THE ESSENCE PROJECT

Reablement

Case studies

Read the full case study for 'Home care reablement for older people: economic evidence' here (PDF)
Annette Bauer, Michela Tinelli, Danielle Guy 2019

KEY POINTS

  • Home care reablement helps older people do things themselves, enabling them to re-learn skills and recover their confidence to live at home.
  • Studies have consistently shown that home care reablement leads to improved functioning and a decrease in dependence as well as reductions in ongoing home care.
  • Across different age groups, home care reablement for older people also has a high probability of reducing costs when compared with standard home care.
  • The National Institute for Health and Care Excellence (NICE) recommends that every older person referred to home care should be offered reablement if it is indicated that person would benefit from it.
  • It is plausible that some people (e.g. those living alone) are less likely to benefit from reablement without additional support. Future research needs to focus on what populations should receive home care reablement and for how long.

Evidence

'The Billion Dollar Question': embedding prevention in older people's services—Ten 'High-Impact' changes
Allen K and Glasby J British Journal of Social Work, 43, 904-924. 2013

With ageing populations, social changes and rising public expectations, many countries are exploring ways of developing a more preventative approach within their health and social care services. In England, this has become a growing priority over time—made even more significant by recent economic change and by the urgent need to reduce public sector spending. However, a key dilemma for policy makers and managers is the patchy nature of the evidence base—with a lack of certainty over how to reform services or prioritise spending in order to develop a more genuinely preventative approach. Against this background, this commentary reviews national and international evidence around ten policy measures and interventions, highlighting some of the most promising approaches as well as the fragmented and contested nature of the evidence base.

At a Glance 53. Reablement: Implications for GPs and Primary Care
Social Care Institute for Excellence Social Care Institute for Excellence, London. 2012

Key messages

Reablement focuses on restoring independence rather than resolving health care issues.
Research findings are positive and show that reablement is cost-effective compared with conventional home care.
It is the intention of the Secretary of State for Health that clinical commissioning groups should embrace reablement.
While reablement usually begins in hospital, this is not inevitable as people can be referred from the community, for instance by general practitioners (GPs) and social workers.
A multidisciplinary team activates a reablement plan with clear objectives and an analysis of likely outcomes. The team could be organised around clusters of practices, with combined health and social care input.
Flexibility and reassessment throughout the intervention period is necessary to ensure improvements in outcomes. Strategies and services should be deployed that lead to improvements in independence and self-care after an illness.
People using reablement must be consulted to assess satisfaction and measure quality of life indices through and after the reablement period.

Economic Evaluation of Social Care Interventions: Lessons Drawn from a Systematic Review of the Methods Used to Evaluate Reablement.
Faria R, Kiss N, Aspinal FJ, et al Health Economics & Outcome Research, Cardiff. 2015

Reablement helps individuals to regain or retain the ability to live independently after an injury and/or exacerbation of an illness. Despite the lack of clear evidence on its effectiveness and cost-effectiveness, or on the optimal model for its implementation, reablement is hailed as one solution to the increased demand for long term care. This study systematically reviews, synthesises and critically appraises the economic evidence on reablement, and makes recommendations to improve future research. A total of 13 studies were included. Data were extracted on: decision, context, study design, intervention, comparators, effectiveness, outcomes, resource use and costs, analytic methods, and study findings. Reablement has been shown to be cost-effective; however the reporting on the decision the study aims to inform and the context could typically be improved and there is uncertainty on the costs and benefits of reablement in the longer term, between different models of service delivery and the impact on carers. All studies used only the data on outcomes and costs that was collected within the study and evaluated cost-effectiveness over the data collection follow-up, but this approach was not justified. These methods results should inform future research. Economic evaluations on reablement should: (i) include all available evidence on the relevant interventions and comparators over the appropriate time horizon, (ii) compare the benefits of the intervention with its opportunity costs and (iii) consider subgroup analysis to identify the groups of individuals most likely to benefit from reablement and therefore better target interventions and resources. More methodological research and guidance is needed on standardised outcome measures on general wellbeing, on informal carer’s burden and on how to trade-off the costs and benefits in different sectors. These recommendations can help improve quality and relevance for decision makers in the future and to guide future economic evaluations and methodological research.

