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Development of an internationally accepted definition of reablement: a Delphi study

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With an ageing society, the demand for health and social care is increasing. Traditionally, staff provide care for their clients rather than with them. In contrast, reablement aims to support people to maximise their competences to manage their everyday life as independently as possible. There is considerable variation between and within countries regarding the conceptual understanding of the approach. This variation affects the ability to evaluate reablement approaches systematically, compare and aggregate findings from different studies, and hinders the development of a robust evidence. Therefore, a Delphi study was conducted in 2018/9 with the aim of reaching agreement on the characteristics, components, aims and target groups of reablement, leading towards an internationally accepted definition of reablement. The study consisted of four Web-based survey rounds. In total, 82 reablement experts from 11 countries participated, reaching agreement on five characteristics ( e.g. person-centred), seven components ( e.g. goal-oriented treatment plan) and five aims ( e.g. increase clients’ independency). Furthermore, most experts agreed that reablement is an inclusive approach irrespective of the person's age, capacity, diagnosis or setting. Based on these features, a definition of reablement was developed, which was accepted by 79 per cent of participating experts. This study is a significant step towards providing conceptual clarity about reablement. Future research should focus on evaluating the implementation of agreed reablement components to inform practice, education and policy.
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ARTICLE
Development of an internationally accepted
definition of reablement: a Delphi study
Silke F. Metzelthin1,2* , Tine Rostgaard3, Matthew Parsons4and Elissa Burton5
1
Department of Health Services Research, Care and Public Health Research Institute, Maastricht
University, Maastricht, The Netherlands,
2
Living Lab in Ageing and Long-term Care, Maastricht,
The Netherlands,
3
Institute of Social Work, Stockholm University, Stockholm, Sweden,
4
Waikato District
Health Board/Te Huataki Waiora School of Health, University of Waikato, Hamilton, New Zealand and
5
School of Physiotherapy & Exercise Science, Faculty of Health Sciences, Curtin University, Perth, Australia
*Corresponding author. Email: s.metzelthin@maastrichtuniversity.nl
(Accepted 7 July 2020)
Abstract
With an ageing society, the demand for health and social care is increasing. Traditionally,
staff provide care for their clients rather than with them. In contrast, reablement aims to
support people to maximise their competences to manage their everyday life as independ-
ently as possible. There is considerable variation between and within countries regarding the
conceptual understanding of the approach. This variation affects the ability to evaluate rea-
blement approaches systematically, compare and aggregate findings from different studies,
and hinders the development of a robust evidence. Therefore, a Delphi study was conducted
in 2018/9 with the aim of reaching agreement on the characteristics, components, aims and
target groups of reablement, leading towards an internationally accepted definition of rea-
blement. The study consisted of four Web-based survey rounds. In total, 82 reablement
experts from 11 countries participated, reaching agreement on five characteristics (e.g. per-
son-centred), seven components (e.g. goal-oriented treatment plan) and five aims (e.g.
increase clientsindependency). Furthermore, most experts agreed that reablement is an
inclusive approach irrespective of the persons age, capacity, diagnosis or setting. Based
on these features, a definition of reablement was developed, which was accepted by 79
per cent of participating experts. This study is a significant step towards providing concep-
tual clarity about reablement. Future research should focus on evaluating the implementa-
tion of agreed reablement components to inform practice, education and policy.
Keywords: reablement; aged people; activities of daily living; health and social care; independence; daily
functioning; person-centred; inter-disciplinary
Introduction
With an ageing society, the demand for health and social care is increasing (Hajek
et al.,2018). Across all Organisation for Economic Co-operation and Development
(OECD) countries, ageing has led to health-care expenditure exceeding Gross
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Ageing & Society (2020), 116
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Domestic Product (GDP) growth and without reforms it will increase from 6 per
cent in 2010 to 14 per cent of GDP in 2060 (De la Maisonneuve and Oliveira
Martins, 2013). Whilst inevitably demand for services is set to increase, capacity
to respond with formal services is limited (Ashby and Beech, 2016;Hayet al.,
2017), through a workforce that is itself both ageing and shrinking (World
Health Organization, 2005). Traditionally, health and social services focus on
acute and episodic care delivered late in the trajectory of an older persons declining
health (Bähler et al.,2015; Picco et al.,2016). There is little attention placed on dis-
ease prevention or early identification of loss of independence (Bähler et al.,2015;
Picco et al.,2016). A valuable approach in preventing functional decline is promot-
ing an older persons active participation in daily activities, ranging from activities
of daily living (ADL; e.g. bathing, dressing) and instrumental activities of daily liv-
ing (IADL; e.g. cleaning, cooking) through to preferred social, leisure and physical
activities at the place of residence or in the local community (Aspinal et al.,2016).
However, health and social care staff often look at older people primarily in terms
of frailty and provide care for their clients rather than with them (Whitehead et al.,
2015; Aspinal et al.,2016). Thereby, despite their best intentions, they may deprive
older people of opportunities to engage in daily activities, which may result in fur-
ther deconditioning and functional decline (Resnick et al.,2012; V&VN, 2012;
Whitehead et al.,2015). To stop this downwards spiral, health and social care
staff are encouraged to focus on abilities and resources of older people to overcome
losses, adapt and maintain independence (Aspinal et al.,2016).
Over the last two decades, reablement has been implemented and evaluated in
many OECD countries. Reablement is often described as an enabling approach
that aims to support older people to maximise their competencies to manage
their everyday life as independently as possible (Aspinal et al.,2016). Reablement
is similar to the approach of function-focused care or restorative care. While
function-focused care has its origin in institutionalised long-term care in the
United States of America (USA), the concept of reablement has been developed
and delivered mainly in home care across the United Kingdom (UK), Australia,
New Zealand and the Scandinavian countries. Common in these approaches is
that an attitude of doing with…’ rather than doing for…’ is promoted among
health and social care professionals. Restorative care is used as a synonym for
both approaches (Metzelthin et al.,2017). While several countries have already
integrated reablement into their national health-care policy, such as Denmark
(Rostgaard, 2016), New Zealand (Parsons et al.,2018), Australia (Commonwealth
of Australia, 2015) and the UK (Beresford et al.,2019), other countries such as
the Netherlands (Metzelthin et al.,2018) or Norway (Tuntland et al.,2015;
Langeland et al.,2019) are still in the phase of conducting research to determine
its feasibility, effectiveness and cost-effectiveness. Despite an increasing interest
in reablement, there is great variation between and even within countries regarding
its conceptual understanding (Aspinal et al.,2016; Doh et al.,2020). For example,
what are the characteristics, components, aims and target groups of reablement?
Some authors even claim that reablement is an ill-defined concept that lacks a
sound theoretical framework, which hinders effective implementation, as there is
no agreement regarding the required features to achieve the intended outcomes
(Legg et al.,2015). In addition, poor conceptual clarity affects the ability to evaluate
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reablement approaches systematically, and compare and aggregate findings from
different studies. This undermines the development of a robust evidence base,
resulting in inconsistent and inadequate care delivery, health and social care curric-
ula, and local and national policies.
When comparing a number of recent literature reviews (Ryburn et al.,2008;
Legg et al.,2015; Whitehead et al.,2015; Cochrane et al.,2016; Tessier et al.,
2016; Sims-Gould et al.,2017) and position papers (Aspinal et al.,2016; Doh
et al.,2020), there is agreement about several features of reablement. For example,
reablement is described as a person-centred and multi-disciplinary approach
(Ryburn et al.,2008; Legg et al.,2015; Whitehead et al.,2015; Aspinal et al.,
2016; Cochrane et al.,2016; Tessier et al.,2016; Sims-Gould et al.,2017; Doh
et al.,2020). In addition, there is agreement across studies that reablement
approaches have to include components like goal setting and training of daily activ-
ities (Ryburn et al.,2008; Legg et al.,2015; Whitehead et al.,2015; Aspinal et al.,
2016; Cochrane et al.,2016; Tessier et al.,2016; Sims-Gould et al.,2017; Doh
et al.,2020). However, other components are less often described, such as regular
assessments (Ryburn et al.,2008; Legg et al.,2015; Tessier et al.,2016) or education
and advice (Whitehead et al.,2015; Cochrane et al.,2016; Sims-Gould et al.,2017).
