Effectiveness of Reablement: A Systematic Review

Abstract

The ageing of the population and the increasing need for long-term care services are global issues. Some countries have adapted homecare programs by introducing an intervention called reablement, which is aimed at optimizing independence. The effectiveness of reablement, as well as its different service models, was examined. A systematic literature review was conducted using MEDLINE, CINAHL, PsycINFO and EBM Reviews to search from 2001 to 2014. Core characteristics and facilitators of reablement implementation were identified from international experiences. Ten studies comprising a total of 14,742 participants (including four randomized trials, most of excellent or good quality) showed a positive impact of reablement, especially on health-related quality of life and service utilization. The implementation of reablement was studied in three regions, and all observed a reduction in healthcare service utilization. Considering its effectiveness and positive impact observed in several countries, the implementation of reablement is a promising avenue to be pursued by policy makers.
Copyright © 2016 Longwoods Publishing.

Full text

HEALTHCARE POLICY Vol.11 No.4, 2016 [49]
RESEARCH PAPER
Effectiveness of Reablement: A Systematic Review
Efficacité de l’autonomisation: une revue systématique
ANNIE TESSIER, PHD
Researcher, Institut national d’excellence en santé et en services sociaux
Montréal, QC
MARIEDOMINIQUE BEAULIEU, MD, MSC, FCFP
Full professor, Department of Family and Emergency Medicine
University of Montréal
Montréal, QC
CARRIE ANNA MCGINN, MSC
Researcher, Institut national d’excellence en santé et en services sociaux
Montréal, QC
RENÉE LATULIPPE, MA
Researcher, Institut national d’excellence en santé et en services sociaux
Montréal, QC
Abstract
The ageing of the population and the increasing need for long-term care services are global issues.
Some countries have adapted homecare programs by introducing an intervention called reablement,
which is aimed at optimizing independence. The effectiveness of reablement, as well as its different
service models, was examined. A systematic literature review was conducted using MEDLINE,
CINAHL, PsycINFO and EBM Reviews to search from 2001 to 2014. Core characteristics and
facilitators of reablement implementation were identified from international experiences.
Ten studies comprising a total of 14,742 participants (including four randomized tri-
als, most of excellent or good quality) showed a positive impact of reablement, especially
on health-related quality of life and service utilization. The implementation of reablement
was studied in three regions, and all observed a reduction in healthcare service utilization.
Considering its effectiveness and positive impact observed in several countries, the implemen-
tation of reablement is a promising avenue to be pursued by policy makers.

[50] HEALTHCARE POLICY Vol.11 No.4, 2016
Annie Tessier et al.
Résumé
Le vieillissement de la population et l’augmentation des besoins en services de longue durée
sont des préoccupations mondiales. Certains pays ont adapté leurs programmes de soutien
à domicile en y intégrant une intervention nommée «autonomisation», laquelle vise à opti-
miser l’indépendance des clients. Nous avons examiné l’efficacité de l’autonomisation ainsi
que ses divers modèles de services. Nous avons procédé à une revue systématique à l’aide des
bases de données MEDLINE, CINAHL et PsycINFO ainsi que des revues fondées sur les
données probantes, entre 2001 et 2014. Un examen d’expériences internationales a permis
dedéterminer les caractéristiques clés de l’autonomisation et les facteurs favorisant le succès
de son implantation.
Dix études qui représentent un échantillon de 14742 participants (dont quatre essais
cliniques aléatoires, pour la plupart de bonne à excellente qualité) montrent un effet positif
de l’autonomisation, particulièrement sur le plan de la qualité de vie liée à la santé et sur
le plan de l’utilisation des services. Nous avons étudié l’implantation de l’autonomisation
dans trois régions, lesquelles ont toutes connu une réduction de l’utilisation des services
desoins de santé. En raison de son efficacité et de l’impact positif observé dans plusieurs
pays, l’implantation de l’autonomisation est une avenue prometteuse que devraient considérer
lesresponsables de politiques.
T
Introduction
The ageing population and the increasing need for long-term care services are global con-
cerns. Some countries have adapted their homecare programs by introducing restorative
homecare, or reablement, to optimize the independence of community-dwelling adults.
Reablement is defined as services for seniors with physical or mental disabilities that help
them adapt to their condition by learning or re-learning the skills needed to function in
everyday life (Social Care Institute for Excellence 2013). The objective is to help seniors live
independent and fulfilling lives, while appropriately reducing the need for continuing support
and reducing the cost of long-term services. Key characteristics are the provision of short-
term, goal-oriented interventions developed by an interdisciplinary team with the user, and
delivery of the interventions by a non-professional under the supervision of a professional
(Table 1). The focus is on promoting and optimizing functional independence rather than
resolving healthproblems.
The objective of this paper is to examine the effectiveness of reablement, and to identify
factors that might contribute to successful implementation for Canadian policy makers.
Areport in French intended for Quebec policy makers regarding implementation of
reablement can be consulted for more details (Tessier et al. 2015).

