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    Paper2:HomeCareReablementServices:Investigatingthelongertermimpacts(prospectivelongitudinalstudy)KarenJones,JulienForderandLesleyCurtis(UniversityofKent)Parvaneh Rabiee, Kate Baxter, Caroline Glendinning, Alison Wilde and Hilary Arksey(UniversityofYork)PaperpreparedaspartofasymposiumonpersonalisationandpreventionfortheSocialPolicyAssociationUKconference,46July2011,LincolnUK.Donotcitewithoutthepermissionoftheauthors.Abstract

    Homecarereablementisanew,shortterminterventioninEnglishhomecarewhichhelpsuserstoregainconfidenceandrelearnselfcareskillsandaimstoreduceneedsforlongertermsupport.ResearchersattheSocialPolicyResearchUnit(UniversityofYork)andatthePersonalSocialServicesResearchUnit(UniversityofKent)workedonatwoyearstudytoevaluatetheservice.ThestudywasfundedbytheDepartmentofHealth(DH)CareServicesEfficiencyDelivery.Thestudyfoundthatreablementwasassociatedwithasignificantdecreaseinsubsequentsocialcareserviceuse.Thecostsofthesocialcareservicesusedbypeopleinthereablementgroupduringthe12monthsofthestudy(excludingthecostsofthereablementinterventionitself)were60percentlessthanthecostsofthesocialcareservicesusedbypeopleusingconventionalhomecareservices.However,thisreductioninsocialcarecostswasalmostentirelyoffsetbytheinitialcostofthereablementintervention.Itwasfoundthatreablementhadpositiveimpactsonusershealthrelatedqualityoflifeandsocialcarerelatedqualityoflifeuptotenmonthsafterreablement,againincomparisonwithusersofconventionalhomecareservices.Atawillingnesstopaythresholdof30,000foreachincreaseinhealthrelatedqualityoflife,thereisaveryhighprobability(99percent)thatreablementiscosteffectiveifhealthandsocialcarecostsaretakenintoaccount,andjustunder100percentprobabilityifsocialcarecostsaloneareincluded.Forsocialcarerelatedoutcomes,atawillingnesstopaythresholdof30,000peroutcomegain,thereisa78percentprobabilitythatreablementiscosteffectiveifbothhealthandsocialcarecostsareincludedanda98percentprobabilitythatreablementiscosteffectiveifjustsocialcarecostsareincluded.Thestudyhighlightedthefactorsthatpromotesuccessfuloutcomesforolderanddisabledserviceusers.Aneffectivereablementservicerequiresstafftrainingandongoingsupervision;clearoutcomesforusers,flexibilityandpromptsupplyofequipment.Widerorganisationalfactorssuchasaccesstospecialistsupportandadequatecapacityinlongtermhomecarearealsoessentialforpromotingoptimumoutcomesforreablementserviceusers.Usersandcarerswerepositiveabouttheimpactofreablementontheirindependence,althoughsomewouldhavelikedmorehelpwithmobilityandactivitiesoutsidethehome.

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    Introduction

    Reablementreferstoaformofshorttermhomecarethathelpspeopletoundertakeactivitiesofdailylivingforthemselves.Kentetal.,(2000)proposedthefollowingdefinition,whichhasbecomegenerallyaccepted:Servicesforpeoplewithpoorphysicalormentalhealthtohelpthemaccommodatetheirillnessbylearningorrelearningtheskillsnecessaryfordailyliving.Reablementissometimesreferredtoasanapproachorphilosophy,asithelpspeopletodevelopboththeconfidenceandthepracticalskillstocarryoutactivitiesthemselves.Theaimistomaximiselongtermindependenceandqualityoflife,although,asPetch(2008),pointsout,thismaynotalwaysbeconsistentwiththewishesofserviceuserswhowelcomeregularsocialcontactfromhomecareworkers.Reablementisgenerallyprovidedfreeofchargeforuptosixweeks,afterwhichanyongoingneedsforsupportaremetbyreferraltostandardhomecareservices.

