Reablement and rehabilitation

Reablement services assist a person to maintain or regain the ability to live at home, usually offered free of charge for a period of up to six weeks.

Technology can help in the following ways

• Services to avoid unnecessary admission to hospital; support timely discharge from hospital; avoid premature admission to long-term residential care; promote faster recovery from illness

Case study – Reablement: integrating NHS, telecare, care and housing

Roseberry Mansions Reablement Service is a ten unit service which provides intensive short term support and therapies to enable people who have been hospitalised to return home or to other appropriate long term accommodation. The service is based within a purpose built extra care scheme with self-contained rooms which are equipped with relevant aids, adaptations, and telecare systems. This safeguards people and helps to give them the confidence to re-establish their skills, as well as enabling then to become familiar with equipment that they may continue to use once they return home. An onsite multi-disciplinary team (MDT) works collaboratively to provide a comprehensive reablement service to people for up to six weeks. 

One Housing and Camden Adult Social Care collaborated to gather quantitative and qualitative data throughout the first ten months of the service provision, with 41 patients assessed.

This cohort demonstrated an NHS a saving of £288,695 over ten months, which extrapolates to a forecast saving of £1.7 million over five years. This does not take in to consideration efficiencies of the onsite team, the aversion of repeated hospital admissions, NHS discharge fees or other potential savings or efficiencies. Therefore, it is reasonable to assume that the savings to the NHS would be considerably higher. The cost benefits to adult social care of customers returning to their homes in a sustainable manner instead of a move to long term nursing care equates to £214,500 per person over five years. Importantly, the service provides a valuable and effective alternative to residential and care placements which are in such short supply, and supports people in the place they want to be.

Case study - Using telehealth as part of an effective reablement service

St Helens Council and Bridgewater Community Healthcare NHS Trust have been using telecare and telehealth to support people with long-term health and care needs for some time, including the services as part of packages of care to help to increase independence and safeguard service users. More recently they have included telehealth as part of their reablement service, with a myclinic multi-user system at the Brookfield reablement unit. Patients with long-term conditions leaving Brookfield may then be offered the use of one of five mymedic telehealth systems to monitor their signs and symptoms at home.

Les Foster is 82 and has COPD. Following a stay in hospital he was admitted to the reablement service at Brookfield in October 2013, spending two and a half weeks there using the myclinic system. Upon returning home, Les used a mymedic system for three weeks to help monitor his condition as it improved. He said “The system is a really big help and I really miss it now it’s gone. It makes you manage your condition better because you have to take your readings every day, whereas before if I felt a bit unwell I would leave it a few days to see how it went before I did anything about it. It gives you real confidence being able to see how things are going with your own eyes, and it’s so reassuring to know someone is looking at your results and will be in touch if something doesn’t look quite right. It’s a brilliant service and I would recommend it to anyone.”

Using telehealth managed by Careline as part of the Reablement Service enables clinical and social care staff to monitor the progress of patients, and intervene at an early stage if a possible problem is detected, preventing deterioration and possible re-admission to hospital. Integrated working is also supported, as staff from health and social care liaise on a daily basis and have access to the same, up-to-date patient information. An issues log has been kept which has enabled the few that have arisen to be dealt with promptly. Using the myclinic system has enabled community matrons to monitor results remotely, saving approximately two days each week visiting Brookfield, time which is now spent supporting patients in the community. Ann Hughes, Reablement Nurse, Bridgewater Community Healthcare NHS Trust commented; “The Telehealth has really helped me prioritise patient care; I can log on any time and access the information and see straight away if the observations are indicating that I need to go out and see someone. I used to go to the reablement unit every day but now I don’t feel I need to and that’s freed my time to make more community visits. Telehealth has given me the flexibility to be more responsive to patients’ needs, and its empowering them to take more responsibility for maintaining their own health stability.”