The Hopkins Rehabilitation Engagement Rating Scale – Reablement Version (HRERS‐RV): Development and psychometric properties

Patient or user engagement with health and social care interventions is receiving increased attention and interest within practice settings and research. An English evaluation of three reablement services wished to include a measure of user‐engagement so as to explore its association with outcomes. As no measure of reablement engagement existed, an existing measure designed for use with physical rehabilitation patients (the Hopkins Rehabilitation Engagement Rating Scale) was adapted and its psychometric properties were tested. The adapted version was completed by reablement staff at the time an individual (n = 129) was discharged from one of the three reablement services. Outcomes data (Barthel Index, Nottingham Extended Activities of Daily Living Scale, General Health Questionnaire‐12) collected by the evaluation study at baseline (that is, at entry into reablement), discharge and 6 months postdischarge was used for some psychometric testing. Internal consistency and construct, predictive and discriminant validity were investigated. The adapted scale measured a single construct and had good internal consistency. Tests of predictive and discriminant validity were positive. Findings from a separate, small‐scale (n = 31) test–retest study offer an early indication that this is acceptable. There was, however, evidence of a ceiling effect and we consider ways this may be ameliorated. The Hopkins Rehabilitation Engagement Rating Scale – Reablement Version offers a means by which user engagement in reablement can be measured using a staff‐completed instrument. The association between engagement and reablement outcomes, revealed when testing for predictive validity, supports the argument for greater attention and investment in research on user engagement in reablement. More broadly, researching engagement within the context of an intervention often delivered by multiple practitioners offers the opportunity to further understand this concept which, in the past, has particularly focused on interventions delivered by a single practitioner. In addition, future work should include developing a companion measure completed by service users.     

Cost‐minimisation analysis of home care reablement for older people in England: A modelling study

Many governments have introduced or encouraged home‐care reablement schemes for older people at home with the aim of improving outcomes and reducing costs. We examined if such schemes have the potential to reduce costs from the perspective of the National Health Service (NHS) and Personal Social Services (PSS) in England. Our study was carried out to inform recommendations of a national guideline. Cost‐minimisation analysis was carried out using decision‐analytic Markov modelling. Home‐care reablement was compared with standard home care. Costs included those of the intervention, home care and hospital admission. Uncertainty was explored using univariate and probabilistic sensitivity analysis. Mean costs per person were £56,499 (95% confidence interval 55,690 to 57,307) in the reablement group, and £58,560 (95% confidence interval 57,800 to 59,319) in the standard care group. The mean difference was ‐£2,061 (95% confidence interval 1,933 to 2,129). The probability that home‐care reablement costs less than standard home care was 94.5% (95% confidence interval 93.1 to 95.9). In sensitivity analyses, this probability remained above 85% in all scenarios. Home‐care reablement can be a successful cost‐minimisation strategy for supporting some older people. More research is needed about the impact of home‐care reablement on health outcomes for different groups of older people; and the effects of different durations of reablement on outcomes and costs for different subpopulations.     

Progress and problems in developing outcomes-focused social care services for older people in England

Social care services for adults are increasingly required to focus on achieving the outcomes that users aspire to, rather than on service inputs or provider concerns. This paper reports a study aimed at assessing progress in developing outcomes-focused services for older people and the factors that help and hinder this. It describes the current policy context and discusses the social care service outcomes desired by older people. It then reports on a postal survey that identified over 70 outcomes-focused social care initiatives across England and Wales, and case studies of progress in developing outcomes-focused social care services in six localities. The study found progress in developing outcomes-focused services was relatively recent and somewhat fragmented. Developments in intermediate care and re-ablement services, focusing on change outcomes, were marked; however, there appeared to be a disjunction between these and the capacity of home care services to address desired maintenance outcomes. Process outcomes were addressed across a range of re-ablement, day care and residential services. The paper concludes by discussing some of the challenges in developing outcomes-focused social care services.     

