Reablement, Rehabilitation, Recovery: Chapter three - Evidence and examples at different system touchpoints

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

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.

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.

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