    EarlyinitiativestodevelopreablementservicesinEnglandweredrivenbythedesiretoencouragepeopledischargedfromintermediatecaretocontinuetodevelopdailylivingskills.Morerecently,however,concernsoverthefutureroleoflocalauthorityinhousehomehelpservicesandthecostoflongtermhomecareserviceshaveprompteditsexpansion.AlmostallEnglishcouncilswithsocialservicesresponsibilitiesarenowproviding,orareintheprocessofimplementingreablementservices.Thevastmajorityprovidereablementtoalleligiblepeoplereferredforhomecareservices;afewprovidetheservicetopeopledischargedfromhospitalonly.Changestotherulesaroundpaymentforpostdischargesupportandhospitalreadmissionswithin30daysofdischarge(DepartmentofHealth,2010a),plustheallocationofupto300mayearforspendingonreablementintheNHS(DepartmentofHealth,2010b),suggeststheimportanceofreablementservicesissettoincrease.

    Theresearchevidencebaseonthecostsandbenefitsofreablementservicesissmall.Ryburnetal.,(2009)provideareviewofstudiesundertakenintheUK,AustraliaandtheUSA,whereitisknownasrestorativecare.OtherstudieshavebeencarriedoutintheUKandAustraliamorerecently.

    Ryburnetal.,(2009)foundthat,overall,theevidencesuggestedthatfunctionalstatusimprovedandtheuseofhomecareservicesreducedafteraperiodofreablementsupportwhencomparedwithconventionalhomecare.AmorerecentAustraliancontrolledtrialoftheHomeIndependenceProgrammeinPerth(LewinandVandermeulen,2010)confirmedthattheoddsofreceivinghomecareservicesshortlyaftercompletingaperiodofrestorativecareandagain12monthslaterwerebothsignificantlyreducedcomparedwithpeopleintheconventionalcaregroup.AnevaluationofthreeageinginplaceprogrammesinNewZealand(Parsonsetal.,2007)hasaddedtotheevidenceonimprovedfunctionalstatus;interventionbyCommunityFIRST(FlexibleIntegratedRestorativeSupportTeam)suggestedatrendforimprovementinactivitiesofdailylivingcomparedwithaconventionalcaregroup.Ryburnetals(2009)reviewalsopointstoagrowingbodyofevidencethat

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    suggestsreablementapproachesleadtoongoingcostsavingsinthehealthandhomecaresectors.Somestudieshavealsoattemptedtocalculatethecosteffectivenessofreablement,butthoseavailableatthetimeofthereviewweregenerallynotrandomisedcontrolledtrialsandsolackedrobustness.

    ResearchevidencefromtheUKincludesanearlystudybyKentetal.,(2000)whichevaluatedapilothomecarereablementserviceinLeicestershire.Thepilotbeganbybeinghighlyselectivebutexpandedtoacceptanyoneassessedasneedinghomecare.Whencomparedtoamatchedgroupinadifferentareaofthecounty,resultsshowedthatthehoursofcareprovidedinitiallytothereablementgroupwerehigherthanforthematchedgroup,butatthetimeoffirstreviewthereablementgroupwasmorelikelytohavediscontinuedhomecareservices.Newbronneretal.,(2007)undertookaretrospectiveanalysisofroutineserviceusedataatperiodsofuptotwoyearspostreablementinfourlocalauthorities.Resultssuggestedthatuptohalfofreablementusersusednofurtherhomecareservicesinthefollowingtwoyears,andforsomewhodidstarttouseconventionalhomecare,thiswasdelayedbyayearormore.Howeverthisstudylackedacomparisongroup,sothereisnowayofknowingwhethertheseimprovementswouldhaveoccurredanyway.WhilebothofthesestudieswereincludedinRyburnetals(2009)review,amorerecentevaluationofapilotreablementschemeinEdinburgh(McLeodandMair,2009)confirmsthesefindings:60%ofpeoplereceivingreablementneededlesshomecare(comparedtoamatchedcontrolgroup)andathirdrequirednofurtherhomecareafterreablement.

