Background
The population is aging worldwide, resulting in a growing proportion of dependent elderly people [
1]. These demographic trends increases the incidence of older people experiencing decline in health and function, leading to more hospitalizations, higher healthcare service utilization, and thus increased health and social costs [
1].
Traditionally, these trends have been met by greater use of homecare, where caregivers visit clients’ homes to provide personal care and perform activities of daily living (ADL) tasks over a long-term period. However, maintaining standards in the care sector becomes problematic with increasing workload and growing demand for care [
2]. Consequently, there is a need for new healthcare services that can optimize independence and assist older people in improving their abilities to perform ADL [
3,
4], and possibly an increase in workforce. In addition, many older people prefer to remain in their homes, creating an increased need for services that can support older people staying at home for as long as possible [
5,
6].
Reablement (or restorative care) can be described as a service that “
aims to help people with disabilities recover their physical function through performing activities of daily living rather than having formal or informal caregivers perform these activities for them [
7,
8],
focusing on supporting independence” [
9]. Reablement differs from traditional home care, which involves personal care and cleaning for people with disabilities [
7]. The following key elements are present in reablement: assistance by interdisciplinary teams; time-limited service for 6–12 weeks; a goal-oriented plan defined by the clients; outcomes in terms of improved ADL and health-related quality of life (HRQoL); and decreased service utilization [
10].
Systematic reviews have synthesized the best available evidence of the effectiveness of time-limited reablement services. Several systematic reviews indicate that the effectiveness of reablement is promising in relation to a range of positive outcomes for reduced service utilization and for improved HRQoL and ADL [
10‐
13]. A review by Sims-Gould et al. showed promising effects on the service usage and functional abilities of clients with evidence suggesting improved mobility and delayed deterioration [
11]. In contrast, no positive effects on HRQoL were found [
11]. Another review reported that reablement may improve functional status and decrease care costs to a small degree. However, the quality of evidence for these results was described as very low [
14]. A review by Legg et al. concluded that reablement was an ill-defined intervention with no proven benefits in terms of increased personal independence or reduced use of home care services [
15]. These two reviews [
14,
15] suggested the need for more robust evidence of the effects of reablement and concluded that uncertainty exists regarding the size and importance of effects due to low-quality studies.
Scientific literature has also sought more qualitative research demonstrating how reablement can be structured and optimized to address the needs of clients and care providers [
11,
16]. More research of who would benefit from reablement with respect to specific eligibility criteria is needed due to the heterogeneity of populations studied to date [
10,
12,
14,
16]. Research concerning which components and processes of reablement are most beneficial, research into the role of occupational therapy, and input from other healthcare professionals are required [
12‐
14,
17,
18]. In addition, there is a need for more process evaluation to assess professionals’ and clients’ views, experiences, and attitudes with reablement as well as which mechanisms and contexts can contribute most to the effects of reablement [
14]. The knowledge base appears inconsistent, given limited evidence from existing randomized controlled trials and systematic reviews in the area [
16]. However, practice-based evidence indicates that reablement is widely used and seems promising for people with functional disabilities [
13].
In Denmark, the municipalities are the main actors in the field of rehabilitation and home care, and they are responsible for providing support and services to citizens. Since January 2015, Danish municipalities have been required to offer home-based reablement to adults with rehabilitation potential [
19‐
21]. Reablement has been implemented in diverse ways, that, however, in line with the key elements of reablement [
10], all must be time-limited, individually organized, based on the client’s own needs and resources, individualized in terms of setting goals in collaboration between client and the interdisciplinary team, and the municipality must provide assistance and support to the extent that it is necessary for the client to achieve his or her goal [
19].
A home-based reablement service has been implemented in a Danish municipality in the Northern Denmark Region. The intervention is a part of the routine home care services provided and is offered to elderly and/or disabled citizens with rehabilitation potential who apply for practical assistance, personal care, aids, food service, or cleaning. The purpose of the intervention is to improve quality of life, help the client become more self-sufficient, and at the same time reduce the need for and expenses of municipal services. This is achieved by focusing on active training instead of passive care, where the client’s own goals for significant activities are central and based on their motivation, resources, and needs. The individualized rehabilitation-based goals determine which efforts are to be initiated and professionals are to be involved. This can include, for example, aids, training, home modification, counseling, or something completely different. When an interdisciplinary reablement course is commenced, it involves reablement professionals (self-help coordinators, licensed therapists, self-help instructors or self-help therapists) from a municipal visitation unit and home care providers. The intervention is tailored to each client’s characteristics and needs. The reablement professionals and the client collaborate to identify initiatives and goals that must be established to support the client in the best possible way.