Exploring the cost-effectiveness of advance care planning (by taking a family carer perspective): Findings of an economic modelling study

Advance care planning is considered an important part of high-quality end-of-life care. Its cost-effectiveness is currently unknown. In this study, we explore the cost-effectiveness of a strategy, in which advance care planning is offered systematically to older people at the end-of-life compared with standard care. We conducted decision-analytic modelling. The perspective was health and social care and the time horizon was 1 year. Outcomes included were quality-adjusted life years as they referred to the surviving carers. Data sources included published studies, national statistics and expert views. Average total cost in the advance care planning versus standard care group was £3,739 versus £3,069. The quality-adjusted life year gain to carers was 0.03 for the intervention in comparison with the standard care group. Based on carer's health-related quality-of-life, the average cost per quality-adjusted life year was £18,965. The probability that the intervention was cost-effective was 55% (70%) at a cost per quality-adjusted life year threshold of £20,000 (£30,000). Conducting cost-effectiveness analysis for advance care planning is challenging due to uncertainties in practice and research, such as a lack of agreement on how advance care planning should be provided and by whom (which influences its costs), and about relevant beneficiary groups (which influences its outcomes). However, even when assuming relatively high costs for the delivery of advance care planning and only one beneficiary group, namely, family carers, our analysis showed that advance care planning was probably cost-effective.     

Managing effective partnerships in older people's services

The integration of older people's services is a challenge to all countries with an ageing population. Although it is widely acknowledged that acute care, long-term care, social care, housing, leisure, education and other services should all operate in a more 'joined-up manner', achieving this in practice remains extremely difficult. Against this background, the European Union (EU) Care and Management of Services for Older People in Europe Network (CARMEN) project set out to explore the management of integrated care in 11 EU countries. Summarising key themes from the project, this paper explores the management of integrated care, the skills required, the mechanisms which aid successful integrated approaches, and future research priorities. Although very challenging, the concept of integrated care is still a promising way forward when seeking to meet the challenges of an ageing society.     

Ideal and reality; Community healthcare professionals’ experiences of user‐involvement in reablement

Many welfare states offer reablement, also known as restorative care, as an intervention to promote healthy ageing and support older adults in regaining or maintaining their independence in daily life. Reablement is a time‐limited, intensive, multidisciplinary, person‐centred and goal‐directed rehabilitative intervention. Reablement emanates from the user’s goals, thus user‐involvement is a key factor. The aim of our study was to explore healthcare professionals’ experiences of user‐involvement in reablement. The context for the study was an urban municipality in south‐eastern Norway where reablement had been implemented into home‐care services 1.5 years prior to the study. Eighteen healthcare professionals recruited from home‐care services participated in focus groups. The material was analysed using qualitative content analysis. The findings resulted in one main theme: Transforming user‐involvement from ideal to reality—a demanding process, and four sub‐themes: (a) An ideal of self‐determination and co‐operation; (b) Diverse ability to commit to what user‐involvement requires; (c) Continuous co‐creation processes; and (d) Challenged by old traditions. User‐involvement is a valued ideal that professionals strive towards when providing healthcare. Two main strategies that professionals use to enable user‐involvement were identified here: spending sufficient time and having patience with users during the initial stage of an intervention, and starting an intervention by introducing small tasks that users can master. It was also seen that if the time and arenas for interdisciplinary meetings were lacking, professionals could demonstrate traditional attitudes and practice when faced with limited user‐involvement in the intervention. There is a need for follow‐up over time at the structural, personal, and cultural levels to develop reablement as an intervention with a strong person‐centred approach. The findings of this study have relevance for practice development in several reablement settings.     

Elderly people's perspectives on health and well-being in rural communities in England: findings from the evaluation of the National Service Framework for Older People

Addressing the problems of meeting the needs of ageing populations in rural areas is recognised as a political and service delivery challenge. The National Service Framework (NSF) for Older People (NSFOP) set out a series of service standards to raise quality, to redress variations in service use and to enhance the effectiveness of services across health and social care in England and alluded to the challenges of meeting such standards in rural communities. This paper reports findings from the consultations undertaken with 713 elderly people as part of the midpoint review of the NSFOP in 2006, presenting and analysing the views and experiences of elderly people from rural areas. The consultations to engage with elderly people employed a mixed methodology that included public events, focus groups and individual interviews. The data reveal participants' views of how different patterns of social change in diverse country areas in England influence health and well-being in later life. The costs and benefits of centralization of services, and the pivotal issue of transport are important themes. The findings raise questions about the unclear and contradictory usages of the term 'rural' in England and the portrayal of rural ageing as a homogeneous experience.     

