Reablement, Rehabilitation, Recovery: Chapter three - Evidence and examples at different system touchpoints
This chapter links the themes in this report to the touchpoints described in the BGS Blueprint, Joining the dots.
BGS Blueprint
In March 2023, BGS published Joining the Dots: A blueprint for preventing and managing frailty in older people. This document sets out what good quality, age-attuned, integrated care looks like for older people with frailty. The Blueprint uses seven touchpoints that an older person may come into contact with throughout their later years.
These touchpoints are not intended to be read as a pathway of care but rather elements of care that should surround the individual as and when they require them, as demonstrated in chapter one of this report. The Blueprint document highlights examples of innovative practice across the UK and is intended to support commissioners and providers to plan services for older people.
Our rehabilitation report focuses on the touchpoint described in the Blueprint as ‘integrated urgent community response, reablement, rehabilitation and intermediate care’. But rehabilitation is key to all of the Blueprint touchpoints, as detailed in the Executive Summary. It is relevant across all stages of older people’s healthcare and in all care settings.
Case study examples
Good Boost is a social enterprise delivering digital musculoskeletal supported-self management services in partnership with 140 leisure centres, swimming pools, community venues and charities. They offer ‘plug and play’ technology-enabled solutions to convert existing spaces and venues into opportunities for rehabilitation to promote wellbeing and manage health. Find out more at www.goodboost.ai
It’s helped me so much with my balance. It’s stopped making me feel isolated. I look forward to coming here on a Friday [because] I get to see people and chat to [them], to know there’s other people out there like me, that’s got the same sort of problems as me, and it’s great and we can compare notes and things like that.” - Participant
Watch the case study video at: www.bgs.org.uk/resources/rehabilitation-case-studies-bgs-autumn-meeting-...
Staff at Guy’s Hospital, London offer an innovative dance programme as an alternative to exercise classes for older adults prescribed strength & balance physiotherapy. Co-designed with patients, physiotherapists and dance artists, the ten-week Breathe Dance for Strength & Balance programme is proving popular and showing promising results. Find out more at https://breatheahr.org
I can walk much better; I can sit up and down on a chair without holding the ends. In fact, I have decided not to have an evening carer anymore because I can do the jobs that she did on my own and that really is a wonderful experience.” - Participant
Watch the case study video at www.bgs.org.uk/resources/rehabilitation-case-studies-bgs-autumn-meeting-...
Enabling independence, promoting wellbeing through physical activity and participation
There is strong evidence that regular exercise, particularly strength and balance training, reduces falls and partially reverses or slows progression of frailty.32-34
A systematic review of ten studies with one or more physical activity components found improved physical performance and some evidence to suggest deterioration was ameliorated for up to 12 months.35 Home-based exercises are a simple, safe and widely applicable intervention that may improve disability in older people with moderate, but not severe, frailty,36,37 and improve physical performance, reduce falls, and preserve health-related quality of life.38 After hospitalisation, they are effective at improving activities of daily living, mobility and quality of life.39
Mild-intensity mixed or singular exercises such as walking or tai-chi are moderately effective and easy to implement.40 Combining muscle strength training and protein supplementation was the most effective and easiest intervention to implement in primary care. Interventions combining resistance and balance training were most successful in treating physical symptoms associated with frailty, reducing falls, and maintaining health benefits. Combining different types of physical exercise may maximise impact on mobility, balance, body mass and levels of activity.41 Programmes should incorporate behaviour change to help older adults to include physical activity as part of lifestyle changes.
Tailored approaches and support are needed to fully involve people with communication, cognitive, sensory or physical impairments in these activities. More evidence from broader, well-developed interventions addressing a wider range of clinically relevant outcomes is needed.42
Case study examples
Age NI Move More Live More programme, funded by Innovate UK, aims to improve activity levels, strength, balance and overall health and wellbeing and reduce falls so that older adults in Northern Ireland can get the most out of later life. It builds on their previous work with former Olympian, Lady Mary Peters, to promote the importance of maintaining strength and balance. The Age NI Move with Mary initiative is a series of five exercise videos catering for every ability.
Watch the Move with Mary videos at: www.ageuk.org.uk/northern-ireland/information-advice/looking-after-yours...
Later Life Training is a not-for-profit organisation that provides specialist, evidence-based, effective exercise training for health and exercise professionals working with older people. The website has links to peer-reviewed scientific publications on the effects of prolonged sedentary behaviour and the benefits of exercise interventions. Find out more at https://laterlifetraining.co.uk
Proactive care and early intervention
Pre-habilitation aims to lower health risks or prevent rapid deterioration for people waiting to undergo planned surgery or cancer treatments.
