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Reablement – what’s the evidence on outcomes? Caroline Glendinning Emeritus Professor of Social Policy Social Policy Research Unit University of York College of Occupational Therapists/Skills for Care 22nd July 2014
Outline of presentation • Background and early evidence • Major studies • SPRU (York)/PSSRU (Kent) 2008-10 • Perth (W Australia) 2005-07 • Concluding remarks
Background – growing interest in re-ablement • England 2000 onwards: development home care re-ablement services in most councils • Scotland 2013: Joint Improvement Team survey • 25/30 councils had home care re-ablement services • 17 of these planning to expand • From selective to inclusive services • Australia, New Zealand – growing provider interest
Early evidence on outcomes of home care re-ablement services • High proportions receiving re-ablement needed no further, or less, home care on discharge than those who received standard home care • 63% needed no further home care on discharge • 26% needed less home care than comparison group • But would they have recovered anyway? • … and how long do the effects last?
SPRU (York)/PSSRU (Kent) study 2008-10 Aimed to investigate longer-term impacts of home care re-ablement services, including: • Compare home care re-ablementvs standard home care • Assess user outcomes and use of NHS and social care services for up to 12 months • Estimate unit costs home care re-ablement services • Assess cost-effectiveness home care re-ablement • Describe organisation and content of home care re-ablement services • Examine user and carer experiences
Study design • 5 re-ablement councils, 5 conventional home care councils • Users recruited on referral – baseline interviews • Re-interviewed after 9-12 months • Data collected on: • Users’ health, quality of life, social care outcomes at baseline and follow-up, using standardised measures • Social care and NHS etc services used by both groups • Costs of re-ablement services (staff, overheads etc) • How re-ablement services organised and delivered • Experiences of users and carers
Results: impacts and costs of home care re-ablement services • Re-ablement had positive impacts on health-related quality of life and social care outcomes • Compared with conventional home care service use • Typical re-ablement episode (39 days) cost £2,088 • More expensive than conventional home care • But 60% less use of social care services subsequently • Over full year, total social care services used by re-ablement group cost £380 less than conventional home care • Re-ablement group – higher health service use and costs • Effects of recent hospital discharge?
Was home care re-ablement cost-effective? CE = compare improvements in outcomes against costs • NICE threshold £20-30K for each outcome gain • Re-ablement was cost-effective in relation to health-related quality of life outcomes • Re-ablement may be cost-effective in relation to social care outcomes • Depends on £ threshold • Higher healthcare costs of re-ablement group • Probability of cost-effectiveness only
User and carer perspectives • Poor initial understanding of re-ablement • Previous experiences of standard home care • Context of referral - crisis, hospital discharge • Value of repeated information • Appreciated frequent visits, monitoring • Quality of relationships crucial • Reported greater independence • improved confidence, relearned self-care skills • People discharged from hospital/recovering from accident/illness reported greater gains than those with long-term/progressive conditions • Felt shortcomings • More help with mobility/activities outside the home • Anxiety about end of re-ablement • Potential for greater carer involvement?
Perth (W Australia) study 2005-7 Assessed impact of ‘restorative’ home care on subsequent service use for 2 years • 750 older people randomised • Restorative home care • Standard home care • Service use records • Home care • A+E attendance • Hospital admissions - number and duration • Calculated costs of all services used
Outcomes after 2 years Compared to standard home care, restorative home care group: • Less likely to use on-going personal care services • Used fewer hours of home and (especially) personal care services • Less likely to be assessed as needing residential care • 30% less likely to have attended A+E • 31% less likely to have unplanned hospital admission • Had lower total (health + social care) service costs (average £1574 - £2380 less)
Reflections.... Growing body of evidence that re-ablement reduces service use and costs in short and longer terms. But outcomes and cost-effectiveness depend on: • How services are organised • Specialist service vs generic/extended assessment • Delays in onward referral • Who receives re-ablement • Inclusive vs selective services • Eligibility thresholds • What’s included in re-ablement interventions • Home care only vs wider range of skills/inputs • Rapid access equipment/AT • How long intervention lasts
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