By Jane Creed, Helen Edwards (physiotherapists) and Jackie Waller (occupational therapist)
“Reablement” is a frequently used term in health and social care, often understood from a systems perspective, referring to support after a period in hospital. But this fails to really explain what reablement is, or its core purpose. In essence, reablement means helping the individual to do things for themselves, rather than the carer doing things for the individual.
Birmingham was an early adopter of reablement, introducing it within a discharge to assess service in 2012. This service is now termed a Pathway Two discharge to assess model, working with patients who are ready for hospital discharge but not able to return to their own home. Patients are transferred to community beds (nursing homes) where, depending on individual need, they receive physiotherapy and/or occupational therapy input and remain for four to six weeks, with the aspiration that regain the capacity to return to their own home.
We were commissioned by CHS Healthcare to provide reablement for the Birmingham discharge to assess beds they manage. Since January 2016, we have also been working together in a discharge to assess and reablement pathway in Gloucestershire.
Much has been learned and gained from this five year experience of providing reablement. A central learning point is critical role of carers; their engagement with and understanding of reablement. For example, during a busy lunch time in a nursing home, it is quicker to place individuals with mobility issues in a wheelchair and bring them to the dining room. Walking with the individual might take ten times as long. There is an impact on resources (it takes longer to do enablement based tasks) and an understanding of the principles of enablement is required.
In the early stages of the Birmingham scheme, reablement beds were commissioned from 20 different nursing homes across the city. We found staff in these homes often had a limited understanding of what enablement is, unsurprisingly, because so many different providers were being used in a sector which already has a high turnover of staff. The service is now configured with just six nursing homes providing larger numbers of beds. This works much better because the care workers all understand the principles of reablement and apply them to the way they provide care.
We are beginning a new pilot in Birmingham of a Pathway One discharge to assess model with enablement. What this means is an individual will be discharged from hospital to their own home with care and reablement provided there. In many ways, this model provides an optimal setting for the principles of reablement. For example, an individual plan might include practice making a cup of tea and practice going up and down stairs. Doing this in a nursing home was not as ideal as the individual practicing on the stairs of their own home, with their specific shape and gradient, or making tea in their own kitchen. Another strength of our pilot is that the care agency providing all of the care and support within the pathway are fully engaged with the principles of reablement. For reablement to be effective, it requires repetition (practice) and consistency.
That repetition and consistency depends upon everyone in the pathway being wholly engaged with its aims. The physiotherapist, for example, may write an individual plan which includes practice going up and down the stairs two times a day. This requires a care worker to accompany the individual during each practice to ensure they are safe. A physiotherapist is not required for the task of stairs practice although equally, once the physiotherapist writes a plan, it is wholly dependent upon the care staff following it consistently (and having the time to do so).
In the Birmingham Pathway One pilot, we have designed a model to provide the right support, care and professional input for the individual at every stage. The pathway will take up to six weeks, although for some individuals, it will be much less. The main physiotherapy and occupational therapy input will be at the start of the pathway, in establishing enablement goals and the correct practice which needs to be undertaken to reach those goals.
The underlying principle throughout is supporting the individual to safely be as independent as possible. The goals must be set at the start of the pathway, be clear and tangible and understood by every professional involved with that individual. Therefore, the carer arriving at a home in the morning knows what they are supporting the individual to do themselves (and the time for this process) and a clear delineation of what they need to do for the individual.