They are assessed while awaiting their planned treatments and supported to be more physically active, to improve their nutrition, and may be offered emotional and psychological support. A systematic review has shown that pre-habilitation prior to elective surgery improves recovery and is cost-effective.43
“[Before pre-habilitation] I was to have some work done on my back, surgery, like metal work, a big operation… so that was like a big tick.” - Pre-habilitation participant44
International studies report promising results from combining proactive CGA for older people in primary care with rehabilitative interventions. Studies from Sweden and Catalonia reported a reduction in hospital stay and in overall healthcare costs in the intervention groups. Rehabilitation is a key intervention of proactive CGA.
Case study examples
The Cancer Older People’s Service at the Beatson, West of Scotland Cancer Centre, and Maggie’s Centre set up a Living Well with Cancer in Older Age Class, led by an exercise expert and supported by a frailty nurse specialist. Older adults can self-refer at any point in their cancer journey and staff can refer to support pre-habilitation or rehabilitation goals. Early outcomes were improved fitness, nutrition and stress and people more able to live well with their cancer.
Watch the case study video at www.bgs.org.uk/resources/rehabilitation-case-studies-bgs-autumn-meeting-...
The Jean Bishop Integrated Care Centre provides proactive care in Hull and East Riding and offers a virtual model for those living in rural and remote locations. Reported benefits include good Patient Reported Outcome Measures (PROMs), reduced unscheduled activity in primary and secondary care and high levels of staff satisfaction and successful recruitment. Learn more about the service at www.hullccg.nhs.uk/integrated-care-centre-2
Reablement, community rehabilitation and intermediate care
Reablement is an approach to home-care services for older adults at risk of functional decline. It is used as a rehabilitation intervention for people who use social care services. Unlike traditional home-care services, reablement is frequently time-limited (usually six to 12 weeks) and is an intensive assets-based, person-centred and goal-directed approach that promotes and maximises independence and wellbeing.47 It aims to ensure positive change using user-defined goals and is designed to enable people to gain, or regain, their confidence, capacities and the necessary skills to live as independently as possible, especially after an illness, deterioration in health or injury.
A multi-centre controlled trial involving 47 municipalities in Norway found significant treatment effects from a four to ten week reablement programme compared to traditional home-based services with some persisting benefit up to 12 months.48 Although previous published studies report mixed results, economic modelling by NICE considers home care reablement has a high probability of being cost saving and recommends it is offered as a first option to people being considered for home care and as part of the review or reassessment process of people already receiving home care.49 A more recent report by the Nuffield Trust analysed NHS Digital Adult Social Care Outcomes Framework data on the proportion of older people at home at 91 days after discharge from hospital into reablement and rehabilitation services at home or in an intermediate care facility.50 Between 2011/12 and 2019/20 this measure of success was consistently around 82%, dropping to 79% in 2020/2021. Success rates are comparable by gender and only fall slightly with increasing age to 77% in the over 85s. Despite these positive outcomes and NICE recommendations, in 2020/2021 only 3% of over 65s received reablement on discharge from hospital. Reablement offers a critical opportunity for integrated systems to invest to save.
Community rehabilitation is provided by healthcare professionals at home, in day hospitals or ambulatory care settings, or in community hospitals or care homes. It may include individual, group and outdoor mobility components, overseen by a multidisciplinary team. The evidence review by NICE, mainly of community stroke or cardiac rehabilitation, reported high levels of patient acceptability, fewer GP presentations and admissions to hospital at six months and reduced length of hospital stay.51 There was also potential benefit in terms of patient satisfaction but no effect on carer quality of life. A cost-consequence analysis of an Australian randomised controlled trial of early supported discharge community rehabilitation for older people with frailty found that community-based rehabilitation was less costly (cost saving: £3238 per patient) and had better outcomes (less delirium, better quality of life, lower length of stay in hospital and in treatment, higher patient satisfaction, higher carer satisfaction and higher GP satisfaction) compared with inpatient rehabilitation.52 Overall, NICE recommends community rehabilitation as a viable alternative to hospital inpatient rehabilitation for patients who have had medical emergencies, maximising and maintaining independence and reducing the overall burden on the health and care system.
| Key message 5 Most rehabilitation is delivered in the community. Rehabilitation at home allows a clearer focus on practical, real-life goals than is possible with hospital in-patient rehabilitation. These goals should be based on ‘what matters to me’ conversations and include the ability to take part in activities that the individual enjoys. |
Reablement and community rehabilitation are both key components of Intermediate Care - a range of integrated services that: promote recovery from illness; prevent unnecessary acute hospital admissions and premature admissions to long-term care; support timely discharge from hospital; and maximise independent living.53 These services are usually delivered for no longer than six weeks and often for as little as one to two weeks.