Furthermore, it is unclear whether reablement is limited to promoting active par-
ticipation in ADL/IADL activities or if increasing and maintaining independence in
other activities also belongs to the aims of reablement. To our knowledge, only
three papers explicitly mention that reablement can also focus on social, leisure
or physical activities (Legg et al.,2015; Aspinal et al.,2016; Doh et al.,2020). In
addition, there is much discussion about the intensity and duration of reablement
approaches. Some authors describe reablement as intense (Ryburn et al.,2008;
Aspinal et al.,2016; Cochrane et al.,2016) and time-limited (Ryburn et al.,
2008; Legg et al.,2015; Aspinal et al.,2016; Cochrane et al.,2016; Tessier et al.,
2016; Sims-Gould et al.,2017; Doh et al.,2020), while others (Whitehead et al.,
2015) report that reablement does not necessarily have to end after a few weeks.
Last but not least, there is discussion about the target group of reablement.
While some authors (Aspinal et al.,2016; Tessier et al.,2016) describe reablement
as an inclusive approach, Ryburn et al. (2008) report that reablement is primarily
aimed at older people at the beginning of their home care journey, often after hos-
pital admission. In addition, people with chronic illnesses, terminal diseases or
dementia are, according to Cochrane et al. (2016), predominantly excluded from
reablement approaches as, in their view, these people have no potential to benefit
from them.
In 2018, the ReAble network (https://reable.auckland.ac.nz/) was established
with 28 members from Denmark, Sweden, Norway, the Netherlands, UK, USA,
Canada, Australia and New Zealand. Individual and country membership was
broadly based on prior experience in implementing or evaluating reablement
approaches. It was of utmost importance to the network to develop an internation-
ally agreed definition of reablement, as this is seen as a first step towards a sound
evidence base. Consequently, a Delphi study was conducted with the aim of reach-
ing agreement on the characteristics, components, aims and target groups of reable-
ment, leading towards an internationally accepted definition of this approach.
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Methods
Design
A Delphi study was conducted between September 2018 and March 2019. The
Delphi technique is a widely used method to reach consensus among experts by
making use of several rounds of opinion collection and feedback (Hasson et al.,
2000). Our Delphi study consisted of four Web-based Delphi survey rounds
using an online survey program (Qualtrics
XM
). Before the start of the Delphi
study, a literature search was conducted with the aim of identifying scientific papers
that describe features (i.e. characteristics, components, aims and target groups) of
reablement. The results of the literature study were used as a starting point when
designing the first Delphi survey.
Participants
Academics as well as practitioners were eligible to participate in the Delphi study, as
long as they had considerable experience with reablement approaches. Participants
were identified by the literature review and word of mouth. With regard to the aca-
demics, eligible participants had to be (a) first author of at least one English peer-
reviewed reablement publication; or (b) member of the ReAble network; or (c)
identified by the members of the ReAble network as experts in the field of reable-
ment. Practitioners were identified by the participating academics. There were no
specific eligibility criteria for this group. In total, 112 experts in the field of reable-
ment (i.e. academics and practitioners) from 11 different countries were invited to
participate. Excluded from participation were the authors of the present paper. All
identified reablement experts (N = 112) were invited by email to participate in the
Delphi study, which included a link to the first survey.
Data collection and analysis
The Web-based survey process consisted of four rounds, each round taking
approximately one month to administer. This included: (a) delivery of the survey,
including reminders to the participants within two weeks; (b) analysis of the results;
and (c) compilation of a new survey including the comments that were collected in
the previous Delphi round. All analyses were conducted using SPSS version 25
(SPSS Inc., Chicago, IL, USA).
Delphi round 1: September 2018 to October 2018
In the first survey round, background characteristics of experts (i.e. age, sex, years of
experiences with reablement approaches) were collected. In addition, experts were
asked to rate the relevance of characteristics (e.g. person-centred, time-limited,
inter-disciplinary), components (e.g. goal-oriented treatment plan, training of
daily activities), aims (e.g. increase clientsindependence) and target groups (e.g.
age, setting) of reablement that were identified in scientific papers. In total, six
characteristics, 11 components, seven aims and six target groups were rated regard-
ing their relevance for a definition of reablement using a nine-point Likert scale,
with higher scores indicating higher importance (see the example in Figure 1).
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In line with previous research, items were identified as important for a definition
of reablement, when they had a median of 79and an interquartile range (IQR) of
2 (Elissen et al.,2017). Items with a median of 13and an IQR 2 were consid-
ered as less important and excluded. The remaining items were considered uncer-
tain. These items were rated again in the next round.
Delphi round 2: October 2018 to November 2018
Uncertain items were rated by experts using a binary answer option (include in def-
inition versus do not include in definition). At least two-thirds of the participants
had to rate includeto consider the item as relevant to include in the definition of
reablement. The results of the first and second survey were used to formulate three
preliminary definitions of reablement.
Delphi round 3: December 2018 to January 2019
The three preliminary definitions of reablement were ranked by experts from 1
(being most preferred) to 3 (being less preferred) to identify the definition that
reached the most agreement among experts. In addition, final comments regarding
the definition were gathered from the experts to fine-tune the preferred definition.
Delphi round 4: February 2019 to March 2019
In the last survey round, the preferred and fine-tuned definition was shared with the
experts. They were asked whether they agreed or did not agree with the definition.
There is no hard cut-off for the level of agreement in Delphi studies (Jorm, 2015), but
other researchers have argued previously that 70 per cent is an adequate level of agree-
ment (Hsu and Sandford, 2007;Feoet al.,2018). Therefore, we stated that the final def-
inition had to be accepted by at least 70 per cent of the experts. Each expert who did not
support the definition of reablement was given an opportunity to explain their decision.
Results
In total, 82 experts participated in the Delphi study, which corresponds with
a response rate of 73 per cent. The experts were from 11 countries: Australia
(N = 9), Canada (N = 2), Denmark (N = 13), Ireland (N = 3), Netherlands (N =
5), New Zealand (N = 8), Norway (N = 17), Sweden (N = 9), Taiwan (N = 1), UK
(N = 8) and USA (N = 7). In total, 77 per cent of experts were working in academia
and the remaining 23 per cent were practitioners (i.e. executive/directors (21%),
Figure 1. Example of survey questions.
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managers/head of area (74%) or nurses (5%)). Experts had on average 8.0 (standard
deviation (SD) = 5.6) years of experience in conducting research about reablement
and 12.0 (SD = 7.2) years of experience in delivering reablement approaches. For
the study flow, see Figure 2.
Delphi round 1
In the first round, 82 out of 112 experts (73%) completed the survey. There was
consensus among experts about the relevance of two characteristics (i.e. person-
centred, holistic), seven components (i.e. assessment, goal-oriented treatment
plan, regular reassessment of treatment plan, training of daily activities, use of
home modifications and assistive devices, involvement of social network, reable-
ment training and support for staff), four aims (i.e. increasing clientsindepen-
dency in daily activities, enabling clients to participate in meaningful activities,
enabling clients to be engaged in the community, reducing need for long-term
Figure 2. Delphi study flowchart.
Note: 1. One expert withdrew from the study during Delphi round 3.
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care needs and related costs) and three target groups (i.e. irrespective of diagnosis,
age, physical capacity). In addition, a number of uncertain features were identified.
More specifically, four characteristics, four components, three aims and three target
groups had to be rated again in Delphi round 2. No irrelevant items were identified.
Delphi round 2
In the second round, 79 of the 82 participating experts (96%) completed the survey.
In addition to the relevant items identified in Delphi round 1, there was consensus
among experts about the relevance of a further three characteristics (i.e. intensive,
multi-disciplinary, co-ordinated), one aim (i.e. enhancing clientsphysical func-
tioning) and two target groups (i.e. irrespective of setting and type of problem).
