 5, 10 and 15 minutes to the microwave dial.

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

Local authorities tend to develop their own data management systems for recording this information, which they may be willing to share with others. They capture data such as the proportion of people requiring:

no ongoing home care
a reduced home care package
increased care hours
long-term (nursing or residential) care.

Recommendations

Data should be recorded at the end of the reablement service and then at follow-up points such as 3, 9 and 12 months in order to monitor whether outcomes are sustained.
Although service outcomes are a popular measure of success, it is important to recognise that they do not provide the whole picture of the impact of reablement on a person’s life. It is good practice, therefore, to add measures of the effect on health and social care-related quality of life.

The Adult Social Care Outcomes Toolkit (ASCOT) provides a well-validated measure of the impact of a service (e.g. reablement) on a person’s social care-related quality of life. It gives an indication of people’s need for help and their outcome gains in the following eight areas (or ‘domains’).

Control over daily life (the individual can choose what to do/when to do it, and has control over their daily life and activities).
Personal cleanliness and comfort (the person feels they are personally clean and comfortable and look presentable or are dressed and groomed in a way that reflects their preferences).
Food and drink (the individual feels they have a nutritious, varied and culturally appropriate diet and enjoys enough food and drink at timely intervals).
Personal safety (the person feels safe and secure, free from the fear of abuse, attack or falling).
Social participation and involvement (the person enjoys meaningful relationships with family and friends and feels involved and part of a community, should this be important to them).
Occupation (the person is sufficiently occupied in a range of meaningful activities which may include work – paid or unpaid – leisure activities or caring for someone).
Accommodation cleanliness and comfort (the person feels all the rooms in their home environment are clean and comfortable).
Dignity (this reflects the negative and positive impact of support and care on the individual’s personal sense of significance).

ASCOT was developed by researchers at the Personal Social Services Research Unit (PSSRU) at the University of Kent. It was used to measure outcomes in the UK’s most robust study of the effectiveness and cost-effectiveness of reablement. For more information and to download the tools needed to measure outcomes in this way, see the Further resources below.

Another approach to capturing the broader benefits of reablement is to measure its effect on a person’s occupational performance. Occupational therapists can reliably measure improvement and outcomes in this area, 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. The FACE is a recording and measurement system for health and social care, designed for both clinical and social assessment. The COPM is an individualised outcome measure, designed to detect change in a person’s own perception of occupational performance over time. Both instruments are designed for use by occupational therapists so if they are going to be adopted then good links between the reablement service and occupational therapists will be particularly important. With training from an occupational therapist, a ‘senior reabler’ could also qualify to use these tools.

Case study: measuring satisfaction and outcomes

Nottingham City Council satisfaction surveys show that 90 per cent of people using the reablement service are satisfied or very satisfied. The service has a strong holistic approach ensuring that links with networks such as faith communities and neighbours are re-established. An outcome tool using a five-step ladder approach is used to ensure that people who use the service are in control and that outcomes are measured by both sides. About 40 per cent of users leave with no need for further services, and as the largest age band is 85–95 this is a very good outcome.

The Outcomes Star is another tool for supporting people’s progress towards self-reliance and can be used to work with people to set goals and agree outcomes. The Outcomes Star is based on an explicit model of the steps that a person takes on their journey toward independence (‘the ladder of change’) and in this sense relates to the objectives of reablement. Unlike the COPM and FACE, the Outcomes Star does not need to be administered by particular professionals, although training is highly recommended and is delivered by the developers.

In judging the success of reablement, commissioners will be concerned with its costs (and cost savings) as well as its effectiveness.

Recommendations

When evaluating the impact of reablement in this way, commissioners should be aware that transferred costs can make the service appear more expensive than it really is. For example, moving an already-funded occupational therapist post from another team to carry out the same range of tasks in the new reablement team results in no extra costs at all.
Overheads should therefore only relate to increased costs caused by reablement. Be aware of any conventions in your financial regulations that may distort the costs of a reablement service and therefore the anticipated ‘cost savings’.

Case study: improving independence and reducing costs

Mr Jones is 79 and has Parkinson’s disease, mild arthritis and diabetes. He lives alone in a ground floor flat and until recently was completely independent except for shopping, as he had to give up driving. His daughter now shops once a week for him and assists with cleaning his flat.

Mr Jones recently fell in the kitchen, losing his balance while getting milk out of the fridge. He sustained a fractured femur and was admitted to hospital for a total hip replacement. After three weeks in hospital Mr Jones began to mobilise reasonably well with a walking aid. He was able get to the toilet without assistance and manage with toilet rails. He could get in and out of his armchair with some difficulty but was unable to get in and out of bed without assistance, and struggled to get dressed, undressed and bathed. He was unable to stand for any length of time so could not cope in the kitchen with meal preparation and making hot drinks.

Mr Jones was discharged home from hospital with a care package of three visits a day to assist with the activities he could not manage independently. He was also referred to the reablement team, and was very keen to try and regain his lost independence. He was assessed by the occupational therapist from the team the day after discharge and a programme of graded activities was planned, to be delivered by reablement assistants.

Mr Jones made good progress over the first month and with support and encouragement started to get dressed and undressed on his own, make himself a hot drink and manage to use the microwave. His confidence grew and following regular reviews by the assistants and occupational therapist the care package was reduced in stages. Within six weeks Mr Jones was able to do everything for himself except get into bed because he was unable to lift his fractured leg over the edge of the mattress. He was also unable to cope with any equipment to assist with this. He could not manage the powered bath lift independently without assistance and opted to have a strip wash twice a week until his bathroom could be adapted with an entry-level shower. He was able to have a morning wash independently by sitting on a stool.

Mr Jones was discharged from the reablement service having had three calls a day, now reduced to an evening visit to assist with getting into bed. Had Mr Jones not improved, this package of three visits per day would have cost £321.25 per week, approximately £16,705 per year. The figures below show the diminishing cost of his package with the reablement service and the final cost of one evening visit resulting in an ongoing yearly cost of £1,942.76

Mr Jones	Hours	Cost
Week 1	17.5	£321.25
Week 2	17.5	£321.25
Week 3	10.5	£194.25
Week 4	10.5	£194.25
Week 5	7	£134.50
Week 6	5.25	£104.63
Week 7	4.5	£94.05
Week 8	1.75	£37.38
		£1,401.56

These figures are an approximate guide to the potential reduction of costs through the reablement service featured in this case study and should be used with caution in considering overall savings since every case is different.