Most intermediate care is provided at home, but some people receive ‘step up’ or ‘step down’ intermediate care in dedicated beds in community hospitals or care homes. Rehabilitation for older people is a core function of the contemporary community hospital which offers a slower-paced and more homely setting than the acute hospital.55 For example, older individuals with frailty in the Sub-Acute care for Frail Elderly (SAFE) transitional care unit in Ontario, Canada experienced shorter hospital stays, were less likely to be discharged to settings other than home and had similar 30-day acute care outcomes as control patients post-discharge.56 A mixed methods study of bed-based intermediate care in an Acute Geriatric Community Hospital (AGCH) in Amsterdam reported that older patients admitted to the AGCH valued the quiet ‘home-like’ environment and found it conducive to recovery and reconnecting with family.57
Urgent community response services may provide both intensive short-term hospital-level care at home through virtual wards58 and Hospital at Home,59 and goal-oriented home-based and bed-based reablement and intermediate care services that optimise recovery through rehabilitation.60 Successful services have a multi-professional team led by clinicians who can provide CGA, first line diagnostics and create both acute and rehabilitation care plans. The extent to which rehabilitation is included in the large-scale deployment of Hospital at Home and virtual wards services varies across the UK. This is a cause for concern.61 Meeting the acute and post-acute rehabilitation needs of older people needs to be explicitly included in the design of these services, and well-integrated with transitional and intermediate care services to fully impact on individuals who experience cyclical decline and are at high risk of readmission.
More information about community rehabilitation services is in our Right Time, Right Place report62 and in a series of videos at www.bgs.org.uk/resources/community-geriatrics-video-case-presentations.
Rehabilitation interventions which incorporated an outdoor mobility component following acute illness or injury led to sustained improvements in physical activity, outdoor mobility and endurance among older adults, with a dose-response relationship for a walking programme.63 There was a possible interaction between the walking programme and social intervention components adding weight to potential benefit from integrated approaches that build connections and wellbeing through local resources and social networks. Rehabilitation must be flexible as patients’ needs evolve over time and as they transition between care settings. It is important to review and reduce rehabilitation intensity over time to avoid over-reliance on services.
These issues are well set out in the Community Rehabilitation Alliance Best Practice Standards:2
- Referral processes are explicit, easy, efficient and equitable
- Rehabilitation interventions are timely, co-ordinated and prevent avoidable disability
- Rehabilitation interventions meet patients’ needs and are delivered in appropriate formats
- Rehabilitation pathways should meet needs and be delivered locally with access to specialist services
- Rehabilitation programmes should enable optimisation, self-management and review
- Rehabilitation services are well led, adequately resourced and linked to other services
- Rehabilitation services involve families.
Case study examples
The Social Care Institute for Excellence has published useful guidance document on the role and principles of reablement. It is designed for those working in or commissioning reablement but may also be useful to carers and those receiving reablement.
Read the briefing at www.scie.org.uk/integrated-care/intermediate-care-reablement/role-and-pr...
The Active Recovery Pilot in Leeds sees physiotherapists and occupational therapists working with social care staff to visit people in their own homes on their first day out of hospital. The cross-organisational working between social care workers and allied health professionals has improved patient outcomes, improved the efficiency of hospital discharges, and helped patients regain their independence more quickly.
Read more at www.csp.org.uk/news/2024-03-25-video-case-study-joined-working-rehab-centre
North East London Foundation Trust has an intensive multidisciplinary Community Rehabilitation Service across three London boroughs. The service operates seven days a week and manages people with complex and intensive rehabilitation needs. They support people to achieve personalised goals at home and identify other resources to help them continue their recovery once discharged from the team.
Watch the case study video at www.bgs.org.uk/resources/rehabilitation-case-studies-bgs-autumn-meeting-...
The Integrated Rehabilitation and Enablement Program (iREAP) in SE Sydney provides a day hospital-based interdisciplinary programme for older people at risk of frailty, falls, or who have Parkinson’s Disease and other neurodegenerative conditions. The group format leverages the benefits of social and peer support and applies health coaching principles to support self-management and enablement. Evidence showed the model improved functional and quality of life outcomes in participants whilst they built enduring networks and supportive relationships.
Read more about the programme at https://aci.health.nsw.gov.au/ie/projects/the-integrated-rehabilitation-...
Reablement and community rehabilitation are both key components of Intermediate Care - a range of integrated services that: promote recovery from illness; prevent unnecessary acute hospital admissions and premature admissions to long-term care; support timely discharge from hospital; and maximise independent living.53 These services are usually delivered for no longer than six weeks and often for as little as one to two weeks.