An overview of all identified characteristics, components, aims and target groups
per round is provided in Table 1.
Delphi round 3
In the third round, 74 of 82 experts (90%) rated three preliminary definitions of
reablement. Definition A was preferred by most experts (45%):
Reablement is a person-centred and holistic approach that aims to increase or main-
tain clientsindependence and participation in daily and meaningful activities (at
home or in the community) and to reduce their need for long-term services and
related costs. Reablement consists of multiple visits and is delivered by a trained
multidisciplinary team, coordinated and supported by a health professional, such
as a registered nurse, social worker or allied health professional. Reablement services
have shared components that include a comprehensive assessment, a goal-oriented
treatment plan and regular reviews of the treatment plan. Clientsgoals can be
reached through training of daily activities, by making use of home modifications
and assistive devices and by involving the social network of the client. Reablement
is an inclusive approach irrespective of age, physical capacity, diagnosis or setting.
Definitions C and B were preferred by 28 and 27 per cent, respectively. In add-
ition, comments were collected to fine-tune the final definition. Comments were
related to staff issues, kind of activities, strategies, language and length of the def-
inition. Table 2 provides more details and shows how these comments were taken
into account when adapting the definition.
There were also some comments which we could not take into account without
harming the results of the previous two Delphi rounds. First, no consensus was
reached that reablement (a) has to include a physical exercise component; (b) is
time-limited; and (c) aims to motivate clients. Therefore, these features were not
included in the definition. Second, in the previous two Delphi rounds, no consen-
sus was reached that reablement approaches are applicable for clients irrespective of
their mental capacity. However, there was consensus that it is appropriate for clients
with all kinds of diagnoses. Therefore, clients with for example Alzheimers disease
or depression do not necessarily have to be excluded from reablement approaches.
Third, in the previous two Delphi rounds, there was consensus that reducing long-
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Table 1. Overview of reablement characteristics, components, aims and target groups
Potential features of reablement
Round 1 (N = 82) Round 2 (N = 79)
Final
resultMedian IQR Result
Include
% (N) Result
Characteristics:
Time-limited (e.g. up to 8 weeks) 7.00 5.00,
9.00
? 65 (51) ––
Intensive (i.e. consisting of
multiple visits)
8.00 5.00,
9.00
? 67 (53) ✓✓
Person-centred (i.e. tailored to
individual needs/capacities)
9.00 9.00,
9.00
✓✓
Holistic (i.e. taking into account
various needs of the client)
9.00 8.00,
9.00
✓✓
Multi-disciplinary (i.e. involving
at least two different disciplines)
8.00 5.00,
9.00
? 75 (59) ✓✓
Co-ordinated by a care manager, a
nurse or allied health staff (e.g.
occupational therapist or
physiotherapist)
8.00 5.00,
9.00
? 67 (53) ✓✓
Components:
Assessment 9.00 8.00,
9.00
✓✓
Goal-oriented treatment plan 9.00 8.00,
9.00
✓✓
Regular reassessment of
treatment plan
9.00 7.00,
9.00
✓✓
Physical exercise (e.g. balance and
strength)
6.00 5.00,
9.00
? 42 (33) ––
Training of daily activities 9.00 7.00,
9.00
✓✓
Regular team meetings 7.00 5.00,
8.00
? 56 (44) ––
Patient education (e.g. healthy
ageing)
7.00 5.00,
9.00
? 59 (47) ––
Use of home modifications and
assistive devices
7.00 6.00,
8.00
✓✓
Involvement of social network
(e.g. family, friends)
8.00 7.00,
9.00
✓✓
Reablement training and support
for staff
9.00 7.00,
9.00
✓✓
Supportive funding model
(e.g. case mix)
5.00 5.00,
8.00
? 29 (23) ––
(Continued)
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term servicesis an aim of reablement. Consequently, this aim cannot be deleted in
the definition as suggested by one expert.
Delphi round 4
After viewing Delphi round 3, one expert asked to be withdrawn from the study.
Therefore, in the last survey round, 79 of 81 experts (98%) participated. Of the
Table 1. (Continued.)
Potential features of reablement
Round 1 (N = 82) Round 2 (N = 79)
Final
result
Median IQR Result Include
%(N)
Result
Aims:
Enhancing clientsphysical
functioning
8.00 6.00,
9.00
? 70 (55) ✓✓
Enhancing clientsmental
functioning
7.00 6.00,
9.00
? 57 (45) ––
Motivating clients to be more
physically active
7.00 5.00,
9.00
? 49 (39) ––
Increasing clientsindependency
in daily activities
9.00 8.00,
9.00
✓✓
Enabling clients to participate in
meaningful activities
9.00 9.00,
9.00
✓✓
Enabling clients to be engaged
in the community
9.00 7.00,
9.00
✓✓
Reducing need for long-term care
needs and related costs
8.00 7.00,
9.00
✓✓
Target group: reablement is an inclusive
approach, irrespective of:
Diagnosis 9.00 8.00,
9.00
✓✓
Age 9.00 7.00,
9.00
✓✓
Physical capacity 9.00 7.00,
9.00
✓✓
Mental capacity 8.00 6.00,
9.00
? 63 (50) ––
Setting (e.g. home care, assisted
living, nursing home care)
7.00 6.00,
9.00
? 68 (54) ✓✓
Type of problem (i.e. acute versus
chronic)
7.00 5.00,
9.00
? 73 (58) ✓✓
Notes: IQR: interquartile range. : consensus among experts about relevance. ?: uncertain features, rated again in the
next round. : irrelevant items according to experts.
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79 experts that completed the survey, 62 experts from across 11 countries agreed
with the definition (79%). Experts from five countries had 100 per cent agreement
on the definition (i.e. Canada, Ireland, New Zealand, Taiwan and the USA).
Denmark and the Netherlands had only one expert each that did not support
the definition, which corresponds with an agreement rate of 92 and 80 per cent,
respectively, within that country. Also two-thirds of the Australian, Swedish and
Table 2. Comments from Delphi round 3
Summary of comments Adaptations
Staff issues:
While some experts wanted to specify all
possible professionals that could be involved
in reablement, others wanted to remove one
or more specific disciplines from the
definition, because they are not important in
their context. There were also experts that
mentioned that not all professionals, who
assess, deliver or co-ordinate reablement,
have a health-care background (e.g. social
care staff)
We decided to use the generic term trained
and coordinated interdisciplinary teamand to
specify no professionals, as this is very
context-specific information
Kind of activities:
Some comments were made that
reablement is not only about ADLs, but also
about IADLs. Furthermore, some experts
emphasised that personal goals/meaningful
activities drive reablement
We specified daily activitiesinto meaningful
activities of daily living, which can be both
ADL and IADL activities
Strategies:
One expert mentioned that training of daily
activities, use of home modifications and
assistive devices, and involving persons
social network are potential strategies,
which are not always applicable
We added the word if applicableto this
particular sentence
Language:
One expert said that the phrase training of
daily activitiessounds very much as if things
are being done to the client
We replaced the term trainingwith
participationin daily activities
One expert suggested to replace the term
multidisciplinaryby interdisciplinary,asit
emphasises the collaboration between
disciplines
We changed multidisciplinaryinto
interdisciplinary
One expert suggested using less medically
oriented language
We replaced the t erms clientswith individuals
and treatment planwith support plan
Length of the definition:
A few experts found that the definition was
too long
We had a critical look at the wording of the
definition and shortened it down where
possible without losing relevant information
Notes: ADL: activity of daily living. IADL: activity of daily living.
