Maximising the potential of reablement

Underpinning research

Reablement is a very promising practice

There is good evidence that reablement improves service outcomes (prolongs people’s ability to live at home, and removes or reduces the need for standard home care). Measured by its capacity to enhance the chances of staying at home, reablement also contributes to user independence and wellbeing. It is feasible to introduce into daily practice in social services and staff welcome the approach. Studies report a slightly higher cost (than traditional home care) but indicate a strong probability of cost savings in the long term. There remains some lack of clarity about the resources required to deliver reablement, particularly about whether the service requires input from professional occupational therapists or whether it can be staffed by trained home care assistants.

There is moderately good evidence that reablement improves outcomes for users, in terms of restoring the ability to perform activities of daily living (ADL) or improving morale. Where users’ views have been collected, users welcome the emphasis on helping them to regain their independence and level of function. This evidence is not as strong as for service outcomes for four reasons. First, some studies have focused on the evidence on service outcomes (e.g. reduction of hours) without fully linking them to independently collected measures of wellbeing for users (e.g. improvement to ADL scores, or morale). Second, not all studies systematically collect the views of people who use services. Third, few studies record the views of carers. Finally, the results on wellbeing vary, with some studies showing that a significant proportion of users do not benefit, or have increased support needs after reablement. Research has not yet identified what causes this variability, nor whether services show better results in relation to service users discharged from an acute admission, or those requesting standard home care support. Evidence is also lacking about the effectiveness of reablement in improving outcomes for people living with dementia.

The evidence base could be improved with more studies that:

• link service outcomes clearly to independently measured wellbeing
• demonstrate sustained effects over a 12-month period
• detail the practices of reablement, and the resources and costs involved
• systematically record the views of both users and carers
• build up the evidence base so that reasons for variable effectiveness can be identified
• include people with cognitive impairment (including as a result of dementia) so that the benefits of supporting them with reablement can be investigated.

Evidence summary

1. What is the practice?

(Description of the practice.)

Reablement comprises ‘services for people with poor physical or mental health to help them accommodate their illness by learning or re-learning the skills necessary for daily living’ [12]. Note that the issues people face may include aspects of limited functioning not readily termed ‘illness’. Restorative home care is another term used in the USA [13], Australia [14] and New Zealand [15]. The focus is on restoring independent functioning rather than resolving health care issues, and on helping people to do things for themselves rather than the traditional home care approach of doing things for people that they cannot do for themselves. Reablement is usually a 6–12 week intervention, focused on dressing, using the stairs, washing and preparing meals, although there is growing recognition of the need for reablement to also address social and psychological needs [16]. Although reablement overlaps with intermediate care, its focus on assisting people to regain their abilities is distinctive. Some schemes (e.g. an ‘intake’ reablement service) accept all referred for home care, excepting only those unlikely to benefit (e.g. because they have end of life care needs). Some schemes operate a more selective focus on those who will benefit most. No single leading model has yet been identified [12]. Apart from one mention of a manual [14], there is little systematic account of what practitioners actually do. There is extensive UK material on implementation issues [17].

2. Why is it thought to be good practice?

(A case for the practice.)

Policy arguments are that:

• reablement supports a service focus on independence and harnesses the joint input of health and social services [18]
• home care services will be overwhelmed unless solutions are found that decrease demand [19]
• reablement services have the potential to be cost-effective [20].

The practice theory is that reablement responds to the wishes of the majority of users to retain independence and control, including staying at home [21].

3. What happened as a result of the practice?

(An account of outcomes and whether stakeholders want them.)

Reablement improves service users’ 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). The best results [10] show that up to 63 per cent of reablement users no longer need the service after 6–12 weeks, and that 26 per cent had a reduced requirement for home care hours. A controlled trial in the UK found significantly better health-related quality of life (measured using the EQ-5D) among the reablement group compared with those using conventional home care for the same period [7]. Notably, the greatest difference was in the ability to perform usual activities, where 23 per cent of reablement users were unable to perform usual activities compared with 43 per cent of people using home care. In the same study, people in the reablement group reported statistically significant improved social care outcomes (measured using ASCOT) at follow-up compared with people using conventional home care. An Australian randomised controlled trial [11] found that at 3 and 12-month follow-up, the restorative care group was significantly less likely to need personal care than the home care group (3 months: 44.3 per cent vs 16.8 per cent; 12 months: 47.2 per cent vs 20.3 per cent).

The results are not consistently good, however. Despite demonstrating significant health-related quality of life benefits for the restorative care group (measured using the SF36), a New Zealand study [15] found no change among intervention or control participants on scales such as ADL and ‘timed up and go’. In another study, a third of users continued to require the same number of hours as at the outset, and in 5 per cent of cases an increase in hours was required [8]. In a further study, two-thirds were assessed as having the same Fair Access to Care Services (FACS) level after six weeks and 12 per cent had a higher level [20]. It is not clear whether to focus the service on hospital discharge or people living in the community: one account suggests that selective ‘discharge support’ schemes have higher rates of success than ‘intake’ services [11], but another reports that community-based users, and those with 5–10 hours assistance requirements at intake, benefited more than those referred from hospital [8].

4. What do people think about the practice?

(An account of processes and whether users and carers find them acceptable, including accessibility.)