    Despitethisgrowingevidencebaseinsupportofreablementservices,untilthepresentstudy,therehadbeennolargescale,longtermevaluationofestablishedreablementservicescomparedtoconventionalservicesintheUK.Muchoftheevidencebaseresteduponsmallorexploratorystudies,evaluationsofpilotschemes,orevaluationswithnocomparisongroup.Thus,thispaperbuildsonthesefindingsbypresentingdataonthecosteffectivenessofreablementservicescomparedtoconventionallyprovidedhomecareintenEnglishlocalauthorities.Foramorecomprehensivereport,seeGlendinningetal.,(2010).

    Whilstthecurrentevidencebaseonhomecarereablementservicesisgrowing,questionsremainaboutthemosteffectivetypesofapproaches;aboutwhatgroupsarelikelytobenefitmost;andaboutthemosteffectivetiminganddurationofreablementinterventions(Ryburnetal.,2009).Furthermore,thereislimitedevidenceaboutlongertermoutcomesandbenefits(McLeodandMair,2009).Thepresentstudy,whichtakesalongitudinalapproach,aimedtofillsomeoftheevidencegapsrelatingtotheprovisionofhomecarereablementservicesinEngland.

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    Thestudyaimedto:

    1. Providerobustresearchevidenceontheimmediateandlongertermbenefitsofhomecarereablement,including:

    a) Userlevelbenefits(healthrelated,qualityoflife,andsocialcarerelatedqualityoflife)

    b) Servicelevelbenefits(reduceddemandforservices,lessuseofexpensiveservices).

    2. Identifythefactorsthataffectthelevelanddurationofbenefitsforserviceusersofaperiodofreablement(e.g.featuresoftheservice;usergroupcharacteristics;typeandlevelofservicesusedafterreablement).

    3. Identifyanyimpactonandsavingsintheuseofsocialcareandotherservicesthatcanbesetagainstthecostsofreablementservices.

    4. Describethecontentandthecostsofhomecarereablementservices.

    Method

    Amixedmethodcomparativedesignwasadopted.ServiceusersfromhomecarereablementservicesinfiveEnglishlocalauthoritieswererecruited,aswereusersofconventionalhomecarefromfivedifferentlocalauthorities.Bothgroupswererecruitedonreferraltoreablement/conventionalhomecareservices.RecruitmentofserviceuserscommencedinNovember2008andlasteduntilJuly2009.

    Bothquantitativeandqualitativedatawerecollectedfromserviceusers,carersandlocalauthoritystaffintheparticipatingsites.

    Quantitativedatacollectionandanalysis

    Fourdifferenttypesofquantitativedatawerecollected.

    Individualoutcomedataforreablementandconventionalhomecareserviceusers

    Outcomedatafrombothreablementandconventionalcareserviceuserswerecollectedontwooccasions:servicecommencement(T1)andbetweennineand12monthslater(T2).Inaddition,postinterventioninterviews(T1+R)wereconductedwithindividualsinthereablementgroupondischargefromreablement,usuallyaroundsixweekslater.T1andT1+Rinterviewswereconductedbylocalauthoritystaff.TheT2interviewswereconductedbyaresearchagencyspecialisinginsocialandmarketresearch.

    Overarchingaspectsofwellbeingweremeasuredusingtwoglobalindicators:theGeneralHealthQuestionnaire(GHQ12;Goldberg,1992)toreflectpsychologicalwellbeing(or,arguablymoreaccurately,absenceofillbeing)andasinglequalityoflifequestionusingasevenpointscale(Bowling,1995).Inordertopickupkeyareasofpeopleslivesthatare

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    specificallyrelevanttosocialcareanearlyversionoftheAdultSocialCareOutcomeToolkit(ASCOT)measurewasuse

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