Improving Independence – Can Homecare Re-ablement Make a Difference in the Long Term?

Abstract

Adult social care services are increasingly developing home care re-ablement services. Findings from a new study of four councils with adult social services responsibilities indicate that re-ablement may reduce the subsequent use of home care services. For some people, it is possible that benefits may be sustained for 12 months or longer. Whilst there is no one single ‘blueprint’ for a successful re-ablement service, a number of common issues did emerge as either enhancing – or limiting – the benefits of home care re-ablement services.

Homecare re-ablement is now very firmly on the agenda of adult social care services.

In 2006, the Department of Health’s Care Services Efficiency Delivery (CSED) Programme, reviewed progress in developing homecare re-ablement services in England.   This showed that by the end of 2006, 60 councils had a homecare re-ablement service of some kind and a further 40 were either planning to establish a service or wished to do so. 

Across health and social care the terms ‘re-ablement’, ‘enablement’, ‘rehabilitation’ and ‘intermediate care’ tend to be used loosely, and the boundaries between the services they refer to are often blurred.  The definition of re-ablement adopted by CSED was: ‘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.’  Some re-ablement services are provided jointly with NHS partners; others are provided within adult social care, but with easy access to health expertise such as therapists.  In some local authorities, re-ablement services are being developed following reviews of in-house home help services.  Probably the most significant distinction in re-ablement services is between:

‘Intake’ services, which commonly accept all referrals of people assessed as needing or being eligible for homecare, and then screen out only those considered unlikely to benefit from re-ablement. 

‘Discharge’ or ‘discharge support’ services which primarily accept referrals of people leaving hospital, accepting only those people certain to benefit from a re-ablement approach.

The evidence from the few services which have been evaluated  suggests that there are significant reductions in use of homecare services following ‘discharge’ from a re-ablement service, compared with assessed levels of need on ‘entry’ to the service.  However, there has been no research into the longer term impact of re-ablement.  How long might any reductions in the use of homecare service last?  What factors might influence subsequent service use?

To begin to address this gap, in 2007 CSED commissioned further research.  The study team worked with four councils with adult social service responsibilities:  Leicestershire County Council, Salford City Council, London Borough of Sutton and Wirral Metropolitan Borough Council.  All four councils had re-ablement services which had been established for at least four years.  Two of the services were ‘intake’ services and two ‘discharge support’ services.

In each council we obtained anonymised information on the use of services by all clients who had an episode of homecare re-ablement in 2004-5, including the level of social care services they used over the following two years (2005/06 and 2006/07).  These data were then analysed to gain an insight into the overall impact of re-ablement, and the duration of that impact.  We examined:

• The ‘population’ of re-ablement service users in each area, including their age, gender, ethnicity and patterns of service use.
• The number of weeks from the end of re-ablement to the point at which they first used homecare services.
• The proportions of re-ablement service users who had continued with the same level of home-care service, increased their use of homecare, or reduced their use of homecare), at the snapshot points of 3, 6, 12, 18 and 24 months after re-ablement.
• The intensity of homecare use after re-ablement at the snapshot points of 3, 6, 12, 18 and 24 months.  This measure drew on the ‘categories’ used in the HH1 returns, which all councils submit to the Department of Health (i.e. two hours or less; two to five hours; six to ten hours; and more than ten hours each week).

The evidence on changes in use of homecare services over the two years after re-ablement appears very positive.  When examining use of home care following a period of re-ablement, in Leicestershire and Sutton, the percentages of service users needing less homecare than they did on leaving re-ablement actually increased over the two year period, including among the 85 years and over age group.  In Salford the percentages of service users needing progressively more homecare increased over the two years, but only slightly.  

When we looked at the intensity of use of homecare, there did not appear to be any notable changes in the proportions of service users in each of the HH1 intensity of homecare usage categories, at the different snapshot points examined.  Given that the data from each site relates to a cohort of service users’ progress over two years, it is perhaps surprising that the proportion of service users in the higher intensity categories does not increase more markedly.  This might be a valuable issue for councils providing re-ablement services to monitor, and an important effect to be examined in any future research into the longer term impact of re-ablement.

The analysis of the time from the end of re-ablement to the first homecare episode suggests that re-ablement service users fall in to two broad groups: those who gain immediate but relatively short term (up to three months) benefit from re-ablement before starting to use homecare services; and those for whom the impact is more sustained, possibly delaying their use of homecare services by a year or more.  This is clearly an important issue which would benefit from further examination.  If it is a genuine effect of re-ablement it would be valuable to identify whether the service users in the two groups share any common characteristics, and whether they benefit from different approaches to re-ablement or different lengths of time in re-ablement.