Home Care Re-ablement Services: Investigating the Longer-term Impacts (Prospective Longitudinal Study)
Glendinning C, Baxter K, Rabiee P Social Policy Research Unit, York. 2010

Abstract
Re-ablement is a new, short-term intervention in English home care. It helps users to regain confidence and relearn self-care skills and aims to reduce needs for longer-term support.

Research by the Social Policy Research Unit, University of York and the Personal Social Services Research Unit, University of Kent examined the immediate and longer-term impacts of home care re-ablement, the cost-effectiveness of the service, and the content and organisation of re-ablement services. People who received home care re-ablement were compared with a group receiving conventional home care services, both groups were followed for up to one year.

The study found that:
* Re-ablement was associated with a significant decrease in subsequent costs of social care service use
* Re-ablement had positive impacts on users’ health-related quality of life and social care-related quality of life, in comparison with users of conventional home care services
* Using the National Institute for Health and Clinical Excellence cost-effectiveness threshold, re-ablement was cost effective in terms of health and social care costs
* The reduction in social care costs was almost entirely offset by the initial cost of the re-ablement intervention. The average cost of a re-ablement episode was 2,088 pounds with a mean cost of 40 pounds per hour of service user contact time.

Recommendations for the future organisation of these services are made in the report. In autumn 2010, 70 million pounds was allocated to NHS Primary Care Trusts to develop re-ablement services, this will be followed by an additional 150 million pounds in 2011/12, rising to 300 pounds million per annum from 2012 to 2015.

Research areas
ill/disabled adults, social care services issues, older people

Home from Hospital: How Housing Services are Relieving Pressures on the NHS
Copeman I, Edwards M, Porteus J National Housing Federation, London. 2017

This report shows how housing services are helping to relieve pressure on the NHS by reducing delays in discharging people from hospital and preventing unnecessary hospital admissions. It features 12 case studies to show the positive impact these services have on people’s lives and the cost benefit to the NHS. The case studies highlight services that will benefit people most at risk of delayed discharge, such as older people, people with mental health problems and people experiencing homelessness. The case studies also demonstrate a diversity of housing and health services including: ‘step down’ bed services for people coming out of hospital who cannot return to their own home immediately; hospital discharge support and housing adaptation services to enable timely and appropriate transfers out of hospital and back to patients’ existing homes; providing a new home for people whose existing home or lack of housing mean that they have nowhere suitable to be discharged to; and Home from Hospital services to keeping people well at home who would otherwise be at risk of being admitted or readmitted to hospital. The report also considers the impact and additional savings that could be made by housing providers if this work were to be scaled up.

Homecare Re-ablement Prospective Longitudinal Study: Final Report
Social Policy Research Unit, University of York Department of Health, London. 2010

A study conducted with ten participating councils to investigate and provide
further information and evidence of the benefits of homecare re-ablement and
the duration of these benefits.

Intermediate Care Including Reablement [NG74]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2017

This guideline covers referral and assessment for intermediate care and how to deliver the service. Intermediate care is a multidisciplinary service that helps people to be as independent as possible. It provides support and rehabilitation to people at risk of hospital admission or who have been in hospital. It aims to ensure people transfer from hospital to the community in a timely way and to prevent unnecessary admissions to hospitals and residential care.
Recommendations

This guideline includes recommendations on:

core principles of intermediate care, including reablement
supporting infrastructure
assessment of need for intermediate care
referral into intermediate care and entering the service
delivering intermediate care
transition from intermediate care
training and development

Who is it for?

Health and social care practitioners who deliver intermediate care and reablement in the community and in bed-based settings
Other practitioners who work in voluntary and community services, including home care, general practice and housing
Health and social care practitioners in acute inpatient settings
Commissioners and providers
Adults using intermediate care and reablement services, and their families and carers

Related NICE guideline:
Appendix C3: Economic report Intermediate care Bauer A and Fernandez JL

Living Well for Longer: The Economic Argument for Investing in the Health and Wellbeing of Older People in Wales
Edwards RT, Spencer LH, Bryning L, et al Centre for Health Economics and Medicines Evaluation, Bangor. 2018

This report by the University of Bangor makes the economic argument for investing in prevention at different stages of the life course, in particular, older people.

Commissioned by Public Health Wales, it brings together robust international and UK evidence on the relative cost-effectiveness and return on investment of devoting public sector resources to programmes and practices supporting older people.