Making choices about support services: disabled adults' and older people's use of information

This paper explores how disabled adults and older people find and use information to help make choices about services. It presents findings from a qualitative longitudinal study in England. Thirty participants had support needs that fluctuated, meaning that additional services might be needed on a temporary basis; and 20 had the sudden onset of support needs resulting from an accident or rapid deterioration in health. Each disabled adult or older person was interviewed three times between 2007 and 2009, using a semi-structured topic guide. They were asked to discuss a recent choice about services, focussing, amongst other things, on their use of information. Interviews were transcribed and coded, then charted according to emergent themes. A wide range of choices and sources of information were discussed. These were dominated by health and to some extent by social care. Key findings are that information was valuable not just in weighing up different service options, but as a precondition for such choices, and that disabled adults and older people with the gradual onset of support needs and no prior knowledge about services can be disadvantaged by their lack of access to relevant information at this pre-choice stage. Timely access to information was also important, especially for people without the support of emergency or crisis management teams. Healthcare professionals were trusted sources of information but direct payment advisers appeared less so. Ensuring that practitioners are confident in their knowledge of direct payments, and have the communication skills to impart that knowledge, is essential. There may be a role also for specialist information advocates or expert lay-advisers in enabling disabled adults and older people to access and consider information about choices at relevant times.     

Costs and health outcomes of intermediate care: results from five UK case study sites

The objectives of this study were to explore the costs and outcomes associated with different types of intermediate care (IC) services, and also to examine the characteristics of patients receiving such services. Five UK case studies of 'whole systems' of IC were used, with data collected on a sample of consecutive IC episodes between January 2003 and January 2004. Statistical differences in costs and outcomes associated with different IC services and patient groups were explored. Factors associated with variation in IC episode outcomes (EuroQol EQ-5D and Barthel Index) were explored using an econometric framework. Data were available for 2253 episodes of IC. In terms of Department of Health criteria, a large proportion of patients (up to 47% of those for whom data were available) in this study were inappropriately admitted to IC services. As regards service function, compared to supported discharge, admission avoidance services were associated with both lower costs and greater health and functional gains. These gains appear to be driven, in part, by illness severity (more dependent patients tended to gain most benefit). In addition, these gains appear to be larger where the admission was appropriate. Our work suggests a need for the development and application of robust and reliable clinical criteria for admission to IC, and close co-operation between hospital and community service providers over selection of patients and targeting of IC and acute care services to meet defined clinical need.     

Buying time II: an economic evaluation of a joint NHS/Social Services residential rehabilitation unit for older people on discharge from hospital

The study's aim was to investigate the cost-effectiveness of an NHS/Social Services short-term residential rehabilitation unit (a form of intermediate care) for older people on discharge from community hospital compared with 'usual' community services. An economic evaluation was conducted alongside a prospective controlled trial, which explored the effectiveness of a rehabilitation unit in a practice setting. The aim of the unit was to help individuals regain independence. A matched control group went home from hospital with the health/social care services they would ordinarily receive. The research was conducted in two matched geographical areas in Devon: one with a rehabilitation unit, one without. Participants were recruited from January 1999 to October 2000 in 10 community hospitals and their eligibility determined using the unit's strict inclusion/exclusion criteria, including 55 years or older and likely to benefit from a short-term rehabilitation programme: potential to improve, realistic, achievable goals, motivation to participate. Ninety-four people were recruited to the intervention and 112 to the control group. Details were collated of the NHS and Social Services resources participants used over a 12-month follow-up. The cost of the resource use was compared between those who went to the unit and those who went straight home. Overall, costs were very similar between the two groups. Aggregated mean NHS/Social Services costs for the 12 months of follow-up were pound 8542.28 for the intervention group and pound 8510.68 for the control. However, there was a clear 'seesaw' effect between the NHS and Social Services: the cost of the unit option fell more heavily on Social Services (pound 5011.56, whereas pound 3530.72 to the NHS), the community option more so on the NHS (pound 5146.74, whereas pound 3363.94 to Social Services). This suggests that residential rehabilitation for older people is no more cost-effective over a year after discharge from community hospital than usual community services. The variability in cost burden between the NHS and Social Services has implications for 'who pays' and being sure that agencies share both pain and gain.     

Buying Time I: a prospective, controlled trial of a joint health/social care residential rehabilitation unit for older people on discharge from hospital

