Home care re- ablement services: Researching effectiveness in prevention

1. Home care re-ablement services: Researching effectiveness in prevention Caroline Glendinning Professor of Social Policy University of York Presentation to SSRG Scotland Conference 28 October 2013

2. Outline • Context – growing interest in re-ablement • Home care re-ablement – evidence on impacts and cost-effectiveness • Success factors – circumstances optimising effectiveness of re-ablement? • Effectiveness in social care - wider reflections on the evidence base

3. Context – growing interest in re-ablement • Most English councils now have home care re-ablement services • From selective to inclusive/intake services • Interest in Australia, New Zealand (particularly providers) • New NHS funding for England to invest in re-ablement • Autumn 2010 - £70m • 2011/12 - £150m • 2012-2015 - £300m p.a.

4. Early evidence on home care re-ablement services • High proportions receiving re-ablementneeded no further, or less, home care • 63% needed no further services • 26% needed less home care • But would they have recovered anyway? • … and how long do the effects last? • York/Kent study aimed to • Provide evidence on longer-term impacts of home care re-ablement • compared outcomes of re-ablementvs. conventional home care services • … up to 12 months later

5. Study design • Comparative study • 5 re-ablement councils, 5 ‘standard’ home care councils • Users recruited on referral • Baseline interviews • Re-interviewed after 9-12 months • Standardised outcome measures • Health • Quality of life • Social care outcomes • Costs of re-ablement, other social care and NHS services used • Organisation and delivery of re-ablement services • Focus groups • Observations • Experiences of users and carers

6. Impact and cost of home care re-ablement • Re-ablement had positive impacts on health-related quality of life and social care outcomes • Compared with conventional home care services • Typical re-ablement episode (39 days) cost £2,088 • Higher 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 costs • Effects of recent hospital discharge?

7. Is home care re-ablement cost-effective? • Compare improvements in outcomes against costs • NICE threshold £20-30K for each outcome gain • Re-ablement is 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 £ threshold • Higher healthcare costs of re-ablement group • Probability of cost-effectiveness only

8. How robust are the results? • Established services not pilot schemes • Small samples after 12 months – couldn’t examine: • Differences within groups • Hospital discharge vs all community referrals • Higher vs lower needs for assistance • Differences between sites, service models (especially OT or NHS involvement) • Standardised outcome measures – but not sensitive enough?

9. Success factors – organisation of services • Service organisation • Thorough initial assessment, regular reassessment • User-focused care plans • Flexibility • Rapid access to OT expertise/equipment • Access to other specialist skills • Physio; mental health; sensory impairment; dementia • Communication and continuity • Small teams • Clear recording systems • Regular discussions • Training and supervision • On-going reinforcement re-ablement ‘ethos’

10. Success factors: Wider environment • User characteristics • Expectations and motivation • Dementia? • Carer involvement • Wider environment • Strong/shared vision of service • Within adult social care • External stakeholders, especially NHS referrals • Direct referral for on-going home care • Capacity within long-term home care services • Approach of long-term home care services

11. Evidence gaps – re-ablement • Across the boundaries – from acute ward to return home • Selection • Continuity • Skillmix • Impacts on NHS service use (esp. readmission) • Roles and impacts on carers • In-house vs outsourced services • Costs, commissioning, quality • Beyond re-ablement – sustaining improvement

12. Prevention – developing wider evidence base • NIHR SSCR workshops and survey • No standard definition, approaches to evaluation • Most popular ‘preventive’ services • Re-ablement • Telecare/telehealth/other technology-based interventions • Information and advice

13. Challenges in evaluating preventive interventions • Causality, ‘soft’ outcomes’, pilot vs ‘bedded in’, diversity of QoL, cognitive/communication issues • Logic model – link interventions > intermediate outputs > outcomes • Outcome measures might include: • ASCOT, others standardised outcome measures • Personal outcomes achieved, QoL domains • Falls-related admissions • Set against costs • Labour-intensive • Budget silos • Short vs long-term costs

14. Further information SPRU/PSSRU evaluation of home care reablement services: bit.ly/hcreable NIHR School for Social Care Research: www.sscr.nihr.ac.uk, especially: • RF9 – Allen and Millar - prevention • MR6 – Netten - outcomes measurement