HEALTHCARE POLICY Vol.11 No.4, 2016 [51]
Effectiveness of Reablement: A Systematic Review
Methods
Effectiveness of reablement
A systematic review was conducted to evaluate the effectiveness of reablement. For a study to
be considered, the participants had to be over 65 years old, have functional limitations and be
living at home. The intervention did not need to be called reablement or restorative care, but
had to promote functional independence, be of short duration (6–12 weeks) and be provided
by paid workers as part of homecare services. The intervention had to be multidisciplinary
in nature. The outcomes of interest were functional status in activities of daily living (ADL)
and instrumental activities of daily living (IADL), health-related quality of life (HRQoL) and
healthcare service utilization. Systematic reviews, meta-analyses, randomized controlled trials
(RCTs) and quasi-experimental and qualitative studies were eligible for inclusion. Case reports
were excluded: studies had to have a control group in order to address whether the change in
outcome was due to the natural evolution of the person’s condition or to the intervention.
Literature searching was carried out in MEDLINE (PubMed), CINAHL (EBSCO),
PsycINFO (OvidSP) and EBM Reviews (OvidSP); the latter included the Cochrane Central
Register of Controlled Trials and the Cochrane Database of Systematic Reviews. Several search
terms were used, including homecare, reablement, autonomy, seniors and aged. Articles had to
be published in either English or French between January 2001 and August 2014. The search
strategy is available in Appendix1 (available at: http://www.longwoods.com/content/24594).
Articles were selected independently by two researchers (AT and MDB). Any discrepan-
cies were resolved by consensus. Articles were excluded if they did not pertain to people older
than 65 years old receiving an intervention promoting autonomy, or if they did not include the
outcomes of interest (function, HRQoL or service utilization). The studies selected from the
TABLE 1. Core characteristics of reablement
Structure Interdisciplinary team of varying composition
Training and ongoing support for team members
Process Free services for 6–12 weeks
Programs accessible to everybody, but some prioritize those leaving the hospital
Generic interventions (not requiring a high degree of professional specialization) offered by non-professionals
Evaluation of users by professionals via structured and comprehensive assessment
Goal-oriented plan developed with users and their caregivers
Treatment plan reviewed regularly
Weekly team meeting
Outcome Improved ADL, IADL and HRQoL and less service utilization
ADL = activity of daily living; IADL = instrumental activity of daily living; HRQoL = health-related quality of life.

[52] HEALTHCARE POLICY Vol.11 No.4, 2016
literature had to have control groups in order to be able to determine whether the change in
outcome was due to the natural evolution of the person’s condition or to the intervention. One
researcher (AT) extracted information from all articles using a template that included research
design, client characteristics, nature of the intervention (e.g., goals, duration and composi-
tion of the team), environment (e.g., country, urban or rural setting and multi-ethnic context),
comparator, outcomes and adverse events. A second researcher validated the accuracy of the
data extraction for 20% of the articles. Methodological quality of each study was assessed inde-
pendently by two researchers (AT and MDB) with the Critical Appraisal Skills Programme
(CASP) (Critical Appraisal Skills Programme 2014) tool for RCTs, and with the Assessment of
Multiple Systematic Reviews (AMSTAR) (Shea et al. 2009) tool for systematic reviews.
Factors contributing to success
Australia, New Zealand and the UK have been at the forefront of developing and testing rea-
blement. Furthermore, their healthcare systems are similar to Canada’s. A narrative review of
the non-peer-reviewed literature was conducted to examine the service models used in these
regions, as well as the facilitators of and barriers to implementation according to this inter-
national experience. The Google Scholar search engine was queried to retrieve information.
In addition, several websites of reputable societies were explored, including the Guidelines
International Network (GIN), the Centre for Reviews and Dissemination (CRD), the
International Network of Agencies for Health Technology Assessment (INAHTA), the
Social Care Institute for Excellence (SCIE) and the National Institute for Health and Care
Excellence (NICE) (Appendix1).
Results
Effectiveness of reablement
The literature search yielded 621 articles: 43 were identified based on the title and abstract.
The full articles were read, resulting in further exclusion. The remaining 13 articles originat-
ed from 10 individual studies (Burton et al. 2013a, 2013b; Glendinning et al. 2011; King et
al. 2012a, 2012b; Lewin et al. 2013a, 2013b; 2014; Lewin and Vandermeulen 2010; Parsons
et al. 2012, 2013; Senior et al. 2014; Tinetti et al. 2002). Seven out of 10 were considered
to be of either excellent or good quality, while three were of fair quality. There were four
RCTs, four controlled before-and-after studies, one data linkage and one qualitative study,
collectively including close to 15,000 participants. All of the included studies referred to the
intervention either as reablement or restorative care. Study characteristics, quality and results
are reported in Table 2. On average, the service users in the studies were 78–80 years old and
required minimal to moderate help with their ADLs.
Seven studies examined the effect of reablement on various aspects of functional capac-
ity (Table 2). Three studies reported no effects of reablement (Burton et al. 2013b; King
et al. 2012b; Senior et al. 2014). Two studies looking exclusively at ADLs demonstrated an
Annie Tessier et al.