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Norwegian experts agreed with the definition (67, 67 and 64%, respectively). Only
the UK had fewer than half of their experts agreeing with the definition (42%). Out
of the 17 experts who were not agreeing with the definition, 11 experts (65%) per-
ceived that there was too much emphasis on physicalfunctioning. Next to enhan-
cing clientsphysical functioning, agreement was reached on increasing clients
independency in daily activities, enabling clients to participate in meaningful activ-
ities and enabling clients to be engaged in the community. This shows a strong
focus on daily, meaningful and social activities. Enabling clients to undertake
these activities may ask for restoring various functions (e.g. physical, cognitive
and social), but in the Delphi study agreement was only reached about physical
functioning. To emphasise that restoring functionality and independence is not
necessarily limited to enhancing physical functioning, the research team replaced
the term physical functioningby physical and/or other functioning. Other rea-
sons experts stated for not agreeing with the definition were that reablement was
not delivered by an inter-disciplinary team in their context (mentioned by three
experts; 18%) or that there was too little emphasis on the meaningfulness of activ-
ities (mentioned by three experts; 18%). Other reasons were only mentioned by a
single expert, e.g. not including time-limited as a characteristic or that reablement
approaches can be delivered to individuals irrespective of the setting. We did not
adapt the definition with regard to these comments, as they were only argued
once. The final definition of reablement is shown below:
Reablement is a person-centred, holistic approach that aims to enhance an indivi-
duals physical and/or other functioning, to increase or maintain their independ-
ence in meaningful activities of daily living at their place of residence and to
reduce their need for long-term services. Reablement consists of multiple visits
and is delivered by a trained and coordinated interdisciplinary team. The approach
includes an initial comprehensive assessment followed by regular reassessments
and the development of goal-oriented support plans. Reablement supports an
individual to achieve their goals, if applicable, through participation in daily activ-
ities, home modifications and assistive devices as well as involvement of their
social network. Reablement is an inclusive approach irrespective of age, capacity,
diagnosis or setting.
Discussion
The aim of this study was to reach agreement on the characteristics, components,
aims and target groups of reablement leading to an international definition of
reablement. The final definition, which was accepted by 79 per cent of the partici-
pating experts, contains a broad range of components. Some of these components
(e.g. goalsetting; Ryburn et al.,2008; Legg et al.,2015; Whitehead et al.,2015;
Aspinal et al.,2016; Cochrane et al.,2016; Tessier et al.,2016; Sims-Gould et al.,
2017; Doh et al.,2020) are in line with previous literature reviews (Ryburn et al.,
2008; Legg et al.,2015; Whitehead et al.,2015; Cochrane et al.,2016; Tessier
et al.,2016; Sims-Gould et al.,2017) and position papers (Aspinal et al.,2016;
Doh et al.,2020), while other components were added (e.g. regular assessments;
Ryburn et al.,2008; Legg et al.,2015; Tessier et al.,2016). Furthermore, agreement
Ageing & Society 11
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was reached among participating experts that reablement approaches aim to
increase or maintain independence in a broad range of daily activities, including
social, leisure or physical activities, which were described only in a few literature
reviews and position papers (Legg et al.,2015; Aspinal et al.,2016; Doh et al.,
2020) previously. What exactly is meant by independence may vary among clients.
For some, it may mean being able to manage all activities without assistance, for
others it could mean maintaining independence in some activities of daily living
(e.g. washing face and brushing teeth) while needing support with other activities
(e.g. going for a walk). Therefore, it is very important that reablement takes into
account clientsgoals.
Participating experts agreed that reablement is an inclusive approach, irrespect-
ive of age, capacity, diagnosis or setting. This finding is in contrast with the review
of Ryburn et al. (2008), who reported that reablement approaches are primarily
aimed at older people at the beginning of their home care journey, often after hos-
pital admission. Also Cochrane et al. (2016) argued in their systematic review that
people with chronic illnesses, terminal diseases or dementia are not considered for
reablement, as they have no potential to benefit from it. However, two recent stud-
ies from Australia (Poulos et al.,2017; Jeon et al.,2018) showed that reablement
approaches can also be promising for people with dementia. According to
Poulos et al. (2017), people with dementia still have the capacity to increase or
maintain their functional ability, which can positively influence their health and
wellbeing. This finding is in line with the case study described by Jeon et al.
(2018), in which reablement resulted in increased confidence and physical strength,
more participation in daily activities and improved wellbeing. However, the authors
acknowledged that additional reablement strategies have to be taken into account to
compensate for affected attention, memory, orientation, and executive function
such as cognitive rehabilitation, assistive devices and a strong involvement of the
informal care-giver (Poulos et al.,2017; Jeon et al.,2018,2019).
In the present Delphi study, participating experts agreed that reablement
approaches do not have to be time-limited, which is in conflict with most previous
literature reviews and discussion papers. While some authors described reablement
as a time-limited approach (Ryburn et al.,2008; Legg et al.,2015; Aspinal et al.,
2016; Cochrane et al.,2016; Tessier et al.,2016; Sims-Gould et al.,2017; Doh
et al.,2020), only Whitehead et al. (2015) reported that reablement does not neces-
sarily have to end after a few weeks. Also the fact that participating experts agreed
that reablement is also a promising approach in institutionalised long-term care is
not in line with previous literature reviews (Ryburn et al.,2008; Legg et al.,2015;
Whitehead et al.,2015; Cochrane et al.,2016; Tessier et al.,2016; Sims-Gould
et al.,2017) and position papers (Aspinal et al.,2016; Doh et al.,2020).
However, there are some recent studies, e.g. the study of Low et al. (2018), that pro-
vided evidence that reablement is also a promising approach with regard to several
clientsoutcomes (i.e. depressive symptoms, functioning and social care related to
quality of life) in residential care. The added value of reablement in a wide range of
care settings is also supported by the work of Resnick et al. (2013), who conducted
several studies in acute (i.e. hospital) and long-term care (i.e. nursing homes,
assisted living and home care).
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There were some differences in agreement rates across countries, with the lowest
agreement rate among experts from the UK (42%). According to a recent National
Health Service report (Beresford et al.,2019), reablement is described as a
time-limitedapproach to make a distinction between reablement and generic
rehabilitation services. Rehabilitation is often offered after an acute event whereas
reablement more often follows a gradual decline and therefore can be applied in
a preventive manner. In addition, rehabilitation is often medically directed and
occurs in hospital or ambulatory settings. Reablement takes a more holistic
approach and is applied in the place of residence. Ultimately, reablement aims to
enable the person to increase or maintain their independence in daily life by pro-
moting an attitude of doing with…’ rather than doing for…’ among health and
social care professionals (Metzelthin et al., 2017). According to the definition, rea-
blement aims to reduce the need for long-term services, which means a reduction
or prevention of services as consequence of reablement. Time-limited refers to the
level of service input. Reablement is often applied as a time-limited intervention,
usually 612 weeks. However, in some cases, people might need support for a
longer period. Reablement even has the potential to be implemented in traditional
long-term care like in the Netherlands or the USA, as long as the ethos of reable-
ment (doing with…’) is respected. Next to the disagreement regarding the time-
limited nature of reablement, the low agreement rate in the UK is potentially
due to the fact that the final definition in the Delphi study states that reablement
is delivered by a trained and coordinated interdisciplinary team. In their report,
Beresford et al. (2019) presented four different patterns of staffing and skill mix
in the UK: (a) reablement workers only, (b) home care reablement, (c) reablement
with occupational therapy, and (d) inter-disciplinary reablement approaches. These
patterns are also recognised in other countries. For example, in New Zealand rea-
blement is delivered by support workers and registered nurses with support from
the wider inter-disciplinary team (King et al.,2012a,2012b), while in the Dutch
Stay Active at Homestudy, reablement is provided by home care teams (i.e.
domestic support workers and nurses) (Metzelthin et al.,2017,2018). In contrast,
in Norway, reablement is strongly influenced by occupational therapists and is
delivered by an inter-disciplinary team that also includes other disciplines such
as nurses, social educators, physiotherapists, home-helpers and assistants
(Langeland et al.,2015,2019; Tuntland et al.,2015). It has to be acknowledged
that the composition of reablement teams can vary between and even within coun-
tries and is not limited to health-care professionals.