Existing research into how reablement operates in practice, which service components work best, who can benefit from the service, and clients’ reactions to reablement is sparse [
10,
16]. Few empirical studies have already explored care professionals’ and clients’ experiences of reablement [
22‐
37]. However, reablement services differ in both content and organization, making it difficult to compare existing research in the field. Moreover, it is relevant to consider both clients’ and care professionals’ perspectives when addressing these knowledge gaps in reablement studies. The Social Care Institute for Excellence (SCIE) have argued that there is no single definition of “successful reablement”, which may look different for different people depending on people’s abilities at the start of the service and other variables which include the motivation for progress and desire for setting goals [
38]. Since there is no single universal definition of successful reablement, the present study focused on reablement professionals’ perspectives on client characteristics and the most important factors associated with successful reablement. Accordingly, the aim of this study was to understand what is needed to achieve a successful Danish home-based reablement service from the perspective of the reablement professionals. To address this aim, an understanding of client characteristics and successful reablement is needed; therefore, the following two research questions (RQ1, RQ2) have been identified:
-
RQ1: How do reablement professionals describe clients participating in home-based reablement?
-
RQ2: Which factors are associated with successful reablement from the reablement professionals’ point of view?
Results
Inter-rater reliability was assessed by calculating percent agreement and Cohen’s unweighted Kappa [
46]. The percent agreement was 98.85 % and Cohen’s Kappa was 0.40, indicating weak [
47], fair [
48‐
50], or fair-to-moderate agreement between the coders [
51]. While answering RQ1 and RQ2, the following themes emerged: “
Heterogeneity of clients and mixed attitudes towards the reablement intervention”, “
Shared understanding and acknowledging the need for help as the first step in reablement”,
Commitment and motivation are essential for successful reablement,
and “Homecare helpers as most important team players”.
Heterogeneity of clients and mixed attitudes towards the reablement intervention
All informants agreed that there, in general, were no clear definition of clients who were referred to reablement and that client characteristics may vary even for clients with similar anticipated rehabilitation potential. The clients had different life situations and could be new to or familiar within the municipal system. No stereotypes existed, but most of them were elderly. One informant claimed:
No, there are no stereotypes, but mostly older clients are represented. There are also many younger ones. When I say older, I mean 65 years or more. It might even be 79–80 years or more.
On the other hand, the informants stated that there seemed to be similarities between clients suffering from the same disease, such as chronic obstructive pulmonary disease, cancer, or arthritis, as illustrated in this quote:
But of course, clients suffering from COPD often have an anxiety problem due to breathing trouble.
The informants also reported that clients had mixed attitudes towards the reablement intervention. Several of the informants highlighted the clients’ understanding or lack thereof, desired independence, and motivation as typical reactions to the reablement intervention.
Shared understanding and acknowledging the need for help as the first step in reablement
Understanding was related to the clients’ acceptance of being screened for rehabilitation potential and possibly undergoing a rehabilitation course to receive help from the municipality. Two informants stated:
Well, that is something they have to go through to receive help. They know it! To receive help from the municipality, they must be screened for rehabilitation potential.
Those we have here in the section for long-term care in the visitation unit usually come from the section for short-term care, and, to begin with, they must go through the same procedures when they enter the municipal system. They have already completed a reablement intervention or similar and know that when new problems come up, the municipality must assess whether the client can manage the task or not.
From the point of view of the informants, understanding reablement was also linked to the clients’ recognition of a given problem, as illustrated in this quotation:
If the client experiences a problem and would like to get better, they react in a way where reablement is considered a help.
The informants described the importance of helping the clients to acknowledge their need for help. Reablement was then considered a meaningful and helpful service for the clients.
Conversely, lack of understanding was related to lack of recognition of having a problem. It may be difficult to acknowledge the need for help, for example, from aids, as it is a very visible sign of impaired functioning. This lack of recognition was exemplified in the following quotation:
I cannot force them, they must be prepared for it, but I think it can be difficult for people to accept that they need an aid. It´s often in people’s own minds, because you can also say that it is visible to others that they really need help, but they do not themselves realize they need it.