HEALTHCARE POLICY Vol.11 No.4, 2016 [53]
improvement in both groups of participants (reablement or usual homecare services) (Lewin
et al. 2013a; Tinetti et al. 2002). In three studies, either ADL, IADL or mobility showed
greater improvement with reablement than with usual services (Lewin and Vandermeulen
2010; Parsons et al. 2013; Tinetti et al. 2002). Finally, reablement was associated with
greater improvement in HRQoL compared to usual homecare services in four studies (total
sample of 1,706 participants). This difference was statistically significant in three studies
(Glendinning et al. 2011; King et al. 2012b; Parsons et al. 2012), and not significant in one
(Lewin et al. 2013a).
Effectiveness of Reablement: A Systematic Review
TABLE 2. Characteristics of included studies
Study (first author,
year; design;
sample size;
country/region) Quality
Results (for the intervention group, compared with controls)
Functional
capacity HRQoL Service utilization Other results
Burton 2013a, 2013b;
CBA; n = 506;
Australia
Fair No effect on physical
activity level (MT, LT)
Glendinning 2011;
CBA; n = 1,015; UK
Fair Greater
improvement
(clinically significant
and SS) (ST)
60% reduction in
ongoing homecare
needs
NS differences
in average costs
between the two
groups (ST) (initial
cost of reablement
offset by a 60%
decrease in long-
term costs)
King 2012a;
Qualitative; n = 25;
New Zealand
Fair Greater paid-
worker job
satisfaction; reduced
staff turnover
King 2012b; RCT;
n = 186; New
Zealand
High NS improvement in
both groups (ST)
Greater
improvement (SS,
but not clinically
significant) (ST)
Greater proportion
of users needing
fewer services (SS)
(ST)
Lewin 2010; CBA;
n = 200; Australia
Moderate Only the intervention
group showed
improvement in
ADL, IADL and
mobility (SS) (ST)
Lower probability of
continuing to require
services (SS) (ST)
NS improvement on
mood in both groups
(ST)
Lewin 2013b; Data
linkage; n = 10,368;
Australia
High Lower probability of
continuing to require
services (SS) (LT)
Cumulative costs
substantially lower
in the intervention
group (MT and TL);
savings of $7,345
CAD per person
after 3 years; median
cost of first 3 months
of intervention about
half that of current
services and less than
a third after 5 years
(ST and LT)