One overview suggests few user studies [19]. However, a narrative account reports ‘high degrees of satisfaction by users and their families’ [22], while a systematic review of outcomes-focused services suggests strong support from reablement users [21]. Among a representative sample of reablement users in another study, the majority ‘were very positive about the new service and were all satisfied with any reductions in hours of service that resulted at the end of the reablement period’. Service users were also particularly pleased at the speed with which any equipment they required to assist them in their homes was put in place. However, the same study reports other views among users: some were concerned about handover at the end of reablement and some about the perceived absence of assistance with domestic tasks at the start of reablement [8]. A study of user views [16], taken from a controlled evaluation [7], found that if people did not fully understand the aims of reablement they were often disappointed since they had expectations of being ‘looked after’ in the way one would expect from conventional home care. The study also found that while goal-setting was seen as valuable, it needed to respond to fluctuating needs and situations. People also found reablement to be lacking in its attention to social needs, including improved community engagement. Few studies report carers’ views: one suggests that carers, as well as users, need motivating to engage with reablement, while another records the negative view of one carer about her husband’s care [8].

5. Will it work in day-to-day services?

(Whether the practice is workable on a day-to-day basis - e.g. do providers have the skills?)

Some reablement services are joint health and social care schemes, some involve social services only. The existing skills of home care staff are the key resource [20]. Councils with social services responsibilities (CSSRs) designate NVQ Level 2 as the base qualification [12] (or the Level 2 Diploma in Health and Social Care, which replaced NVQs in January 2011), although additional training in reablement is also essential [23]. In addition to reablement care workers, some teams include occupational therapists (or train home care staff in occupational therapy skills). It is unclear whether occupational therapy skills are essential to successful outcomes [12] but 30 per cent of users in one study saw an occupational therapist [20] and interaction with an occupational therapist was especially valued by care workers in another study [8]. An Australian scheme includes a nurse, physiotherapist and occupational therapist, just one of which works with the individual [14]. An early UK study indicates the key role played by a reablement co-ordinator trained in occupational therapy [10]. One study suggested that staff with less experience in traditional home care work made better reablement workers [24]. Data from Care Services Efficiency Delivery (CSED) interviews with managers [12] suggests they value the impact on users and services. Another study reported that staff valued the increased flexibility of a reablement approach, better interprofessional working and better management [8]. CSED interviews with managers also point to the need to encourage a culture of reablement, particularly among independent providers [12] and another study pointed to the risk that handover to a more traditional home care service might undo the progress made using a reablement approach [8].

6. What will people do differently as a result of the practice?

Staff need to learn ‘to 'watch' and not interfere when a service user [is] struggling to get something done’ [24] (confirmed in another study) [8]. Staffing needs to be flexible to allow the time required and continuity of care worker [24]. Service recording must be detailed and record achievement at each contact [24]. Independent sector providers need to adapt their service to support reablement [12]. Users need to change their expectations: ‘reablement was considered to be more successful if service users were motivated – people have got to want to do it’ [24]. Unpaid carers (family or friends) could contribute to the reablement process if they were given advice about how to sustain service users’ capabilities and independence [16].

7. Is there any evidence on costs and benefits?

(Whether the practice is affordable: any information on costs and savings.)

The SPRU/PSSRU study [7] is the only one to have conducted a formal cost-effectiveness analysis. It reports that reablement requires higher upfront investment than conventional home care, although the study also identifies savings of up to 60 per cent in the costs of subsequent social care provision among the reablement group. The study also found evidence that reablement does not reduce health care costs, although this may be explained in part by weaknesses in data collection, which relied on self-reported information on health care use. For the cost-effectiveness analysis, social and health care costs were analysed separately with EQ-5D and ASCOT results. Analysis showed, from a social care perspective, a high probability that reablement is cost-effective. The results are less convincing when health care costs are used, although still more likely than not to be cost-effective.

Although no other study involved formal cost-effectiveness analyses, some report on investment in and savings from reablement. Reflecting the SPRU/PSSRU findings, they show or imply longer-term cost savings as a result of investment in reablement, albeit that the reablement service is generally more expensive to deliver than the control.

Kent et al. [10]. found that 62 per cent of reablement users had their care package discontinued at first review, compared with 5 per cent of control group users. A total of 26 per cent of reablement users had their care package decreased at first review, compared with 13 per cent of control group users. It can be assumed that the costs of delivering reablement were higher than the costs of delivering the control because average care hours provided to control group users were 5.5 compared with 8 delivered to reablement users. Lewin et al. [25]. reported that there was no significant difference between the direct care costs of the experimental and control groups for the year of the study (F(1,191) = 2.746 p = 0.099). However, as 57 per cent of the experimental group were no longer needing services at one year, whereas 81 per cent of the control group were, it is reasonable to expect that the experimental group would show cost savings in the longer term. Lewin’s subsequent randomised controlled trial [11] reinforced these findings: at 3 and 12 months follow-up, the reablement group were significantly less likely to need ongoing personal care than the control (3 months: 44.3 per cent vs 16.8 per cent; 12 months: 47.2 per cent vs 20.3 per cent). McLeod et al. [8].report that the overall costs of providing reablement were greater than those attributed to the traditional service over the same period – management costs in particular were markedly higher, mostly due to lower management to staff ratios in the reablement service. However, at the end of the reablement period, 41 per cent of reablement service capacity was available for new clients, whereas no capacity was released in the control service. Tinetti et al. [13] imply cost savings from restorative (reablement) clients having shorter and less intensive home care episodes. The authors also suggest that capacity gains were made to health because restorative clients had a reduced likelihood of emergency department visits. In a subsequent study, Tinetti et al. [26] found individuals using the restorative model were 32 per cent less likely to be readmitted to hospital than those receiving usual (home) care on discharge. Finally, King et al. [15] imply that restorative care provides cost benefits because of improved health-related quality of life, plus a statistically significant number of restorative clients requiring reduced care hours (29 per cent) compared with those using home care (0 per cent).