This study has several strengths and limitations that need to be discussed. First,
in this study a large sample of reablement experts, both academics and practi-
tioners, from 11 countries participated. However, selection bias may have occurred
since most experts were identified based on at least one English peer-reviewed rea-
blement publication. In addition, all experts needed sufficient English skills to fill in
the surveys. Consequently, practitioners, especially from non-English-speaking
countries, might have been underrepresented in the sample. In addition, all mem-
bers of the ReAble network were invited to participate in the Delphi study. As most
network members are from Denmark, Sweden and Norway, the Scandinavian
countries were overrepresented in our sample. Reablement is applied in different
ways across the world, mostly influenced by contextual circumstances.
Ageing & Society 13
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Consequently, experts may have had different approaches in mind when participat-
ing in the Delphi study. A strength of our study is that we incorporated both the
state-of-the-art literature and the opinions of experts, which has not been done
before. For example, a previous discussion paper was based on literature only
(Doh et al.,2020). However, it must be acknowledged that we did not conduct a
systematic literature review of the reablement literature.
In conclusion, this Delphi study succeeded in developing an internationally
accepted definition of reablement, across academia and practice. However, to
ensure its widespread use, it is important to translate the definition into various
languages, with back translation to ensure validity and to contextualise it to take
into account national and local policy and institutional contexts. Although we
are aware of the differences between and within countries in how reablement
approaches are applied in practice, this study is a first step towards more conceptual
clarity when defining reablement. Future research can be conducted regarding the
implementation of agreed reablement components. For example, a wide variety of
assessment tools are used to evaluate the capabilities of clients. In addition, research
is needed in other promising target groups, such as people with chronic illnesses or
terminal diseases. More research in this field will facilitate collaborative learning,
which potentially leads towards more effective service delivery and better client out-
comes. Furthermore, the evidence would be valuable for the development of edu-
cational programmes for health and social care staff, and local and national policies.
Acknowledgements. We thank the experts for their participation in this study.
Author contributions.
All authors were involved in the conception and design of the study. EB was responsible for the data collection and ana-
lysis. All authors were involved in the interpretation of the data. SFM made a first draft of the paper. MP, TR and EB
revised it critically for important intellectual content and gave approval for the final version to be published.
Financial support. This work was supported by the Western Australian Department of Health Merit
Award. The initiation of the ReAble network has been funded by the Nordic NORDFORSK research fund-
ing agency.
Conflict of interest. The authors declare no conflicts of interest.
Ethical standards. Potential participants were informed by an information sheet about the aim and the
design of the study. Completion of the first Delphi survey was taken as evidence of consent. Participation
was voluntary and participants could withdraw from the study at any time without providing a reason for
withdrawal. There were no risks related to participating in this study. All collected data were de-identified
(coded). Only the research team had access to the code. Any collected information was treated confiden-
tially and used only in this project. Ethical approval to conduct this study was granted by the Curtin
University Human Research Ethics Committee (reference number 15130-04).
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S0144686X20000999
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... Reablement is mainly implemented in home and community care settings (Cochrane et al., 2016;Doh et al., 2020) and " [. . .] aims to enhance an individual's physical and/or other functioning, to increase or maintain their independence in meaningful activities of daily living at their place of residence and to reduce their need for long-term services" (Metzelthin et al., 2022). Evidence regarding positive effects of reablement-based interventions on health-related outcomes for seniors is inconsistent Sims-Gould et al., 2017;Tessier et al., 2016). ...
... The intervention was inspired by the concept of reablement (Metzelthin et al., 2022) and combined elements of health and social care by building a community-based network to assist and support older people and their relatives in their homes. More specifically, an initial comprehensive geriatric assessment was conducted to identify each IG participant's resources and risks regarding medical conditions, social aspects and physical performance. ...
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This prospective, quasi-experimental study aims to compare healthcare resource utilization (HCRU) and costs of a multi-component care approach for older people in a community setting (intervention group (IG)) with usual care in a matched control group (CG) during a 21-month observation period. The reablement-oriented intervention included a geriatric assessment, a case and network management and digital supporting tools. Regression models were applied to determine intervention effects regarding hospitalization, total hospital length of stay (LOS), number of physician consultations, and healthcare costs using claims data. 872 subjects were included in the IG and 1,768 in the CG. The analyses showed that the intervention did not affect hospitalization (OR = 1.153; 95% CI: 0.971–1.369, p = .105). However, participating in the IG lead to a small but significant increase of physician contacts by a factor of 1.078 (Exp(ß) = 1.078; 95% CI: 1.011–1.149; p = .022). A non-significant mean difference in costs of €1,183 (95% CI: €−261.6 to €2,627.6, p = .108) per participant was identified. Further research is needed to generate robust evidence on the optimal design of care approaches for older people and the health economic implications of such interventions to improve care and resource allocation decision-making.
... Over the last two decades, reablement has emerged as a practice model in community-based home aged age [10]. The reablement model challenges the traditional model of aged care of maintenance and support, shifting to a focus which aimed at preventing further functional decline and a restoration of lost function [11][12][13][14]. ...
... The reablement model challenges the traditional model of aged care of maintenance and support, shifting to a focus which aimed at preventing further functional decline and a restoration of lost function [11][12][13][14]. A recent Delphi study defined reablement as a "personcentered and holistic approach that aims to increase or maintain a clients' independence and participation in daily and meaningful activities (at home or in the community) and to reduce their need for long-term services and related costs" [10]. Despite its increasing adoption into practice, there remains variation between, and even within, some countries regarding its conceptual understanding and implementation [15]. ...
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Background The ageing of Australia's population is placing significant pressure on health and social aged care services due to increasing demand for the provision and a relative decrease in the healthcare workforce. Reablement has been introduced by the Australian Commonwealth Government and is aimed at increasing older people's independence to age in place and decreasing dependency on aged care services. To date, research on reablement practice has focussed on interventions from physiotherapists, occupational therapists, and nurses, with no data available on podiatrist involvement. The aim of this research was to explore Australian podiatrists' understanding and current practice of implementing a reablement approach to older clients. Methods A qualitative exploratory study was conducted with Australian podiatrists who had experience working with older people and were familiar with the reablement model. Podiatrists were recruited after completing a prior web-based survey. Promotion of the web-based survey was via professional networks and Twitter. Interviews were audio-recorded, transcribed verbatim, and analysed using Braun and Clarke's approach to thematic analysis. Results Fourteen podiatrists were interviewed. Using thematic analysis, three themes were generated: (i) Thinking and practicing differently, (ii) Reconciling practice with competing pressures, (ii) Funding influences on podiatry practice and reablement. Rather than identifying practice examples that demonstrate involvement by podiatrists in older peoples reablement, our analysis identified system level barriers which gave negative influence on podiatrists' ability to implement the reablement model. Conclusions The participants in this study considered their role in reablement for older people was limited. While some participants felt unskilled to implement the reablement model, it is factors such as inadequate funding arrangements and clients' perceptions of podiatrists' roles have a more significant impact on current practice and are seemingly more intractable.
... Another strategy to reduce job strain would be to apply a reablement approach, where teamwork, structured planning, and communication is central [58]. Reablement has been tested and implemented in home care organisations in several countries [59][60][61][62]. ...
