Home care re-ablement

Warum wurde diese Initiative implementiert?

Homecare re-ablement services were developed as an approach seeking to bring greater quality into preventative and rehabilitative home care services. Specifically, they aim to maximise long-term independence and quality of life and to minimise the need for ongoing care support.

Early initiatives focused on the gaps and interfaces of hospital discharge, responding to the need for continued encouragement and enablement of skills for practical and domestic tasks when users returned to their homes. Re-ablement services now focus beyond hospital discharge, serving all eligible (those with relevant physical or mental health needs of all ages), according to a local Fair Access to Care Services (FACS) criteria.

Over the last 10 years their potential to bridge financial gaps has become clearer. Their time-limited nature (up to 6 weeks) and ultimate aims of keeping people living independently in the community for longer, aim to reduce demand on more expensive acute, residential or ongoing home care services.

Many re-ablement services are joint ventures between Councils and NHS Trusts, thus bringing together health and social care actors within prevention and rehabilitation work. Currently in England, Councils have responsibility for developing home care services as part of adult social care and NHS trusts have responsibility for medical and nursing care.

The key target group for re-ablement services is adults, living at home with the greatest need and potential to re-learn the practical tasks of daily living. In practice home care re-ablement primarily serves older people.

Beschreibung

People over 65 are the primary users of re-ablement services. Within policy, the re-ablement concept and services emerged from significant UK investment in intermediate care services (Secretary of State for Health, 2000). Political acknowledgement has remained consistent as the new coalition government have endorsed the approach in their new vision for social care (Department of Health, 2010), announcing £70m in new resources in 2010/11 and up to £300m a year for re­-ablement initiatives over the next four years.

In practice local authorities approach re-ablement services in different ways in terms of target group (some focus on ‘hospital discharge’ (in 22 local authorities), others on ‘intake’ taking a range of referrals who meet eligibility criteria (in 130 local authorities). Research shows that the features of home care re-ablement services that remain consistent are:

• Helping people ‘to do’ rather than ‘doing to or for people’
• Time-limited with an focus on setting and achieving outcomes
• Continuous rather than one-off assessment and observation

The Care Services Efficiency Delivery  (CSED) programme was set up in December 2004 to help councils to identify and develop more efficient ways of delivering adult social care. CSED have played a central role in supporting the implementation of services through monitoring activities, commissioning long-term research and evaluation and production of a Homecare Re-ablement Toolkit.

Local councils lead homecare reablement services with key actors being project managers, home care workers, other intermediate care workers (Council services that work with re-ablement), social workers (for referrals), service directors/commissioners, acute and NHS Trust colleagues (often as partners in delivery of services). The exact nature of collaboration between actors and organizations varies from region to region. This variation was seen as an important factor for evaluating such services. The national evaluatin illustrates that target groups are changing to accommodate all adults over 18 years of age, previously re-ablement services had tended to focus on hospital discharge of older people, rather than this broader ‘intake’ approach.

Welche Effekte wurden erzielt?

A study of long-term impacts highlights significant reductions in use of social care services for those users who have received re-ablement services. Over a year period those who had received re-ablement services cost 60% less than people using conventional home care services (Glendinning, 2010). Similar patterns of reduced services use were also seen in earlier localised findings. A pilot re-ablement project in one English midlands city showed that approximately 60% were able to discontinue all support after their first review, compared to only 5% in a control group of traditional home care services.

In addition to evidence of service use, the long term study showed a corresponding increase in quality of life. Users were tested via wellbeing measures for health (EQ-5D, Health related quality of life) and social care (ASCOT). Findings demonstrated much better outcomes, in particular for health related wellbeing.

Significant cost savings to the system as a whole had been the vision (e.g. by reducing length of acute stays, readmission, ongoing homecare costs), this has not been played out by audit and evaluation evidence. In Edinburgh, for instance, overall costs of delivering re-ablement services was seen to be higher than for traditional services, due to involvement of more management staff and higher staff training and supervision  (McLeod et al. 2009). The most recent UK evidence suggests that re-ablement is cost-effective in relation to health-related quality of life outcomes and from a social care perspective, however there is little evidence to suggest it reduces health care costs (Glendinning 2010, Francis 2011).

The overall research message around costs and outcomes is positive. Although re-ablement services cost more to set up and deliver, they do result in reduced care use over time and better user outcomes for the same costs.

Re-ablement approaches have been successfully implemented in Australia, with research demonstrating promising outcomes for users (Lewin, 2010).

Worin bestehen die Stärken und Schwächen der Initiative?

A key strength of re-ablement is that it improves users perceived quality of life and reduced future use of social care support.

Weaknesses as reported by users come when their care is transferred back to a conventional home care service, after the initial 6 weeks. Abilities and associated benefits to wellbeing and independence can easily be lost once care loses its enabling focus; carrying out tasks for users rather than helping them to develop skills. In the case of most re-ablement services traditional home care services and staff are gradually being trained in the re-ablement approach as it becomes mainstreamed in each region.

One possible disincentive or explanation for why some regions have still not started developing such serives is the initial financial investment. Instigating new collaborations and setting up reablement services is seen to involve an initial outlay with services becoming cost effective over time.

Within research literatures there is an identified opportunity or need to strengthen user and carer views towards re-ablement services. Impact on informal carers is reported to be varied but with individuals reported:

• Learning new and more structured ways of approaching practical care tasks
• Increased ‘peace of mind’
• Increased confidence in their own care skills

However, the level direct support given to informal carers by the re-ablement teams can vary. Where practical and emotional support has been given out it was highly valued by carers. Yet in some cases carers report disappointment as no information or support had been received.

A possible threat to re-ablement comes in the challenge to fully transform the national approach to home care. The pioneering managers, care staff and allied health partners have been seen to approach the new services with enthusiasm, however retraining the entire home care work force (who have not volunteered) may be more challenging.

Impressum

Links zu anderen INTERLINKS-Initiativen

• Intermediate Care

Externe Links und Literatur

• Department of Health (2010) A vision for adult social care: Capable communities and active citizens.
• Glendinning, C., Jones, K., Baxter, K., Rabiee, P., Curtis, L., Wilde, A., Arksey, H. and Forder, J. (2010) HomeCare Re-ablement Services: Investigating the longer-term impacts (prospective longitudinal study). York: Social Policy Research Unit, University of York.
• Kent, J., Payne, C., Stewart, M. and Unell, J. (2000) External Evaluation of the Home Care Re-ablement Pilot Project. Leicester, Centre for Group Care and Community Care Studies, De Montfort University.
• Lewin, G. and Vandermeulen, S. (2010) ‘A non-randomised controlled trail of Home Independence Program (HIP): an Australian restorative programme for older care home clients’, Health & Social Care in the Community, Vol 18, no 1: 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.
• Secretary of State for Health (2000) The NHS Plan. A Plan for Investment, A Plan for Reform. 

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