Torbay and South Devon Intermediate care service was ‘enhanced’ by employing GPs and pharmacists as well as involving the voluntary sector to be part of a daily interdisciplinary team meetings, working alongside social workers and community staff (the traditional model). Enhancing intermediate care through greater acute, primary care and voluntary sector integration can lead to more complex older patients being managed in the community, with modest impacts on service efficiency, system activity, and notional costs off-set by perceived benefits.54
Read more about the service at https://ijic.org/articles/10.5334/ijic.s3584
The Older People’s Short Term Assessment Team in the South Eastern Health & Social Care Trust, Northern Ireland provides Intermediate Care Services to older adults through a single point of access and a multidisciplinary team that includes social workers, occupational therapists, physiotherapists and intermediate care support workers. The team aims to unlock potential and improve quality of life while building capacity to live well at home, for as long as possible.
Read more about the team at https://setrust.hscni.net/service/older-peoples-short-term-assessment-team
The UK Community Hospital Association has published highlights on innovations in rehabilitation services developed during the pandemic. This ranged from digital innovation to reduce the need for home visits to rapid training, utilising the skills of physiotherapy, occupational therapy and nursing staff alongside a suite of supportive resources, which enabled clinicians to become available for redeployment to community wards.
Find out more www.communityhospitals.org.uk/pdf/case-studies/Rehabilitation_v2%20Full%...
Rehabilitation in acute hospital care
Deconditioning
Older patients are at risk of deconditioning in hospital from long periods of immobility resulting in loss of muscle mass, functional decline and increased risk of death or long term care. Effective care requires early mobilisation, rapid establishment of rehabilitation goals, and continued rehabilitation input until their condition has stabilised. Comprehensive guidance is set out in the Silver Book II.64 Active Hospitals65 aim to change the physical activity culture within hospitals to encourage patients to move more. The ‘Sit up, get dressed, keep moving’ campaign encourages older people in hospital to be active and supports healthcare professionals to help their patients remain active to support recovery and reduce readmissions. This work complements the #endPJparalysis international campaign.66
| Key message 6 Older people with acute illness decondition rapidly so need rehabilitation to start as soon as possible – healthcare professionals should not wait for a crisis to pass before providing rehabilitation at home, hospital or care home. All staff in all care settings, including acute and virtual wards, should prevent older people deconditioning by encouraging mobility and offering early active rehabilitation. |
Case study examples
Group activities in acute wards at Liverpool University Hospitals NHS Trust help patients maintain independence, wellbeing, and positive mental health while in a restricted hospital environment. Bed disco at Broadgreen Hospital is an inclusive, fun way of preventing deconditioning or promoting reconditioning and benefits both patients and staff.
You can partake if you are in bed, if you’re only able to sit up [or], if you’re standing and walking. We can tailor it to get you to exercise and move at your pace but also to do something that is going to be clinically effective. Bed discos involve cardiovascular exercise. They can involve coordination, range of movement, we can put strength training in there, we can put balance activities as well. But they are about fun, they are about motivation and it’s about getting a person to want to be active, want to exercise. The mood lifts that we have seen as well as the physical benefits are fantastic.” - Clinical Specialist Physiotherapist, Liverpool
Watch the case study video at www.bgs.org.uk/resources/rehabilitation-case-studies-bgs-autumn-meeting-...
NHS Highland and the team behind ‘The Broons’ legendary comic characters have joined forces to launch an educational ‘deconditioning’ comic strip for Scotland’s ageing population. The information features The Broons’ characters and is likely to be identifiable to all ages, but particularly older people and their families.
Read more about the initiative at www.nhshighland.scot.nhs.uk/news/2024/02/nhs-highland-and-the-broons-emb...
At Nottingham University Hospitals NHS Trust, a programme was developed to train and support Physical Activity Champions on acute hospital wards as part of the Active Hospitals project. Healthcare assistants reported an increased confidence in promoting physical activity for older people in the hospital setting and supporting exercises using ‘Keep Moving’ resources.
Patients do ask about how to be more active, so it’s always brilliant to let them know that we have volunteers that come and help. All the volunteers are another bright smiley face and a positive interaction for the patients who might otherwise have been having a bad day.” - Healthcare Assistant67
Read more about Active Hospitals at www.nuh.nhs.uk/active-hospitals.