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Background Home care staff (HCS) provide essential service to enable older adults to age in place. However, unreasonable demands in the work environment to deliver a safe, effective service with high quality has a negative impact on the individual employee’s well-being and the care provided to the older adults. The psychosocial work environment is associated with employees´ well-being, although, knowledge regarding which individual and organisational factors that contribute to job strain for HCS is limited. These factors need to be identified to develop targeted interventions and create sustainable work situations for HCS. This study aimed to explore how HCS´s perceived job strain is associated with, and to what extent can be explained by, individual and organisational factors of the psychosocial work environment and psychosomatic health. Method An explorative cross-sectional questionnaire survey design was used in a large Swedish county. Five home care agencies with a total of 481 HCS were asked to respond to a questionnaire regarding their perceived level of job strain (Strain in Dementia Care Scale), psychosocial work environment (QPSNordic³⁴⁺), and psychosomatic health (Satisfaction with Work Questionnaire). Multiple linear regression (MLR) analyses were conducted to explore the association between job strain and individual and organisational factors. Results In total, 226 (46%) HCS responded to the questionnaire. Both individual and organisational factors were significant predictors of job strain and explained a variance ranging between 39 to 51% (p = 0.001). The organisational factor job demand and the individual factor feeling worried and restless was most frequently represented in these MRL models. A higher job strain was also associated with adverse outcomes regarding leadership, organisational culture and climate, and control at work. Conclusion This study indicates that there is an intertwined complexity of individual and organisational factors that are associated with the HCS´s perception of job strain. Implementation of new multidimensional work strategies, such as a reablement approach, could support the development of efficient strategies for HCS and reduce the level of job strain. Policy changes for the provision of home care are also needed to support the development of a sustainable and healthy psychosocial work environment.
... Against this background, Rahja et al.'s [4] systematic review considering the impact of reablement interventions for care homes residents on independence with activities of daily living (ADLs) and quality of life (QoL) is welcome. The review defines reablement, using criteria developed by Metzelthin et al. [5], as being goal-oriented, delivered by an interdisciplinary team and including multiple sessions. Reablement interventions could include participation in ADLs, home modifications and assistive devices, and could involve social networks. ...
... Recognizing that Delphi studies can consist of any number of rounds, [37] this prediction was not only based on the format of each round in this study, but also on the fact that Delphi studies commonly involve 3-5 rounds, [37] and that most Delphi studies that have been conducted by health science researchers to establish agreed definitions have consisted of 3-5 rounds. [39][40][41][42][43][47][48][49][50][51][52][53][54][55][56][57][58][59][60][70][71][72][73][74] However, we did set a maximum number of rounds in advance -if consensus was not reached on the definitions by a fifth round, then a sixth and final round would take place in the form of a meeting with participants via teleconferencing software to achieve consensus through discussion. ...
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Introduction With the social prescribing movement gaining traction globally, there is a need for an agreed definition of social prescribing. There are two types of definitions — conceptual and operational, meaning agreement on both types of definitions is needed. Objective The aim of this study was to establish internationally accepted conceptual and operational definitions of social prescribing. Design A three-round Delphi study was conducted. Methods Consensus was defined a priori as ≥80% agreement. In Round 1, participants were asked to list key elements that are essential to the conceptual definition of social prescribing and to provide corresponding statements that operationalize each of the key elements. In Round 2, participants were asked to rate their agreement with items from the first round for inclusion in the conceptual and/or operational definitions of social prescribing. Based on the findings from this round, the conceptual and operational definitions of social prescribing were developed, including long and short versions of the conceptual definition. In Round 3, participants were asked to rate their agreement with the conceptual and operational definitions of social prescribing. Participants This study involved an international, multidisciplinary panel of experts. The expert panel (n=48) represented 26 different countries across five continents, numerous expert groups, and a variety of years of experience with social prescribing, with the average being 5 years (range = 1-20 years). Results After three rounds, internationally accepted conceptual and operational definitions of social prescribing were established. The definitions were transformed into the Common Understanding of Social Prescribing (CUSP) conceptual framework. Conclusion This foundational work offers a common thread — a shared sense of what social prescribing is, which may be woven into social prescribing research, policy, and practice to foster common understanding of this concept.
Article
The effect of Reablement, a multi‐faceted intervention is unclear, specifically, which interventions improve outcomes. This Systematic Review evaluates randomised controlled trials (RCTs) describing Reablement investigating the population, interventions, who delivered them, the effect and sustainability of outcomes. Database search from inception to August 2021 included AMED, ASSIA, BNI, CINHALL, EMBASE, HMIC, MEDLINE, PUBMED, PsycINFO, Google Scholar, Web of Science, Clinicaltrials.gov. Two researchers undertook data collection and quality assessment, following the PRISMA (2020) statement. They measured effect by changed primary or secondary outcomes: no ongoing service, functional ability, quality of life and mobility. The reviewers reported the analysis narratively, due to heterogeneity of outcome measures, strengthened by the SWiM reporting guideline. The search criteria resulted in eight international studies, five studies had a risk of bias limitations in either design or method. Ongoing service requirement decreased in five studies, with improved effect at 3 months shown in studies with occupational therapist involvement. Functional ability increased statistically in four studies at 3 months. Increase in quality of life was statistically significant in three studies, at 6 and 7 months. None of the studies reported a statistically significant improvement in functional mobility. Reablement is effective in the context of Health and Social Care. The outcomes were sustained at 3 months, with less sustainability at 6 months. There was no statistical result for the professional role regarding assessment, delivery and evaluation of interventions, and further research is justified.
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This innovative volume presents twenty comparative case studies of important global questions, such as 'Where should our food come from?' 'What should we do about climate change?' and 'Where should innovation come from?' A variety of solutions are proposed and compared, including market-based, economic, and neoliberal approaches, as well as those determined by humane values and ethical and socially responsible perspectives. Drawing on original research, its chapters show that more responsible solutions are very often both more effective and better aligned with human values. Providing an important counterpoint to the standard capitalist thinking propounded in business school education, People Before Markets reveals the problematic assumptions of incumbent frameworks for solving global problems and inspires the next generation of business and social science students to pursue more effective and human-centered solutions.
Article
This innovative volume presents twenty comparative case studies of important global questions, such as 'Where should our food come from?' 'What should we do about climate change?' and 'Where should innovation come from?' A variety of solutions are proposed and compared, including market-based, economic, and neoliberal approaches, as well as those determined by humane values and ethical and socially responsible perspectives. Drawing on original research, its chapters show that more responsible solutions are very often both more effective and better aligned with human values. Providing an important counterpoint to the standard capitalist thinking propounded in business school education, People Before Markets reveals the problematic assumptions of incumbent frameworks for solving global problems and inspires the next generation of business and social science students to pursue more effective and human-centered solutions.
Article
Background: Most evidence for reablement comes from community-based interventions. Objective: To determine the effect of reablement interventions provided in permanent residential aged care (PRAC) homes on residents' level of function in activities of daily living (ADL) and quality of life (QoL). Design: Systematic review and meta-analysis. Setting: PRAC homes. Subjects: Residents in PRAC. Methods: Six databases and grey literature were searched until November 2021. Quantitative studies involving a control group or pre-post evaluation were included. Outcomes of interest were the effectiveness of the reablement intervention on overall ADL or QoL in the last available follow-up. Results: Twelve studies involving 2,620 residents were included. The reablement interventions varied; the primary focus areas were organisational approaches (e.g. educating staff; n = 10) and improving physical function (e.g. increasing physical activity; n = 9). Not all studies could be pooled in the meta-analysis due to reported data and heterogeneity. There was no significant effect of reablement intervention versus usual care on ADL function (five studies, standardised mean difference (SMD): 0.17, 95% confidence interval (CI): -0.25 to 0.59, very low quality evidence). Reablement appeared more beneficial than usual care in improving QoL; however, the overall effect was not statistically significant (four studies, SMD: 0.73, 95% CI: -0.07 to 1.52; very low quality evidence). Conclusions: Few studies focus on reablement in PRAC homes and their clinical heterogeneity is considerable. There is insufficient evidence for reablement in terms of improving ADL or QoL for residents in PRAC. Tools that are more sensitive to change may be beneficial.