In relation to housing, it notes that the Welsh Government spends around £50 million per year on adapting the homes of older and disabled people, helping them to live safely and independently.

For every £1 invested in Care & Repair there is £7.50 savings to the taxpayer. It comes to the conclusion that it is cost-effective to improve housing by providing heating and insulation for high risk groups of over 65s.

Maximising the Potential of Reablement
Social Care Institute for Excellence Social Care Institute for Excellence, London. 2013

This guide is based on research and practice evidence about the effectiveness and cost-effectiveness of reablement.

National Evaluation of Partnerships for Older People Projects: Final Report
Windle K, Wagland R, Forder J, et al Personal Social Services Research Unit, Kent. 2009

The Partnership for Older People Projects (POPP) were funded by the Department of Health to
develop services for older people, aimed at promoting their health, well‐being and independence
and preventing or delaying their need for higher intensity or institutional care. The evaluation found
that a wide range of projects resulted in improved quality of life for participants and considerable
savings, as well as better local working relationships.
 Twenty‐nine local authorities were involved as pilot sites, working with health and voluntary
sector partners to develop services, with funding of £60m
 Those projects developed ranged from low level services, such as lunch‐clubs, to more formal
preventive initiatives, such as hospital discharge and rapid response services
 Over a quarter of a million people (264,637) used one or more of these services
 The reduction in hospital emergency bed days resulted in considerable savings, to the extent
that for every extra £1 spent on the POPP services, there has been approximately a £1.20
additional benefit in savings on emergency bed days. This is the headline estimate drawn from a
statistically valid range of £0.80 to £1.60 saving on emergency bed days for every extra £1 spent
on the projects.
 Overnight hospital stays were seemingly reduced by 47% and use of Accident & Emergency
departments by 29%. Reductions were also seen in physiotherapy/occupational therapy and
clinic or outpatient appointments with a total cost reduction of £2,166 per person
 A practical example of what works is pro‐active case coordination services, where visits to A&E
departments fell by 60%, hospital overnight stays were reduced by 48%, phone calls to GPs fell
by 28%, visits to practice nurses reduced by 25% and GP appointments reduced by 10%
 Efficiency gains in health service use appear to have been achieved without any adverse impact
on the use of social care resources
 The overwhelming majority of the POPP projects have been sustained, with only 3% being closed
– either because they did not deliver the intended outcomes or because local strategic priorities
had changed
 PCTs have contributed to the sustainability of the POPP projects within all 29 pilot sites.
Moreover, within almost half of the sites, one or more of the projects are being entirely
sustained through PCT funding – a total of 20% of POPP projects. There are a further 14% of
projects for which PCTs are providing at least half of the necessary ongoing funding
 POPP services appear to have improved users’ quality of life, varying with the nature of
individual projects; those providing services to individuals with complex needs were particularly
successful, but low‐level preventive projects also had an impact
 All local projects involved older people in their design and management, although to varying
degrees, including as members of steering or programme boards, in staff recruitment panels, as
volunteers or in the evaluation
 Improved relationships with health agencies and the voluntary sector in the locality were
generally reported as a result of partnership working, although there were some difficulties
securing the involvement of GPs

Preventing Loneliness and Social Isolation: Interventions and Outcomes. SCIE Research Briefing 39
Windle K, Francis J, Coomber C Social Care Institute for Excellence, London. 2011

This is one in a series of research briefings about preventive care and support for adults.

Prevention is broadly defined to include a wide range of services that:

promote independence
prevent or delay the deterioration of wellbeing resulting from ageing, illness or disability
delay the need for more costly and intensive services.

Preventive services represent a continuum of support ranging from the most intensive, ‘tertiary services’ such as intermediate care or reablement, down to ‘secondary’ or early intervention, and finally, ‘primary prevention’ aimed at promoting wellbeing. Primary prevention is generally designed for people with few social care needs or symptoms of illness. The focus therefore is on maintaining independence and good health and promoting wellbeing. The range of these ‘wellbeing’ interventions includes activities to reduce social isolation, practical help with tasks like shopping or gardening, universal healthy living advice, intergenerational activities and transport, and other ways of helping people get out and about.

