reablement – what’s the evidence on outcomes?

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Reablement whats the evidence on outcomes? . Caroline Glendinning Emeritus Professor of Social Policy Social Policy Research Unit University of York College of Occupational Therapists/Skills for Care 22 nd July 2014 . Outline of presentation. Background and early evidence - PowerPoint PPT Presentation

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Investigating the longer-term impact of home care re-ablement services The Organisation and Delivery of Home Care Re-ablement Services

Reablement whats the evidence on outcomes? Caroline GlendinningEmeritus Professor of Social Policy Social Policy Research UnitUniversity of York

College of Occupational Therapists/Skills for Care 22nd July 2014

Background and early evidence

Major studies SPRU (York)/PSSRU (Kent) 2008-10 Perth (W Australia) 2005-07

Concluding remarks Outline of presentationBackground growing interest in re-ablementEngland 2000 onwards: development home care re-ablement services in most councilsScotland 2013: Joint Improvement Team survey25/30 councils had home care re-ablement services17 of these planning to expandFrom selective to inclusive services Australia, New Zealand growing provider interest

3High proportions receiving re-ablement needed no further, or less, home care on discharge than those who received standard home care 63% needed no further home care on discharge 26% needed less home care than comparison group

But would they have recovered anyway? and how long do the effects last?

Early evidence on outcomes of home care re-ablement services 4Aimed to investigate longer-term impacts of home care re-ablement services, including: Compare home care re-ablement vs standard home care Assess user outcomes and use of NHS and social care services for up to 12 months Estimate unit costs home care re-ablement servicesAssess cost-effectiveness home care re-ablement Describe organisation and content of home care re-ablement services Examine user and carer experiences

SPRU (York)/PSSRU (Kent) study 2008-10 Study design 5 re-ablement councils, 5 conventional home care councilsUsers recruited on referral baseline interviewsRe-interviewed after 9-12 months Data collected on: Users health, quality of life, social care outcomes at baseline and follow-up, using standardised measures Social care and NHS etc services used by both groups Costs of re-ablement services (staff, overheads etc)How re-ablement services organised and delivered Experiences of users and carers

6Results: impacts and costs of home care re-ablement servicesRe-ablement had positive impacts on health-related quality of life and social care outcomesCompared with conventional home care service useTypical re-ablement episode (39 days) cost 2,088More expensive than conventional home care But 60% less use of social care services subsequently Over full year, total social care services used by re-ablement group cost 380 less than conventional home care Re-ablement group higher health service use and costsEffects of recent hospital discharge?

Home care re-ablement appears to have positive impacts on individuals health-related quality of life and social care outcomes up to 12 months later. Re-ablement was associated with greater improvements in health-related quality of life, compared with people using conventional home care services; and to a lesser extent with improvements in social care outcomes the ability to look after oneself and engage in chosen daily activities. These results took into account differences in the characteristics of the two groups. Established methodologies estimated that a typical period of re-ablement (average 39 days) costs 2,088; an hour of service user contact time costs 40. These are higher than conventional home care services. Although evidence was limited, re-ablement services employing occupational therapists cost no more than those employing only social care staff. The mean costs of re-ablement plus any other social care services used during the first eight weeks of the study was 1,640. This was significantly higher than the conventional home care services that were used by the comparison group during the same period (570). However, people having re-ablement used less social care services in the following ten months (mean cost 790) than the comparison group (mean cost 2,240). After accounting for baseline differences, the costs of the social care services (excluding re-ablement) used by people in the re-ablement group were 60 per cent lower than those used by the comparison group over the year. These lower social care services costs following re-ablement cancelled out the higher cost of re-ablement. Over the full year, the total cost of the social care services used by the re-ablement group was just 380 lower than those used by the comparison group; the difference was not statistically significant.People in the re-ablement group had significantly higher health service costs during the eight weeks following referral to re-ablement. More people in this group had just been discharged from hospital and these people had significantly higher healthcare costs (mean 1,850) than those referred to re-ablement from the community (mean 1,020). However, there were no significant differences in the mean costs of the health services used by the re-ablement and comparison groups, whether referred from hospital or the community, over the subsequent ten months, and therefore over the duration of the study as a whole.