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Objective Social prescribing is a person-centred model of care with emphases on lessening the impact of unmet social needs, supporting the delivery of personalised care, and reducing non-medical resource use in the primary care setting. The purpose of this systematic review was to synthesise the effect of social prescribing for older adults within primary care. Design We followed standard systematic review guidelines, including protocol registration, screening studies (title/abstract and full text) and assessing the study quality. Eligibility and information sources We searched multiple online databases for studies that included older adults 60+ years (group mean age), an intervention defined and called social prescribing (or social prescription) via health provider referrals to non-medical services, and quantitative physical and psychosocial outcomes and/or health resource use. We included experimental and observational studies from all years and languages and conducted a narrative synthesis. The date of the last search was 24 March 2022. Results We screened 406 citations (after removing duplicates) and included seven studies. All studies except one were before–after design without a control group, and all except one study was conducted in the UK. Studies included 12–159 participants (baseline), there were more women than men, the group mean (SD) age was 76.1 (4.0) years and data collection (baseline to final) occurred on average 19.4 (14.0) weeks apart. Social prescribing referrals came from health and social providers. Studies had considerable risk of bias, programme implementation details were missing, and for studies that reported data (n=6) on average only 66% of participants completed studies (per-protocol). There were some positive effects of social prescribing on physical and psychosocial outcomes (eg, social participation, well-being). Findings varied for health resource use. These results may change with new evidence. Conclusions There were few peer-reviewed studies available for social prescribing and older adults. Next steps for social prescribing should include co-creating initiatives with providers, older people and communities to identify meaningful outcomes, and feasible and robust methods for uptake of the prescription and community programmes. This should be considered in advance or in parallel with determining its effectiveness for meaningful outcomes at multiple levels (person, provider and programme).
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Background: A major gap exists internationally in providing support to maintain functional and social independence of older people with dementia living at home. This project evaluates a model of care that integrates evidence-based strategies into a person-centred interdisciplinary rehabilitation package: Interdisciplinary Home-bAsed Reablement Program (I-HARP). Two central aims are: 1) to determine the effectiveness of I-HARP on functional independence, mobility, quality of life and depression among people with dementia, their home environmental safety, carer burden and quality of life, and I-HARP cost-effectiveness; and 2) to evaluate the processes, outcomes and influencing factors of the I-HARP implementation. Methods: I-HARP is a 4-month model of care, integrated in community aged care services and hospital-based community geriatric services, and consists of: 1) 8-12 home visits, tailored to the individual client's needs, by an occupational therapist, registered nurse, and other allied health staff; 2) minor home modifications/assistive devices to the value of <A$1000 per participant; and 3) three individual carer support sessions. The overarching design is a mixed-methods action research approach, consisting of a multi-centre pragmatic parallel-arm randomised controlled trial (RCT) and realist evaluation, conducted in two phases. Participants include 176 dyads (person aged > 60 years with mild to moderate dementia and his/her carer). During Phase I, I-HARP advisory group is established and training of I-HARP interventionists is completed, and the effectiveness of I-HARP is examined using a pragmatic RCT. Phase II, conducted concurrently with Phase I, focuses on the process evaluation of the I-HARP implementation using a realist approach. Semi-structured interviews with participants and focus groups with I-HARP interventionists and participating site managers will provide insights into the contexts, mechanisms and outcomes of I-HARP. Discussion: I-HARP is being evaluated within the real-world systems of hospital-based and community-based aged care services in Australia. Future directions and strategies for reablement approaches to care for community dwelling people living with dementia, will be developed. The study will provide evidence to inform key stakeholders in their decision making and the use/delivery of the program, as well as influence future systems-thinking and changes for dementia care. Trial registration: Australian New Zealand Clinical Trial Registry ACTR N12618000600246 (approved 18/04/2018).
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Background Reablement is an intensive, time-limited intervention for people at risk of needing social care or an increased intensity of care. Differing from home care, it seeks to restore functioning and self-care skills. In England, it is a core element of intermediate care. The existing evidence base is limited. Objectives To describe reablement services in England and develop a service model typology; to conduct a mixed-methods comparative evaluation of service models investigating outcomes, factors that have an impact on outcomes, costs and cost-effectiveness, and user and practitioner experiences; and to investigate specialist reablement services/practices for people with dementia. Methods Work package (WP) 1, which took place in 2015, surveyed reablement services in England. Data were collected on organisational characteristics, service delivery and practice, and service costs and caseload. WP2 was an observational study of three reablement services, each representing a different service model. Data were collected on health (EuroQol-5 Dimensions, five-level version) and social care related (Adult Social Care Outcomes Toolkit – self-completed) quality of life, practitioner (Barthel Index of Activities of Daily Living) and self-reported (Nottingham Extended Activities of Daily Living scale) functioning, individual and service characteristics, and resource use. They were collected on entry into reablement ( n = 186), at discharge ( n = 128) and, for those reaching the point on the study timeline, at 6 months post discharge ( n = 64). Interviews with staff and service users explored experiences of delivering or receiving reablement and its perceived impacts. In WP3, staff in eight reablement services were interviewed to investigate their experiences of reabling people with dementia. Results A total of 201 services in 139 local authorities took part in the survey. Services varied in their organisational base, their relationship with other intermediate care services, their use of outsourced providers, their skill mix and the scope of their reablement input. These characteristics influenced aspects of service delivery and practice. The average cost per case was £1728. Lower than expected sample sizes meant that a comparison of service models in WP2 was not possible. The findings are preliminary. At discharge (T1), significant improvements in mean score on outcome measures, except self-reported functioning, were observed. Further improvements were observed at 6 months post discharge (T2), but these were significant for self-reported functioning only. There was some evidence that individual (e.g. engagement, mental health) and service (e.g. service structure) characteristics were associated with outcomes and resource use at T1. Staff’s views on factors affecting outcomes typically aligned with, or offered possible explanations for, these associations. However, it was not possible to establish the significance of these findings in terms of practice or commissioning decisions. Service users expressed satisfaction with reablement and identified two core impacts: regained independence and, during reablement, companionship. Staff participating in WP3 believed that people with dementia can benefit from reablement, but objectives may differ and expectations for regained independence may be inappropriate. Furthermore, staff believed that flexibility in practice (e.g. duration of home visits) should be incorporated into delivery models and adequate provision made for specialist training of staff. Conclusions The study contributes to our understanding of reablement, and what the impacts are on outcomes and costs. Staff believe that reablement can be appropriate for people with dementia. Findings will be of interest to commissioners and service managers. Future research should further investigate the factors that have an impact on outcomes, and reabling people with dementia. Funding The National Institute for Health Research Health Services and Delivery Research programme.
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Background Reablement is an emerging approach in rehabilitation services, but evidence for its efficacy is rather weak and inconsistent. The purpose of the present study is therefore to investigate the health effects of reablement in home-dwelling adults. Methods A multicenter, clinical controlled trial involving 47 municipalities in Norway, with assessments at baseline, and after 10 weeks and at 6 and 12 months. The sample consisted of 707 persons that received a 4–10 week reablement program and 121 underwent treatment as usual. Primary outcomes were activity performance and satisfaction with performance measured by the Canadian Occupational Performance Measure (COPM, 1–10). Secondary outcomes included the Short Physical Performance Measure Battery (SPPB), the European Quality of Life Scale (EQ-5D-5 L), and the Sense of Coherence Questionnaire (SOC). Overall treatment effects were estimated with mixed-model repeated measures analyses. Results Significant treatment effects in the rehabilitation group compared with the control group were found in COPM-Performance and COPM-Satisfaction scores at 10 weeks (mean differences between groups (MD), 1.61, 95% confidence interval (CI), 1.13, 2.10 and MD 1.47, CI 0.98, 1.97, respectively), and at 6 months (MD 1.42; CI 0.82,2.02 and MD 1.37; CI 0.77,1.98, respectively). There were also significant treatment effects in the SPPB-subscales for balance and walking after 6 months, in the total SPPB score and in the subscale for sit-to-stand after 12 months. In the EQ-5D-5 L assessment, significant treatment effects were found in the subscales for mobility, and for usual activities and health after 6 months. There was a significant difference in the SOC after six months. Conclusion Reablement seems to be a more effective rehabilitation service for persons with functional decline than traditional home-based services after six months. After 12 months, the differences between the groups decreased. Trial registration The trial was registered at ClinicalTrials.gov on October 24, 2014, (retrospectively registered) identifier: NCT02273934.