Just as the range of wellbeing services is extensive, so too is the available literature examining how well they work. For this research briefing, the focus has been narrowed to the effectiveness and cost-effectiveness of services aimed at preventing social isolation and loneliness. Our review question was: ‘To what extent does investment in services that prevent social isolation improve people’s wellbeing and reduce the need for ongoing care and support?’

While ‘social isolation’ and ‘loneliness’ are often used interchangeably, one paper examined the distinct meanings that people attach to each concept. ‘Loneliness’ was reported as being a subjective, negative feeling associated with loss (e.g. loss of a partner or children relocating), while ‘social isolation’ was described as imposed isolation from normal social networks caused by loss of mobility or deteriorating health. This briefing focuses on services aimed at reducing the effects of both loneliness and social isolation. Although the terms might have slightly different meanings, the experience of both is generally negative and the resulting impacts are undesirable at the individual, community and societal levels.
Key messages

Older people are particularly vulnerable to social isolation or loneliness owing to loss of friends and family, mobility or income.
Social isolation and loneliness impact upon individuals’ quality of life and wellbeing, adversely affecting health and increasing their use of health and social care services.
The interventions to tackle social isolation or loneliness include: befriending, mentoring, Community Navigators, social group schemes.
People who use befriending or Community Navigator services reported that they were less lonely and socially isolated following the intervention.
The outcomes from mentoring services are less clear; one study reported improvements in mental and physical health, another that no difference was found.
Where longitudinal studies recorded survival rates, older people who were part of a social group intervention had a greater chance of survival than those who had not received such a service.
Users report high satisfaction with services, benefiting from such interventions by increasing their social interaction and community involvement, taking up or going back to hobbies and participating in wider community activities.
Users argued for flexibility and adaptation of services. One-to-one services could be more flexible, while enjoyment of group activities would be greater if these could be tailored to users’ preferences.
When planning services to reduce social isolation or loneliness, strong partnership arrangements need to be in place between organisations to ensure developed services can be sustained.
We need to invest in proven projects. Community Navigator interventions have been shown to be effective in identifying those individuals who are socially isolated. Befriending services can be effective in reducing depression and cost-effective.
Research needs to be carried out on interventions that include different genders, populations and localities.
There is an urgent need for more longitudinal, randomised controlled trials that incorporate standardised quality-of-life and cost measures.

Reablement, reactivation, rehabilitation and restorative interventions with older adults in receipt of home care: a systematic review
Sims-Gould J, Tong CE, Wallis-Meyer L, et al Journal of the American Medical Directors Association, 18, 653-663. 2017

Abstract
OBJECTIVE:
To systematically review the impact of reablement, reactivation, rehabilitation, and restorative (4R) programs for older adults in receipt of home care services.

DESIGN:
Systematic review.

DATA SOURCES:
We searched the following electronic bibliographic databases: MEDLINE, EMBASE, PsycINFO, CINAHL (Cumulative Index to Nursing and Allied Health), SPORTDiscus and The Cochrane Library and reference lists.

STUDY SELECTION:
Randomized controlled trials that describe original data on the impact of home-based rehabilitative care and were written in English.

DATA EXTRACTION AND SYNTHESIS:
Fifteen studies were identified. Study details were recorded using a predefined data abstraction form. Methodological quality was assessed by 2 independent reviewers. If there were discrepancies, a third author resolved these.

MAIN OUTCOMES AND MEASURES:
Given the tailored and personalized approach of the 4R interventions, a range of primary outcomes were assessed, including functional abilities, strength, gait speed, social support, loneliness, and the execution of activities of daily living (ADL) and instrumental ADL (IADL). 4R interventions are intended to reduce the long-term use of home care services. As such, health care resource utilization will be assessed as a secondary outcome.

RESULTS:
There are 2 distinct clusters of interventions located in this systematic review (defined by hospitalizations): (1) “hospital to home” programs, in which participants are discharged from hospital wards with a 4R home care, and (2) those that focus on clients receiving home care without a hospital stay immediately preceding. Reflecting the highly tailored and personalized nature of 4R interventions, the studies included in this review assessed a wide range of outcomes, including survival, place of residence, health care service usage, functional abilities, strength, walking impairments, balance, falls efficacy and rates of falls, pain, quality of life, loneliness, mental state, and depression. The most commonly reported and statistically significant outcomes were those pertaining to the service usage and functional abilities of participants.