General rehabilitation
Effective components of inpatient rehabilitation for older adults include endurance exercise, early intervention and shaping knowledge on post-discharge walking endurance. A review of studies showed that early intervention, repeated practice, goal planning, enhanced medical care and/or discharge planning increased the probability of discharge to home.68 There is much debate about how to assess patients’ potential to benefit from rehabilitation, particularly faced with the dynamic pattern and complexities of frailty in acute illness. A structured Rehabilitation Potential Assessment Tool (RePAT) was found to support clinicians in decision-making and encourage them to be more aware of biases.69
Rehabilitation following surgery
Increasing numbers of older people undergo emergency or elective surgery.70 Clinician-reported, patient-reported and process-related outcomes are poorer in older surgical patients compared to younger people.71 Older surgical patients who receive CGA-based perioperative care and rehabilitation have better outcomes and experience in both emergency and elective surgical settings.72 However, implementation of such services is still patchy.73
A joint guideline from the Centre for Perioperative Care and the BGS covers all aspects of perioperative care relevant to adults with frailty undergoing elective and emergency surgery.74
The case for early mobilisation and rehabilitation after hip fracture is robust.75,76 Functional recovery and survival are better for patients, both with or without dementia, who are mobilised earlier after surgery.77 People with dementia who receive enhanced care and rehabilitation in hospital are less likely to develop delirium. Orthogeriatric-led care reduces the length of hospital stay by three to four days.78
Older patients with critical illness may have or may develop common geriatric syndromes. NICE guidance recommends comprehensive assessment at an early stage, careful reassessment at each transition in their care and at two to three months after hospital discharge as needs change. It notes these multi-dimensional needs often require an MDT and geriatric expertise.79
Rehabilitation and enablement within care homes
The BGS report, Ambitions for Change,80 makes 11 recommendations to improve healthcare delivered in care homes. Recommendation 6 calls for equitable access to rehabilitation: “Regardless of where they live, care home residents should be able to access NHS-funded rehabilitation, equipment and other services according to their needs, in the same way that an individual living in their own home would.”
Access to rehabilitation in a care home varies across areas. Some residents in some care homes may have access to a therapist to assess their needs but equipment or exercise support are unlikely to be funded by the NHS in the way they would be for an individual at home, with an expectation that they will be funded by the care home or by the resident’s family. This inequity must be addressed. A fundamental requirement is prevention of falls as all care home residents should be considered at high risk of falls and can benefit from a multifactorial fall risk assessment and tailored interventions, repeated at least once annually or when a resident’s condition changes.81 Promotion of physical activity may conflict with a traditional care and protect ethos in care homes. Where possible, an exercise specialist (physiotherapist or exercise physiologist) should be consulted to provide specialist advice on feasible and safe exercise and physical activity, tailored for residents.
As well as providing long-term care, some care homes provide ‘step up’ and ‘step down’ intermediate care for older people who need time to regain confidence and mobility to be able to return home. A short stay can create a safe environment where people can re-engage socially and regain their ability and confidence to return home. This may be useful for people whose home environment is not suitable or who lack a family carer to provide overnight support. A retrospective comparison of two older adult hospital inpatient cohorts found the introduction of a discharge pathway to intermediate care in a care home corresponded with reduced length of hospital stay but there was no change in the number or characteristics of patients discharged to a care home long-term and similar 6-month outcomes. Costs were not considered.82 More published peer-reviewed studies of this model of care are required to provide further evidence of its effectiveness.
Regardless of where rehabilitation takes place, it should be addressed to meet the needs of the individual and set out in a personalised care plan which should be adjusted as the person’s situation changes.
Guidance from the National Care Forum and Care Provider Alliance has useful tips and case studies for planning and delivering effective intermediate care in care homes.83 The good practice report highlights the required staffing and need for a dedicated area with appropriate furniture, dining space, accessible toilets and kitchen appliances for making a drink and snack.
| Key message 7 Relational and informational continuity and coordination of care are the essence of person-centred integrated care. Older people should have a personalised care plan that addresses their rehabilitation needs and is contextualised to their health trajectory, social circumstances and cultural norms. This plan should be iterative, following the patient across transfers of care, and promote continuous enablement as their needs change. |
Case study examples
The Care Inspectorate’s Care about Physical Activity (CAPA) programme in Scotland, helps care providers build physical activity and more movement into the lives of older individuals they support.
Residents that were quite hesitant for socialising, never mind exercising, we’ve seen a big difference… We had a few residents that were really struggling, and their physical and mental wellbeing has gone through the roof which has been amazing to see… [For some residents] life existed in a wheelchair for them, and all of a sudden, all of the staff have the confidence to ensure that they are walking, that they are attending classes, they are keen to go on and start their day.” - Care Home Activity Coordinator.
Watch the case study video: www.bgs.org.uk/resources/rehabilitation-case-studies-bgs-autumn-meeting-...