The study's objective was to determine the effectiveness of a joint NHS/Social Services rehabilitation unit (a form of intermediate care) for older people on discharge from community hospital, compared with 'usual' community services. This was a controlled clinical trial in a practice setting. The intervention was 6 weeks in a rehabilitation unit where individuals worked with care/rehabilitation assistants and occupational therapists to regain independence. Controls went home with the health/social care services they would ordinarily receive. Participants were from two matched geographical areas in Devon: one with a rehabilitation unit, one without. Recruitment was from January 1999 to October 2001 in 10 community hospitals. Study eligibility was assessed using the unit's inclusion/exclusion criteria: 55 years or older and 'likely to benefit from a short-term rehabilitation programme' ('potential to improve', 'realistic and achievable goals' and 'motivation to participate'). Ninety-four people were recruited to the intervention and 112 to the control. The mean (standard deviation) age was 81.8 (8.0) years. The main outcome measure was prevention of institutionalisation assessed by the number of days from baseline interview to admission to residential/nursing care or death ('survival-at-home time'). Secondary outcome measures were time to hospital re-admission over 12 months, quality of life and coping ability. There were no significant differences between the groups on any outcome measure. Adjusted hazard ratio (95% CI) for 'survival-at-home time' was 1.13 (0.70-1.84), and 0.84 (0.53-1.33) for 'time to hospital re-admission'. However, attending the unit was associated with earlier hospital discharge. Median (interquartile range) days in hospital for the intervention graph was 27 (20, 40), and for the control graph was 35 (22, 47) (U = 4234, P = 0.029). These findings suggest a stay in a rehabilitation unit is no more effective than 'usual' care at diverting older people from hospital/long-term care. Alternative service configurations may be as effective, having implications for tailoring services more specifically to individual need and/or user preferences. However, the unit did appear to facilitate earlier discharges from community hospital.     

The costs of care: An ethnography of care work in residential homes for older people

The cost of social care, the work conditions experienced by care workers and the quality of care provided by residential homes for older people are all linked, yet we know very little about how this relationship works in practice. Drawing upon an ethnography of two differently priced residential care homes for older people in Southern England, I examine the implications of different financial regimes for care-giving practices. I show how the scheduling and allocation of resources—conveyed, for example, in formal routines and staffing levels—structure the care workers’ time, tasks and activities in each setting. This acts to symbolically demarcate what, or who, is valued. I argue that the availability of resources facilitates and impedes the symbolic culture of care work, shapes care workers’ ability to afford dignity to the individuals in their care and affects how care workers experience, and relate to, their labour. I conclude by discussing how current practices of funding and pricing social care have effects seeping beyond the practical and measurable, and into the realm of the symbolic.     

The Impact of Home-Based Primary Care on Outcomes Among Older Adults in South Korea

ObjectivesAlthough Korea issued a law and developed benefits of National Health Insurance (NHI) to enable the provision of home-based primary care (HBPC) along with implementation of a pilot project for community care for older adults in August 2019, the outcomes of HBPC services were not surveyed in Korea. This study aimed to assess the outcomes of HBPC among older adults.DesignAnalyses were conducted using data from the National Health Insurance Service in connection with administrative survey data. Difference-in-differences analysis was performed using a generalized estimating equation and Cox proportional hazards model.Setting and ParticipantsOverall, 538 older adults who used HBPC services in a pilot project for community care and 2059 propensity score–matched older individuals who did not use HBPC services in Korea were included.MethodsThe length of home stay, total costs of NHI, hospitalizations, and admission to long-term care (LTC) facilities were measured as outcomes, and the outcomes of the participants were compared to those of the control group.ResultsThe findings indicated an increase of 8.3 days (95% CI 2.1-14.5) in the length of home stay and a reduction of US$1241 (95% CI −2342 to −139) in total costs of NHI among older adults who used HBPC services compared to the control group. The odds ratio for rates of hospitalization among older adults who utilized HBPC services was 0.77 (95% CI 0.60-0.98) and the hazard ratio for the admission of LTC facilities was 0.12 (95% CI 0.04-0.32) in comparison to the control group.Conclusions and ImplicationsThe HBPC intervention has resulted in an increased length of home stay and reduced total costs, hospitalizations, and admission to LTC facilities among Korean older adults. In the future, new HBPC models must be developed to provide interprofessional team–based HBPC services with a standardized protocol of service provision.     

Conducting an advance care planning group among older adults living in residential care homes: An initiative of social workers in Hong Kong

This study aimed to examine the effects of an advance care planning (ACP) group which was developed by social workers in Hong Kong for older adults. A quasi-experimental study was conducted. Participants were recruited from 14 residential care homes. The ACP intervention group included 59 participants for analyses, and the control group 58. Three major outcomes were measured at two time points: (a) Quality-of-life concerns, (b) End-of-life preference and (c) Advance directive (AD)-related outcomes (awareness of AD, AD completion, willingness to complete AD and communication with family members about AD). Findings indicate that the ACP group enhanced participants’ awareness of AD compared with the control group. Participants were also more willing to complete AD, and more participants communicated with family members about AD after participating in the ACP group. No significant difference was found in other outcomes. This study demonstrates the efforts of social workers in promoting ACP in Hong Kong and the effectiveness of an ACP group for enhancing older adults’ awareness of AD. Findings support the role of social workers in promoting ACP for deprived groups, like frail older adults. The ACP group could be considered a first step in enhancing older adults’ awareness of and willingness to discuss end-of-life issues. Further follow-up is required to develop individualised ACP for older adults.     

