2. PRACTICE ISSUE TWO: Specialist services to shift the balance of care
Homecare reablement can be defined as an input that aims to: Maximise [service] users long-term independence, choice and quality of life, to appropriately minimise on-going support required and to consequently minimize the whole-life cost of care. CSED, 2007 The aim therefore is to increase service users’ confidence and skills with the eventual goal being a reduction or withdrawal of services required. To date, the research findings have been largely positive. An evaluation undertaken by De Montfort University (2000) provided evidence of a reduction in commissioned hours for those undergoing a period of reablement when compared with a control group. A more recent evaluation in Edinburgh found a considerable reduction in hours required, with two thirds of service users requiring no further service at the end of the reablement period (McLeod and Mair, 2009). Similarly, positive results were reported by Ryburn and her colleagues (2009) in their literature review of reablement in the UK and the USA. A study published by the Department of Health (2010) added a longitudinal element to the research. Their findings were mixed. While they found that older people with higher level needs had reduced packages of care after a period of reablement, their comparison with control groups suggested that when taken together there was no statistically significant difference in the costs for health and social care. Slasberg (2009) has questioned the methodology of such studies. In relation to the Leicester study for example, he highlighted that those allocated a package of reablement were those thought to be most likely to benefit. This suggests conversely that those allocated to the control group were less likely to benefit and so it is unsurprising that they required a greater number of homecare hours. He found that reablement was unlikely to reduce the number of admissions overall as despite having higher than average homecare provision this has not resulted in fewer admissions to residential care. He suggests that a change in focus from the provision of reablement services to the development of a reablement culture aimed at all service users is necessary.
Four case study sites were selected that offered reablement services (two as part of the homecare service and two as part of the hospital discharge process). A range of data was routinely gathered on those who received homecare reablement and services subsequently used and interviews were carried out with service managers. The study found substantial reductions in homecare packages two years after receiving a reablement service. One of the key messages emerging from the study was the need to promote the reablement approach across all of adult social care to ensure long term outcomes. This requires a more flexible approach than perhaps the standard six week package allows. It also requires a shift in attitudes amongst staff, service users and carers. Staff training is required. Social Policy Research Unit (2007) Home care reablement: Retrospective, Longitudinal Study
Implications for practice
For homecare reablement to be effective:
- a clearly agreed assessment process is essential
- person-centred flexible support ensures greatest success for service users
- inclusion of an OT in a team can promote faster access to equipment and adaptations
- staff should have a pro reablement attitude and be supported via appropriate training, eg SVQ level 2
- referral systems to follow-on services should be transparent to avoid delays
- there should be acknowledgement of the importance of working with carers on the reablement journey.
Prevention of admission/supported discharge models
Delayed discharge continues to be a significant problem across the UK, although numbers have reduced over recent years. For example, NHS Scotland (Information and Statistics Division, 2010) reports that in July 2010 there were 62 patients delayed over six weeks compared to 2,162 patients in October 2001 when figures were at their highest. Particular groups are more likely to experience a delayed discharge including older people with higher level needs. This relates to the availability of support networks of friends and family, levels of affluence and availability of staff (eg Gilbert et al, 2010). The Commission for Social Care Inspection published a review in 2004 of major initiatives to speed up hospital discharge. They found that although the process of discharge was speeded up, if appropriate services were not in place the well being of service users suffered. Hubbard et al (2008) also found that there was a need to develop interim care measures to support those with higher level needs to prevent delayed discharge. The available evidence on the success of various models of admission prevention and supported discharge is mixed. Walker and Jamrozik (2005) found that screening for medical emergencies made no significant impact on admissions among the over 75s. Wilson and colleagues (2006) found that depression was common among those being discharged from hospital and that it was a major risk to their long term survival in the community. On the other hand Hyde et al (2000) in a systematic review did confirm that supported discharge is associated with a reduction in future hospital admissions. Significantly the national evaluation of the Partnership for Older Peoples Projects in England found that overall interventions to prevent or delay older people’s need for high intensity or institutional care could reduce overnight stays in hospital by 47% and could improve their quality of life, particularly for those with complex needs (PSSRU, 2009) The disparity in the evidence can be accounted for by differences in outcomes being measured, populations being studied, definitions adopted and research methods used (Glasby et al, 2004). What is clear is that the evidence suggests that inter-related medical, functional and social problems need to be taken into account via appropriate assessment and screening. Shepperd et al (2010) found that a structured discharge plan tailored to the individual’s needs results in a small reduction in length of hospital stay and a reduction in readmission rates for older people. However, the impact of discharge planning on mortality, health outcomes and costs remains uncertain.