CONCLUSIONS:
From cost savings to improvements in clinical outcomes, 4R interventions show some promise in the home care context. However, there are several key issues across studies, including questions surrounding the generalizability of the results, in particular with respect to the ineligibility criteria for most interventions; the lack of information provided on the interventions; and lack of information on staff training.

Research briefing 36: Reablement: a cost-effective route to better outcomes
Francis J, Fisher M, Rutter D Research Briefing, Social Care Institute for Excellence Research, London. 2011

This is one in a series of research briefings about preventive care and support for adults. Prevention is broadly defined to include a wide range of services that:

promote independence
prevent or delay the deterioration of wellbeing resulting from ageing, illness or disability
delay the need for more costly and intensive services.

Preventive services represent a continuum of support ranging from ‘primary prevention’ aimed at promoting wellbeing, through to ‘secondary’ or early intervention, and on to ‘tertiary services’ such as intermediate care provided by health and social care professionals. Tertiary services are aimed at minimising disability or deterioration from established health conditions or complex social care needs.1 The emphasis is on maximising people’s functioning and independence through approaches such as rehabilitation, intermediate care and reablement. This research briefing focuses on reablement.

Reablement: Key Issues for Commissioners of Adult Social Care
Social Care Institute for Excellence, Association of Directors of Adult Social Services Social Care Institute for Excellence, London. 2012

A short briefing paper which outlines research and practice evidence about reablement and describes what is required for successful implementation. Sections cover: setting up a reablement service, tips for commissioners, key considerations in providing an efficient and cost effective service. It also presents two case examples of the impact reablement can have on the population and on local authority budgets. Links are provided to freely available evidence and information.

Safe at Home: A Preventive Handyperson Service in Devon
Evans S Housing Learning and Improvement Network, London. 2011

This case study showcases a successful handyperson scheme in Devon. It describes how the scheme was established and its subsequent evolution in the face of changes in the organisational and financial landscape. A range of Evaluation data are included to demonstrate the value of the scheme in promoting independence and reducing risks at home for older people and children and families across the community. Publication of this case study follows the launch of the national evaluation of the government funded handyperson programme by York Health Economics Consortium and the Centre for Housing Policy at the University of York.

Tackling Loneliness and Social Isolation: The Role of Commissioners
Social Care Institute for Excellence Social Care Institute for Excellence, London. 2018

With one million people aged 65 and over in the UK reporting they are often or always lonely, few would refute the need to tackle this issue. (1)
However, loneliness and social isolation are conditions that are difficult to identify, complex to address and hard to resolve. The evidence base for interventions to address the problems of loneliness and social isolation is emerging but inconclusive at this stage.

The Cost Effectiveness of Homecare Re-ablement: A Discussion Paper to Explore the Conclusions that can be Drawn from the Body of Evidence
Gerald Pilkington Associates Gerald Pilkington Associates, Hampshire. 2011

The report ‘Homecare Re-ablement Prospective Longitudinal Study Final Report’ (Dec 2010) commissioned by the Department of Health’s Care Services Efficiency Delivery programme (CSED) has provided further insight and understanding about the nature and beneficial impacts of homecare re-ablement. However, some of the report content has resulted in a lack of clarity. The aim of this paper is to set out some of the background to the report and provide clarity on the learnings that can be gained with regard to the cost effectiveness of homecare re-ablement services. Contrary to impressions set out in various articles, the report does not indicate that homecare re-ablement as an approach has little financial benefits for a council. What it does illustrate is that councils should undertake a baseline exercise to establish an understanding of the local position and then to operationally performance manage their service to ensure that it is and remains cost effective whilst maximising the benefits of independence for as large a number of people as possible.

The Home Cure
Wood C and Salter J Demos, London. 2012

A report by Demos that describes the policy background and current evidence about cost effectiveness of reablement services. Based on research with Midland Heart Housing Association it makes recommendations for improving outcomes by engaging housing providers in reablement. In particular it suggests ways to ensure that the reablement process can continue for those who need more than 6 weeks support and that more attention is given to regaining independence outside the home.

The MoRE project: Models of reablement evaluation: a mixed methods evaluation of a complex intervention
Beresford B, Aspinal F, Parker G, et al Socia Policy Research Unit, York. 2017

This mixed-methods study aims to evaluate the effectiveness and cost-effectiveness of different ways of providing reablement in England.

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