[54] HEALTHCARE POLICY Vol.11 No.4, 2016
According to seven studies (eight articles; total sample of 14,006 participants), reable-
ment had a positive effect on service utilization in the first year. Fewer people required
homecare services after receiving reablement compared to those receiving usual homecare
services (Glendinning et al. 2011; King et al. 2012b; Lewin et al. 2013a, 2013b; 2014; Lewin
and Vandermeulen 2010; Senior et al. 2014; Tinetti et al. 2002). The absolute risk reduction
ranged across the studies between 55% at three months and 22% at 12 months. However,
only one study indicated that the effects were maintained in the long term (five years) (Lewin
et al. 2013b). Evidence was limited but suggested benefits of reablement on visits to the emer-
gency department, risk of residential care placement and mortality (Lewin et al. 2014; Senior
et al. 2014; Tinetti et al. 2002). One study found no effect on caregivers’ burden (Senior et
al. 2014), while another reported greater job satisfaction in the group of employees providing
reablement when compared to those delivering usual homecare services (King et al. 2012a).
Annie Tessier et al.
Study (first author,
year; design;
sample size;
country/region) Quality
Results (for the intervention group, compared with controls)
Functional
capacity HRQoL Service utilization Other results
Lewin 2013a;
Lewin 2014; RCT;
n = 750; (n = 300
for data on function
and HRQoL);
Australia
Moderate NS difference
between the groups:
both improved (ST)
NS difference
between the groups:
both improved (ST)
NS difference
between groups
for hours of
homecare services,
hospital admissions,
emergency
department visits
(ST and MT) in the
intention to treat
analysis, SS difference
in the analysis per
the actual treatment
received
Average total home
services costs 22%
lower at 1 year and
30% lower at 2
years (NS)
Parsons 2012;
Parsons 2013; RCT;
n = 205; New
Zealand
High Greater
improvement (SS)
(ST)
Only the intervention
group showed
improvement (SS)
(ST)
NS difference
between the groups
for social support
(ST)
Senior 2014; RCT;
n = 105; New
Zealand
Moderate NS difference
between the groups
for ADL, IADL (MT)
NS reduction in the
risk of death and/
or residential care
placement (MT)
SS slower rate of
decline in physical
health of caregivers
(MT); no effect on
caregiver burden
(MT)
Tinetti 2002; CBA;
n = 1,382; US
Moderate Greater
improvement in
IADL and mobility
(SS) (ST); NS
difference between
groups for ADL:
both improved
SS reduction in the
risk of residential
care placement,
emergency
department visits and
length of homecare
episode (ST)
ADL = activity of daily living; CBA = controlled before-and-after study; HRQoL = health-related quality of life; IADL = instrumental activity of daily living; LT = long
term (more than 3 years); MT = medium term (1–3 years); NS = not statistically significant; RCT = randomized controlled trial; SS = statistically significant; ST = short
term (less than 1 year).
TABLE 2. Characteristics of included studies (continued)

HEALTHCARE POLICY Vol.11 No.4, 2016 [55]
The efficiency of reablement was examined in three studies (total sample of 12,133 par-
ticipants). Generally, the cost of reablement was higher than that of usual homecare services
because reablement requires more resources, including a need for more training, supervi-
sion and user evaluation at the outset. In the subsequent months, however, reablement was
associated with a decrease in homecare service utilization. In one study, balanced total costs,
when both reablement and ongoing homecare services were considered, were achieved within
the first year (Glendinning et al. 2011). The results of an RCT suggest that reablement was
cost-effective in the long term: the cost of reablement compared with usual homecare was,
on average, 22% lower in the first year, and 30% lower over two years (Lewin et al. 2014).
According to a large database analysis, the median cumulative cost of all homecare services
in the reablement group was approximately half that of the usual homecare group at three
months, and less than one-third the cost for the 6,656 persons who were followed for nearly
five years (Lewin et al. 2013b).
One of the difficulties in establishing the cost-benefit of reablement is the wide differ-
ences in cost across clinical settings. For example, the study of Glendinning and colleagues
was carried out in five similar clinical settings and reported an average cost per user ranging
from £1,609 to £3,575 (Glendinning et al. 2011).
Factors contributing to success
In Australia, New Zealand and the UK, reablement was first introduced in the setting
of pilot projects near the beginning of 2000. Such projects showed a reduction in ser-
vices needed and enhanced user satisfaction (Ghatorae 2013; McLeod and Mair 2009).
Consequently, the projects were expanded to service the general population. Most of these
regions have gradually moved from insourcing to outsourcing services to non-governmental
organizations. The service model is similar from one country to another. In almost all set-
tings, reablement is available to all who need homecare services without discrimination,
including those with cognitive impairment, for whom the evidence actually suggests less
benefit. Most of the associated services arise from the community rather than from the
hospitalsetting.
Facilitators of and barriers to the success of reablement have been identified through
interviews with service managers, users and frontline staff (McLeod and Mair 2009; Rabiee
and Glendinning 2011). Similarly, the Social Care Institute for Excellence (SCIE) in the UK
has identified contributing factors in their practical guide entitled “Maximising the potential
of reablement to support the implementation and delivery of reablement”; these factors are
summarized in Table3 (Social Care Institute for Excellence 2013). Staff training has been
recognized as a key element for success, along with the engagement of patients and their car-
egivers in the reablement plan to establish realistic expectations. An efficient handover process
is required, and the scope of services should address social needs. The Care Services Efficiency
Delivery (CSED) program, also in the UK, has developed a toolkit, which provides practical
help for the implementation of reablement (Care Services Efficiency Delivery 2011).
Effectiveness of Reablement: A Systematic Review