The early supported discharge scheme aimed to ensure a co¬ordinated and seamless transition for patients. It comprised a transitional care nurse and social care officers with an interest in dementia care. The team had links with a range of other professionals as well as the out of hours community alarm service, overnight community nursing and social work services. The six week duration of the programme was removed as it had resulted in few patients being accepted onto the service. The service resulted in a reduction in stay in hospital, a reduction in multiple emergency admissions, improved user and carer satisfaction and reduction in mainstream homecare packages on discharge. There were cost benefits for health and the local authority as a result of savings from the reduction in bed days, readmission and a reduction in care packages. Overall there was a reduction in costs of 55% (£4,303) per patient although this did not include the additional costs involved in running the service. Perth and Kinross: Transitional care at home service
Delayed discharge and people with dementia
People with dementia who have other health problems are more likely to be inappropriately admitted to hospital and are more likely to remain in hospital for longer, to the detriment of their own wellbeing. They are also more likely to be discharged to a care home. Inappropriate admissions can be addressed by increasing the availability of step up intermediate care services that offer a temporarily higher level of care for someone living at home to cope with a short-term need, instead of the person going into hospital. Step-down facilities, which offer rehabilitation following a hospital stay, can increase the number of people who return to their own homes.
Implications for practice
For delayed discharge models to be effective:
- requires a whole system approach which includes identifying the main causes for delay in the local system, developing services to tackle these causes, evaluating impact and monitoring the statistics
- discharge planning needs to begin on admission to hospital
- early supported discharge models can be effective: however they require clear commitment from carers in order to ensure an effective outcome for all involved.
It has been difficult to establish a reliable evidence base on the effectiveness of intermediate care as there is such a wide range of services available under this umbrella term. It appears that intermediate care is clinically equivalent to traditional in-patient services and makes little difference to the length of time that service users are able to stay in their own homes (Parker et al, 2000; Trappe-Lomax et al, 2006). It is thought that services have been too small, inadequately targeted or insufficiently integrated to achieve a whole system change to the care of older people (Young and Stevenson, 2006). The National Evaluation of the costs and outcomes of intermediate care (Barton et al, 2006) identified a number of benefits relating primarily to service user experiences and outcomes, particularly in relation to independence, quality of life and increased confidence (Regen et al, 2008). The research evidence highlights the importance of patient-centred, flexible and holistic services. One of the most important functions of intermediate care from the perspective of service users and carers was to support their reintegration into social networks (McLeod, et al, 2008). Challenges in delivering intermediate care relate to difficulties in the recruitment and retention of staff and a lack of effective joint working. (Barton et al, 2006; Regen et al, 2008). In addition, it is recommended that models of intermediate care adopt a holistic approach, providing practical support to maintain and enhance quality of life, provide an educational function, for example in terms of learning to use new technology as well as addressing psychological barriers that might exist in terms of returning to previous social networks.
The review aimed to map the development of intermediate care across England and to assess its impact on the lives of service users. It involved a postal survey of intermediate care co-ordinators and case studies of intermediate care systems. The research found that services differed in size and function; however generally the six week time limit was viewed as too narrow in scope. Partnership working was viewed as the single most important driver to the success of intermediate care although barriers relating to long term funding and staff shortages were identified. Service users reported satisfaction with the multi¬disciplinary aspect of intermediate care. Overall, costs and outcomes vary depending on the clinical need of the service user and the model of service adopted, with admission avoidance services costing less than supported discharge schemes. Barton et al (2006) National evaluation of the costs and outcomes of intermediate care
Rapid Response Teams
There is evidence to suggest that Rapid Response Teams assist in getting people home from hospital quicker and ensure that individuals can remain out of hospital (Beech et al, 2004). The evidence around the effectiveness of Rapid Response Teams is generally positive. Beech and colleagues found that 5.7 per cent of rapid response team patients were readmitted to acute hospital care. This is similar to other studies such as the National Audit Office study in 2003. On the other hand, a study by Young and Stevenson (2006) could not identify any clinical difference between those receiving intermediate care from the Rapid Response Team and a control group.
Implications for practice
For intermediate care services to be effective:
- Strict time limits can be unhelpful and require to be flexible without being endless
- Effective partnership working with multi¬disciplinary teams is most important element in success
- Home-like settings provide key benefits
- Stable funding with appropriate levels of staff is essential
- Ensuring awareness of role of service across agencies and disciplines
- A whole systems approach is required to ensure a clear care pathway.
Falls Prevention and Intermediate Care
Gilbert and colleagues (2010) found that older people admitted to hospital after a fall are more likely to be discharged to a care home than those (with similar characteristics) who are admitted to hospital for any other reason. Falls strategies are important in ensuring older people with higher level needs remain at home. Research into the effectiveness of such services found that a dedicated service reduced the need for emergency admissions (Rose et al, 2002). A Cochrane Review of interventions preventing falls in older people in the community (Gillespie and Handoll, 2009) found that exercise routines and other interventions that reduce and prevent falls could reduce overall care costs by preventing admission to hospital. Exercise-based interventions such as strength and balance training were effective in reducing falls as was Tai Chi and individually developed home-based exercise programmes. A gradual withdrawal of some psychotropic medications and a comprehensive prescribing modification programme for GPs were also found to reduce falls.
Implications for practice
For falls prevention work to be effective:
- A clear falls prevention strategy needs to be in place and part of the care pathway
- Multi-factorial programmes are seen to be most effective including person-centred exercise programmes
- Withdrawal of sedative or hypnotic medications can also increase success
- Surgical interventions, eg cataract operations, can produce effective outcomes.