7Was home care re-ablement cost-effective? CE = compare improvements in outcomes against costs NICE threshold 20-30K for each outcome gain Re-ablement was cost-effective in relation to health-related quality of life outcomes Re-ablement may be cost-effective in relation to social care outcomes Depends on thresholdHigher healthcare costs of re-ablement group

Probability of cost-effectiveness only User and carer perspectives Poor initial understanding of re-ablementPrevious experiences of standard home careContext of referral - crisis, hospital discharge Value of repeated information Appreciated frequent visits, monitoring Quality of relationships crucial Reported greater independenceimproved confidence, relearned self-care skills People discharged from hospital/recovering from accident/illness reported greater gains than those with long-term/progressive conditionsFelt shortcomings More help with mobility/activities outside the home Anxiety about end of re-ablementPotential for greater carer involvement?

Assessed impact of restorative home care on subsequent service use for 2 years 750 older people randomised Restorative home care Standard home care

Service use recordsHome care A+E attendance Hospital admissions - number and duration

Calculated costs of all services used

Perth (W Australia) study 2005-7Compared to standard home care, restorative home care group: Less likely to use on-going personal care services Used fewer hours of home and (especially) personal care services Less likely to be assessed as needing residential care 30% less likely to have attended A+E31% less likely to have unplanned hospital admissionHad lower total (health + social care) service costs (average 1574 - 2380 less)

Outcomes after 2 yearsGrowing body of evidence that re-ablement reduces service use and costs in short and longer terms. But outcomes and cost-effectiveness depend on: How services are organised Specialist service vs generic/extended assessment Delays in onward referralWho receives re-ablement Inclusive vs selective services Eligibility thresholds Whats included in re-ablement interventions Home care only vs wider range of skills/inputs Rapid access equipment/AT How long intervention lasts

Reflections....Growing evidence that re-ablement reduces service use and costs in short and longer terms. Outcomes and cost-effectiveness depend on:

How services are organised: Specialist service vs generic/extended assessment Delays in onward referral Risk of diluting reablement approach Who receives re-ablement SPRU inclusive LA servicesW Australia excluded dementia, terminal illnessRising eligibility thresholds for adult social care will affect recruitment into service Key factors affecting impact and outcomes: hospital discharge, simple vs complex/chronic conditions and dementia Whats included in re-ablementSPRU home care only W Australia domestic, personal and health careRapid access to OT skills and equipment essential we concluded it didnt matter too much whether or not OTs were part of reablement teams, so long as there was rapid access to OT skills and equipment (but could investigate further). Skillmix will of course also affect costs How long re-ablement lastsEngland up to 6 weeksW Australia up to 12 weeks Duration will affect costs and outcomes longer intervention more expensive but also more likely to be reflected in positive gains.

W Australia depending on individual goals can include strength, balance, endurance programmes to maintain mobility, chronic disease self-management, medication, continence and nutrition management, falls prevention, social engavement 12caroline.glendinning@york.ac.uk

www.york.ac.uk/spru

http://php.york.ac.uk/inst/spru/ research/summs/reablement2.php

ResearchWorks2011-01

Home care re-ablement is a relatively new, short-term intervention in English social care. It aims to reduce needs for long-term support by helping people (re)learn daily living skills. A large-scale study examined the longer-term impacts of home care re-ablement; the cost-effectiveness of re-ablement; and the content and organisation of re-ablement services. People receiving re-ablement were compared with those who received conventional home care; both groups were followedfor up to one year.SPRU: Caroline Glendinning, Kate Baxter, Parvaneh Rabiee, Alison Wilde, Hilary Arksey PSSRU: Karen Jones, Lesley Curtis, Julien ForderHome care re-ablement services:investigating the longer-terms impacts

Key findings There were no net cost savings to health and social care in the first year of re-ablement, compared with conventional home care.

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