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Background According to the principles of Reablement, home care services are meant to be goal-oriented, holistic and person-centred taking into account the capabilities and opportunities of older adults. However, home care services traditionally focus on doing things for older adults rather than with them. To implement Reablement in practice, the ‘Stay Active at Home’ programme was developed. It is assumed that the programme leads to a reduction in sedentary behaviour in older adults and consequently more cost-effective outcomes in terms of their health and wellbeing. However, this has yet to be proven. Methods/ design A two-group cluster randomised controlled trial with 12 months follow-up will be conducted. Ten nursing teams will be selected, pre-stratified on working area and randomised into an intervention group (‘Stay Active at Home’) or control group (no training). All nurses of the participating teams are eligible to participate in the study. Older adults and, if applicable, their domestic support workers (DSWs) will be allocated to the intervention or control group as well, based on the allocation of the nursing team. Older adults are eligible to participate, if they: 1) receive homecare services by the selected teams; and 2) are 65 years or older. Older adults will be excluded if they: 1) are terminally ill or bedbound; 2) have serious cognitive or psychological problems; or 3) are unable to communicate in Dutch. DSWs are eligible to participate if they provide services to clients who fulfil the eligibility criteria for older adults. The study consists of an effect evaluation (primary outcome: sedentary behaviour in older adults), an economic evaluation and a process evaluation. Data for the effect and economic evaluation will be collected at baseline and 6 and/or 12 months after baseline using performance-based and self-reported measures. In addition, data from client records will be extracted. A mixed-methods design will be applied for the process evaluation, collecting data of older adults and professionals throughout the study period. Discussion This study will result in evidence about the effectiveness, cost-effectiveness and feasibility of the ‘Stay Active at Home’ programme. Trial registration ClinicalTrials.gov: NCT03293303, registered on 20 September 2017.
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Background: The protective, custodial, task-oriented care provided in residential aged care facilitates decreases health and wellbeing of residents. The aim of the study was to conduct a feasibility study of LifeFul - a 12 month reablement program in residential aged care. Methods: LifeFul was developed based on systematic reviews of reablement and staff behaviour change in residential aged care, and in consultation with aged care providers, consumers and clinicians. LifeFul includes: engaging and supporting facility leaders to facilitate organisational change, procedural changes including dedicated rostering, assigning each resident a 'focus' carer and focusing on the psychosocial care of residents part of handovers and staff training. The study was conducted in three Australian residential aged care facilities. A pre-post mixed methods design was used to evaluate recruitment and retention, fidelity and adherence, acceptability, enablers and barriers and suitability of outcome measures for the program. Results: Eighty of 146 residents agreed to participate at baseline and 69 of these were followed up at 12 months. One hundred and four of 157 staff participated at baseline and 85 of 123 who were still working at the facilities participated at 12 months. Staff perceived the program to be acceptable, barriers included having insufficient time, having insufficient staff, negative attitudes, misunderstanding new procedures, and lack of sufficient leadership support. Quantitative data were promising in regards to residents' depression symptoms, functioning and social care related quality of life. Conclusion: It is feasible to deliver and evaluate LifeFul. The program could be improved through increased leadership training and support, and by focusing efforts on residents having a 'best week' rather than on completing a document each handover. Trial registration: Registered prospectively on 22nd January 2016 on ANZCTR369802 .
Article
In this paper we tell of our critical review of reablement – an emerging global practice model in community- and home-based care for older people. Whereas the reablement approach is gaining global acceptance, there are questions and concerns among researchers and policy makers about what reablement means and how it is used in practice. We examined the literature on reablement between 2005 and 2017 using clearly defined inclusion criteria. We focused on identifying within authors’ accounts its essential features and how it is practised. In our examination of conceptualisation, we found nine essential features of reablement, the most predominant being the wish to improve the functionality of clients so they can continue to live in their own homes. Of course, we found variability in policy and geographic contexts, but we were not perturbed by this. Rather, we found the under-representation of social connectivity for clients to be regrettable. We constructed a typology of four theoretical types of reablement to help us reflect on the current state of research and practice, and we tentatively offer this for the consideration of the research, practice and policy communities.
Article
Worldwide increases in the numbers of older people alongside an accompanying international policy incentive to support ageing-in-place have focussed the importance of home-care services as an alternative to institutionalisation. Despite this, funding models that facilitate a responsive, flexible approach are lacking. Casemix provides one solution, but the transition from the well-established hospital system to community has been problematic. This research seeks to develop a Casemix funding solution for home-care services through meaningful client profile groups and supporting pathways. Unique assessments from 3,135 older people were collected from two health board regions in 2012. Of these, 1,009 arose from older people with non-complex needs using the interRAI-Contact Assessment (CA) and 2,126 from the interRAI-Home-Care (HC) from older people with complex needs. Home-care service hours were collected for 3 months following each assessment and the mean weekly hours were calculated. Data were analysed using a decision tree analysis, whereby mean hours of weekly home-care was the dependent variable with responses from the assessment tools, the independent variables. A total of three main groups were developed from the interRAI-CA, each one further classified into “stable” or “flexible.” The classification explained 16% of formal home-care service hour variability. Analysis of the interRAI-HC generated 33 clusters, organised through eight disability “sub” groups and five “lead” groups. The groupings explained 24% of formal home-care services hour variance. Adopting a Casemix system within home-care services can facilitate a more appropriate response to the changing needs of older people.
Article
Aims: To generate a standardised definition for fundamental care and identify the discrete elements that constitute such care. Background: There is poor conceptual clarity surrounding fundamental care. The Fundamentals of Care Framework aims to overcome this problem by outlining three core dimensions underpinning such care. Implementing the Framework requires a standardised definition for fundamental care that reflects the Framework's conceptual understanding, as well as agreement on the elements that comprise such care (i.e., patient needs, such as nutrition, and nurse actions, such as empathy). This study sought to achieve this consensus. Design: Modified Delphi study. Methods: Three phases: (1) engaging stakeholders via an interactive workshop; (2) using workshop findings to develop a preliminary definition for, and identify the discrete elements that constitute, fundamental care; and (3) gaining consensus on the definition and elements via a two-round Delphi approach (Round 1 n=38; Round 2 n=28). Results: Delphi participants perceived both the definition and elements generated from the workshop as comprehensive, but beyond the scope of fundamental care. Participants questioned whether the definition should focus on patient needs and nurse actions, or more broadly on how fundamental care should be delivered (e.g., through a trusting nurse-patient relationship), and the outcomes of this care delivery. There were also mixed opinions whether the definition should be nursing specific. Conclusions: This study has initiated crucial dialogue around how fundamental care is conceptualised and defined. Future work should focus on further refinements of the definition and elements with a larger, international group of practising nurses and service users. This article is protected by copyright. All rights reserved.
Article
Objective: to investigate how frailty and frailty symptoms affect healthcare costs in older age longitudinally. Methods: data were gathered from a prospective cohort study in Saarland, Germany (two waves with 3-year interval, n = 1,636 aged 57–84 years at baseline). Frailty was assessed by the five Fried frailty criteria. Frailty was defined as having at least three criteria, the presence of 1–2 criteria as ‘pre-frail’. Healthcare costs were quantified based on self-reported healthcare use in the sectors of inpatient treatment, outpatient treatment, professional nursing care and informal care as well as the provision of pharmaceuticals, medical supplies and dental prostheses. Results: while the onset of pre-frailty did not increase (log) total healthcare costs after adjusting for potential confounders including comorbidity, progression from non-frailty to frailty was associated with an increase in total healthcare costs (for example, costs increased by ~54 and 101% if 3 and 4 or 5 symptoms were present, respectively). This association of frailty onset with increased healthcare costs was in particular observed in the inpatient sector and for informal nursing care. Among the frailty symptoms, the onset of exhaustion was associated with an increase in total healthcare costs, whereas changes in slowness, weakness, weight loss and low-physical activity were not significantly associated with an increase in total healthcare costs. Conclusions: our data stress the economic relevance of frailty in late life. Postponing or reducing frailty might be fruitful in order to reduce healthcare costs.