We also carried out interviews with re-ablement service managers and at least one care management team manager in each of the four authorities.  We were interested in their perceptions of the impact of re-ablement services on the demand for social care services.  The managers in all four authorities believed the re-ablement services had the effect of reducing demand for on-going social care support.  This was not just because re-ablement improved people’s physical functioning and ability to manage practical tasks in the home; managers also stressed the importance of building confidence and promoting well-being, which could have far-reaching impact on many aspects of users’ lives.

The re-ablement service and care management team managers also suggested that a number of factors could affect whether, and for how long, any benefits of re-ablement service were sustained.  These included:
• Access to appropriate housing.
• Access to equipment, assistive technology and telecare.
• Access to, and information about, wider social and community support.

In addition, carer involvement, carers’ attitudes to re-ablement, and their access to ongoing support was considered a key factor in achieving positive outcomes for re-ablement service users.

Where people required ongoing homecare support following re-ablement, this was often provided by independent sector organisations. Managers were concerned that current commissioning arrangements could undermine the benefits of re-ablement, including:
• Inflexible contracts which made it difficult to provide flexible hours as required.
• Funding arrangements which did not offer incentives for providers to identify and promote users’ continuing independence, if this was likely to mean reductions in the provision of home care services.
• A culture (reinforced by contractual arrangements) concerned with inputs rather than outcomes.
• Home care staff not trained in a re-ablement approach.

Key lessons for CASSRs establishing re-ablement services

The four re-ablement services differed in their histories and operation, and the results of the data analysis give no indication of a ‘blueprint’ for a successful re-ablement homecare service.  However, some of the key lessons shared by sites were:

• Training: Staff training in the ethos and practice of re-ablement is key.  This is particularly important where new re-ablement services staff are not being recruited but are transferring from existing home help services.

• Communicating the re-ablement ethos: The service should communicate its re-ablement ethos clearly to staff, other agencies, service users and carers.  This enables effective referral and ensures that everyone understands the short-term, goal-oriented nature of the service.

• Capacity: This is an issue both for the re-ablement service itself and for ongoing home care and other services.  It is vital that both access to re-ablement, and the ability to refer on for longer term support are adequate, so that the re-ablement service does not get blocked.

• Flexibility: Most re-ablement services are offered for six weeks.  However, some flexibility around this target should be possible, where individuals can benefit from a longer period of re-ablement.

• Access: Access to re-ablement services should be as wide as possible.  Several managers commented on the value of assisting people with small changes and the need to avoid focussing on those who will most obviously benefit.  Indeed, those sites that currently operated a more selective ‘discharge support’ service were all planning to move towards a more open ‘intake’ approach.

• Relationship to other professionals: The skill-mix of re-ablement teams varied – some included occupational therapists, others did not.  However, close working relationships with other services, easy access to other professional skills and resources, and the ability to make swift referrals were of obvious importance.

• Relationship with carers: Re-ablement staff need to work with carers in order to build up understanding so that issues such as perceptions of risk can be dealt with appropriately.

• Role in assessment/review: Responsibilities for assessments and reviews varied between sites; some experienced tensions around this or were concerned about duplication of effort.  Discussions with the sites highlighted the need for clarity of role, and the importance of the re-ablement service in undertaking regular reviews.

• A ‘whole systems’ approach: Whilst none of the sites claimed to have achieved a whole systems re-ablement culture, they all regarded this as an important area of development, so that this approach could be sustained on a multi-professional and cross-agency basis.  In particular, they stressed the importance of independent homecare providers being able to at least sustain the gains achieved during re-ablement.  This needed changes to commissioning/ contracting arrangements, including working with independent sector providers to increase the flexibility and skills of homecare staff, and in some areas improving capacity in the sector as a whole.

Without robust and detailed baseline data, and a control group for comparison, we cannot be completely certain that the patterns of service use which emerged from the study are directly and predominantly the result of re-ablement.  However, the findings do suggest that re-ablement has the potential to reduce demand for homecare services both in the short and long-term.  For councils currently developing re-ablement services, there are important lessons to be learned about how to get the most from their investment in homecare re-ablement.

Notes on the authors

Liz Newbronner is a Director of Acton Shapiro Consultancy and Research and a Visiting Fellow in the Department of Health Sciences at the University of York.  She has a MBA in Health and Social Services Management and has worked in both the NHS management and university research.

Ruth Chamberlain is a Senior Researcher with Acton Shapiro. She has Masters Degrees in Women’s Studies and Applied Social Studies and is a qualified social worker.

The research reported here was funded by the Department of Health.  Any views are those of the authors alone.

Further information on re-ablement can be obtained from the Department of Health’s Care Services Efficiency Delivery (CSED) Programme: www.csed.csip.org.uk.

Notes

 .  Care Services Efficiency Delivery Programme (2007) Homecare Re-ablement Workstream Discussion Document.

 .  Centre for Group Care and Community Care Studies, De Montfort University and Leicestershire County Council (2000) External Evaluation of the Homecare Re-ablement Pilot Project.