Title: Models Of Reablement Evaluation: a mixed methods evaluation of a complex intervention (The MORE project)
Funder: Department of Health (England)

Abstract: BACKGROUNDA rapidly ageing population and advances in technology have led to a dramatic rise in the number of people living longer with long-term conditions (HM Government 2007; Allen and Glasby 2009) affecting their ability to live independently. This has resulted in a significant rise in hospital admissions (Robinson 2009) and increasing pressure on social care services. Improvements in care in some childhood conditions have led to increasing numbers of young people with complex needs surviving into adulthood (Fraser et al. 2012). Attempts to bring about a real shift to community-based care and avoid unnecessary/lengthy hospital admissions or ‘unnecessary dependency’ on social care services have long dominated health and social care policies and strategies (DH 2005; DH 2006). The government has invested in reablement services as there is some evidence that they can enhance independence and have the potential to contain costs. This was signalled by £70 million extra funding made available to the NHS in 2010 to support hospital discharge (DH 2010a) followed by £300 million/year over 2012-15 for ‘reablement spending’ (DH 2010b). More recently the government announced an investment of £91.6 billion in local NHS services in 2012/3 including £150 million for reablement (DH 2011a). The promotion of reablement services within the Care and Support 2012 White Paper also firmly establishes reablement as a priority for local authorities (HM Government 2012). While existing research suggests that reablement can lead to improvements in health-related quality of life social care outcomes and physical functioning (Glendinning et al. 2010; McLeod et al. 2009) and can remove/decrease the need for commissioned health and home care services (Glendinning et al. 2010; McLeod et al. 2009; Pilkington 2008; Lewin and Vandermeulen 2010; Le Mesurier and Cumella 1999) the evidence base around reablement services remains patchy and underdeveloped and significant questions remain. Reablement is reported to work differently for different people - it is less effective for those with chronic/complex health problems compared to people recovering from acute illnesses or falls (Rabiee and Glendinning 2011). Considerable variation is also reported in local arrangements for self-care services for long-term conditions (Challis et al. 2010). It is still unclear which models of reablement services work best for which service users at what cost and why. Evidence on longer term impacts is also limited. Indeed for some groups the evidence base is virtually non-existent. Further research is essential to support the development and commissioning of effective cost-effective and appropriate reablement services. WHY THIS RESEARCH IS NEEDED NOWAs numbers of people with long-term conditions rise and public finance constraints persist managing demands on care services will remain a key priority for the NHS and social care commissioners. Advancing knowledge about reablement services may help prevent or delay people from requiring long-term care and support reduce the risk of hospital admissions/re-admissions and maximise cost containment.The rapid move towards development of reablement services that are funded and provided in different ways and by different organisations (CSED accessed 2011) has created a knowledge gap that cannot be addressed by the existing body of research in this area. New research is needed to explore issues not addressed in existing research. Specifically we aim to find out which models of interventions are more effective in improving outcomes for what groups of service users at what cost and why. Are reablement services equally effective for younger and older people; and for those at higher or lower risks of hospital re-admission? What is the optimum skill-mix of reablement teams timing and duration for various reablement interventions? How are services and practice developing and in what contexts in terms of meeting the reablement needs of ‘atypical’ or ‘higher need’ groups for example people with dementia and younger adults?As set out above re-ablement is highly topical and there has been and will be significant investment in re-ablement services. At the moment however there are unrealised opportunities to maximise outcomes and to achieve cost-savings and commissioners service managers and practitioners are making decisions in a situation of limited evidence. This research is therefore both relevant and timely as it offers a unique opportunity to provide new evidence on different models of reablement services which will be of direct benefit to NHS managers commissioners and their partner organisations: local authorities third sector and independent providers. A thorough and creative dissemination strategy will ensure the research has maximum impact. AIMS AND OBJECTIVESThis research aims to establish:1. The characteristics of generic and specialist reablement services in England2. The impact different models of reablement have on service-level and service user outcomes3. The impact different models of reablement have on different groups of service users4. The indicative costs for the health and social care system of different models of reablement5. How the local context influences the ability of reablement services to achieve their goals6. What specialist practice & services exist and how it/they developed for individuals with complex needs or ‘atypical’ populations who would benefit from reablement.To achieve these aims we will:1. Undertake a national (England) survey to map different models of reablement services that currently exist.2. Carry out outcome process and economic evaluations of different generic reablement models.3. Carry out a qualitative study of specialist reablement practice and service models.4. Disseminate findings to providers commissioners and users of reablement services.METHODSThis comprehensive study comprises three work-packages (WPs) extending over 34 months. WORK-PACKAGE 1: Mapping and modelling reablement servicesA survey of all reablement service providers in England will gather data on organisation case mix skill-mix costs or charges of the services the nature of any outcome data collected and contextual information. Cluster analysis will be used to develop a typology of reablement service models. WORK-PACKAGE 2: Evaluation of generic reablement service modelsThis work-package comprises three elements2a: Outcomes evaluationA clustered repeated measures design will evaluate the outcomes of different models of reablement (as identified in WP1) to explore which work best for which people. Two hundred people in each of 4 models will be recruited and outcome data collected at baseline at the end of reablement and six months later. Outcomes measured will be health and social care-related quality of life mental health user defined goal attainment and other service/resource use. Multi-level modelling will explore change over time for different service users and in different models. Local study investigators will collect outcomes socio-demographic service use and contextual data.2b: Process evaluationA qualitative process evaluation will explore the immediate and wider context of reablement provision including resource use and how and why effects may vary between service users. Qualitative interviews with commissioners managers practitioners service users and carers will be carried out.2c: Economic evaluationUsing data collected in work-packages 1 2a and 2b the economic evaluation will compare the costs and consequences of different generic reablement models in comparable populations. Methods will be a systematic review cost-effectiveness analysis cost-consequence analysis and decision analytic modelling. Costing vignettes will be produced.WORK-PACKAGE 3: Specialist practice and service modelsQualitative interviews will be held with managers and practitioners in specialist services and in generic services that have developed different approaches to reable particular client groups. This will help understanding of how and why these services/approaches developed and the costs associated with them.DISSEMINATIONDissemination will include production of practitioner and commissioner guidelines a national dissemination event publication of papers in peer-reviewed (open-access) papers and conference presentations.PROJECT COSTSThe project team includes researchers who are experts in the topic and research approaches health economists a statistician an occupational therapist an independent practitioner who is a national expert on reablement and includes service users as advisors. The main cost of the project (total £891599 over 34 months) is for research staff. Given the large (and increasing) number of people using reablement services and the potential savings to the NHS and local authorities by providing effective and appropriate reablement this provides value for money.


Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;8.2 HEALTH AND WELFARE ECONOMICS
Health categories: GENERIC HEALTH RELEVANCE