Prevention: developing a framework for conceptualizing and evaluating outcomes of preventive services for older people

There is growing preoccupation among policy makers and commissioners in developing preventive strategies and services. There is simultaneous concern with evidence‐based purchasing and provision, within health and social care. In social care the evidence base regarding prevention is neither extensive nor robust. As the review of recent policy documents indicates, the concept of prevention is extremely slippery. What preventive services are and whether they are effective depends on the specific policy context, the overall service objectives and the perspective on outcomes adopted (user, carer, professional, service). Focusing on older people, the paper seeks a way through the confusion, locating prevention within a theoretical model of successful ageing. This conceptualises ageing as involving adaptation to the changing balance between gains and losses over the life course. Successful ageing is perceived as the attainment of valued goals, the minimisation of losses and maximisation of gains through the linked processes of selective compensation and optimisation. The paper then identifies necessary elaborations of the model to take into account the wider cultural and socio‐economic context. This shapes and constrains the goals pursued and the resources available in adopting particular adaptation strategies. Within this model, preventive services may be conceived as resources to be drawn upon to support compensatory strategies. Similarly, outcomes and effectiveness of services may be evaluated in terms of whether they facilitate/allow older people to achieve valued goals. In developing and evaluating preventive services in social care the question of interest is reformulated: what contribution do specific services make in optimising gains and compensating for the losses that accompany ageing? This framework is explored in respect of two substantive areas ripe for secondary prevention services and strategies – bereavement and instrumental support in the home.     

Mechanisms to enhance the effectiveness of allied health and social care assistants in community‐based rehabilitation services: a qualitative study

This research aims to describe the factors associated with successful employment of allied health and social care assistants in community‐based rehabilitation services (CBRS) in England. The research involved the thematic analysis of interviews and focus groups with 153 professionally qualified and assistant staff from 11 older people's interdisciplinary community rehabilitation teams. Data were collected between November 2006 and December 2008. Assistants were perceived as a focal point for care delivery and conduits for enabling a service to achieve goals within interdisciplinary team structures. Nine mechanisms were identified that promoted the successful employment of assistants: (i) Multidisciplinary team input into assistant training and support; (ii) Ensuring the timely assessment of clients by qualified staff; (iii) Establishing clear communication structures between qualified and assistant staff; (iv) Co‐location of teams to promote communication and skill sharing; (v) Removing barriers that prevent staff working to their full scope of practice; (vi) Facilitating role flexibility of assistants, while upholding the principles of reablement; (vii) Allowing sufficient time for client–staff interaction; (viii) Ensuring an appropriate ratio of assistant to qualified staff to enable sufficient training and supervision of assistants; and (ix) Appropriately, resourcing the role for training and reimbursement to reflect responsibility. We conclude that upholding these mechanisms may help to optimise the efficiency and productivity of assistant and professionally qualified staff in CBRS.     

Food provision for older people receiving home care from the perspectives of home‐care workers

Malnutrition is a significant cause of morbidity and mortality, particularly among older people. Attention has focused on the inadequacies of food provision in institutions, yet the majority suffering from malnutrition live in the community. The aim of this study was to explore barriers and facilitators to food provision for older people receiving home care. It was a qualitative exploratory study using semi‐structured interviews with nine home‐care workers in June 2013 employed by independent agencies in a large city in northern England. Data were analysed thematically, based on the principles of grounded theory. Findings showed that significant time pressures limited home‐care workers in their ability to socially engage with service users at mealtimes, or provide them with anything other than ready meals. Enabling choice was considered more important than providing a healthy diet, but choice was limited by food availability and reliance on families for shopping. Despite their knowledge of service users and their central role in providing food, home‐care workers received little nutritional training and were not involved by healthcare professionals in the management of malnutrition. Despite the rhetoric of individual choice and importance of social engagement and nutrition for health and well‐being, nutritional care has been significantly compromised by cuts to social care budgets. The potential role for home‐care workers in promoting good nutrition in older people is undervalued and undermined by the lack of recognition, training and time dedicated to food‐related care. This has led to a situation whereby good quality food and enjoyable mealtimes are denied to many older people on the basis that they are unaffordable luxuries rather than an integral component of fundamental care.