[56] HEALTHCARE POLICY Vol.11 No.4, 2016
Discussion
There is good evidence supporting the effectiveness of reablement, particularly regarding
HRQoL and service utilization. The added value of recognizing the importance of patient
participation in decision-making is well documented, and is likely related to the observed
improvement in HRQoL (Legare et al. 2014). Similarly, involving the patient in goal-setting
has been shown to lead to significant improvement in HRQoL, possibly via individualized
activities (Parsons 2012).
Reablement has shown a positive effect on functional capacity, an effect which is com-
parable with that of usual homecare services. In the reviewed studies, most users required
minimal-to-moderate assistance with their ADL prior to the intervention, and their func-
tional status was assessed with tools that included few complex activities (the Barthel Index
and the Nottingham Extended Activity of Daily Living). The small changes reported in
functional capacity, which may be surprising considering the reported impact on HRQoL, are
possibly due to the limited sensitivity of the assessment tools used. Reablement may be more
effective for certain clientele. The homogeneity of the populations studied to date precludes
an analysis of who would best benefit from reablement. Specific eligibility criteria may emerge
from future studies. Although reablement has the potential to be cost-effective, this is diffi-
cult to quantify considering the wide range of costs reported in the literature across settings.
The present results are consistent with two recent systematic reviews. The first was restricted
to examining dependency and concluded there was limited evidence for a reduction associated
with reablement (Whitehead et al. 2015). The second reported, as in the present study, that
reablement had a positive impact on HRQoL, costs and service utilization (Ryburn et al. 2009).
Annie Tessier et al.
TABLE 3. Factors contributing to the success of reablement
Organization Strong and shared vision of the service
Thorough and consistent recording system
Service users User characteristics: greatest benefit for those recovering from falls or fractures; benefit may be less for those likely to
need ongoing support such as people with dementia or mental health problems
Expectations of service users and carers (reablement worked better for newly referred people)
Staff Staff commitment, attitude and skills
Training on the principles of delivering a reablement service (e.g., learning to “stand back”)
Professionals not necessarily full-time members of the team but frontline workers need access to specialist skills
Intervention Although regaining physical ability is central, addressing psychological support as well as social needs is also vitally important
Access to equipment
Flexible and prompt intervention
Goal-oriented intervention: goals are established with the user and informal carers, broken down into achievable targets
Program
evaluation
Less focus on time and tasks; instead, reablement should be evaluated on the basis of the outcomes that the service will
support the individual to achieve

HEALTHCARE POLICY Vol.11 No.4, 2016 [57]
Three regions have implemented reablement for more than 10 years. They have per-
formed extensive program evaluation, documenting positive impact on service utilization and
user satisfaction. Their experience has permitted the identification of factors contributing
to success, which policy makers can consider when developing strategic plans to improve
homecare. For example, appropriate training has been identified as a facilitator, consistent
with Ontario’s recent decision to increase support for homecare workers. Finally, reablement
can be successfully delivered by non-professionals among whom it has been associated with
greater job satisfaction. This offers additional advantages given that recruitment and reten-
tion of qualified employees are major challenges in the homecare industry.
In general, seniors wish to live at home. However, in Quebec, as well as in the rest of
Canada, almost one in four disabled seniors report unmet homecare needs, one of these being
walking outside (Dubuc et al. 2011; Turcotte 2014). One of the challenges of our society is
to reduce the barriers to social participation of older people. With this in mind, reablement,
which targets both psychosocial and physical needs, is a promising approach.
Conclusion
One of the objectives of the Quebec Health Ministry’s action plan for 2015–2020 is to
improve homecare services through systematic evaluation of needs and treatment plans for
all elderly (Ministère de la Santé et des Services Sociaux 2015). The reablement approach is
in keeping with this objective, with a focus on independence in the community rather than
services in institutions. It promotes investment in staff and greater participation of users and
their families in decision-making about their care. In addition to improving HRQoL and
reducing healthcare service utilization in the short term, reablement can potentially increase
employee satisfaction at a reasonable marginal cost.
Correspondence may be directed to: Annie Tessier, Institut national d’excellence en santé et en
services sociaux, 2021 Union, Montréal, QC H3A 2S9; e-mail: annie.tessier@inesss.qc.ca.
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