Lack of understanding was also expressed when old age or habits were not reason enough to be provided help if the need for such did not exist. One informant expressed this point as follows:
Yes, some people think that it’s absurd – “why cannot I [the client] get help getting washed on my back?” or “It’s just nice that you wash my hair” or “I cannot understand that I have to do it myself, now that I am 85 [years old]!”
They [the clients] have paid taxes throughout their lives, and this makes it hard to understand that we come and want them to do it [participate in reablement/themselves].
Another typical reaction was the desire for independence – especially regarding personal care. The majority would like to take care of themselves. By contrast, informants described that clients were not always satisfied with theamount of practical assistance, such as cleaning:
Many of them [the clients] want independence – others like to get daily visits where practical assistance [e.g. cleaning or bathing] is included. This may create a dilemma in cases where the municipality wants the client to be independent rather than it being the client’s own desire.
The informants expressed that some clients preferred getting help because they did not have the strength or the interest to clean their home. In that case, more resistance from the clients was experienced. The informants stated that clients could find it strange to be checked and trained in something they could manage but did not want to do anymore. Therefore, the informants identified the importance of moving the clients’ focus from passive to more active roles in reablement.
Commitment and motivation are essential for successful reablement
The informants stated that it was vital that clients as well as actors such as home care providers understood the purpose of the reablement intervention. One informant mentioned that the best results were obtained when all involved actors participated with great commitment. Another informant described the quality of information given to clients as very important, as illustrated by the quote:
I think that it’s the feeling I have while visiting a client. That it is going well, and you get to talk, and you feel that the client is informed, and I get the information I need. Having informed the client so that he or she knows what is going to happen in the future and feels safe.
From the informants’ perspective, a central aspect of reablement is empowering clients and making them as self-reliant as possible with or without the use of aids. The informants made the point that some clients had received services prior to participating in reablement, where the goal of the reablement intervention, depending on the client’s situation, was to maintain or improve the current level of functioning, and to reduce or maintain the current need for help. An alternative could be supporting the clients in clarifying what they were not able to accomplish and find other ways of managing the problem. Getting the client to acknowledge his or her limitations, as well as identifying other solutions for doing activities was a major part of reablement. Thus, the informants felt responsible for motivating clients to gain more self-control and to make them understand that they were not necessarily hampered by their perceived level of functional capability. The informants highlighted that empowerment was an important factor in reablement.
One informant felt that a successful reablement course included giving clients experiences of success and satisfaction. The informants expressed the importance of setting individual goals in collaboration with the client and identifying their need for support, and that finding possible solutions was an important part of their work. In addition, the informants described the relevance of getting people to live their lives again by supporting networking where enhanced quality of life as an outcome is an important factor in the reablement intervention, as illustrated by the quotation:
For various reasons, the home care providers are the primary social network in the reablement courses that I have had. Clients insist on keeping their municipal services. But we can actually support clients in getting a better social network and continuing networking, and we stay with them until it´s established. The purpose is to make them independent of passive services and become as self-reliant as possible, and I think it affects HRQoL.
Several of the informants highlighted motivation as being of major importance to the reablement intervention. Motivation was expressed in different ways. One informant said:
It is also the healthiest [of clients] who get the most out of it and are motivated.
The informants described the importance of the clients’ success experiences in the initial stage of reablement as they were closely related to enhanced motivation. The informants also mentioned chemistry between clients and the reablement team as important for enhancing motivation. A tendency of enhanced motivation existed when professionals could prove to the clients that their role was to support them in the best possible way to become fully or partially self-reliant.
All informants reported that motivation in terms of user involvement and staff group collaboration was an essential aspect of a successful home-based reablement intervention.
The informants stated that some clients were already motivated in the initial stage of reablement, while others might become motivated over time. However, motivation was closely linked to the understanding of reablement and individual goal setting. The reablement intervention should make sense before clients were motivated to continue. Several informants pointed out that they therefore prioritized motivating and informing clients adequately before start-up:
Motivation is our keyword, always. That’s what we do most since we have to motivate everyone on our way.
To promote motivation, the informants expressed the importance of setting individual goals for each reablement course in close collaboration with the clients. Motivation could also arise during the reablement intervention when clients experienced progress through training. Success experiences with the training resulted in enhanced motivation and trust between the clients and reablement professionals.
Motivation was also necessary in relation to collaboration between the reablement team and other staff groups. The informants highlighted the importance of shared understanding between the reablement team and other involved actors. They emphasized that they had the main responsibility for carrying out reablement and were the link between many parties, and therefore had to motivate and identify where to act first with their collaborators. The informants agreed that motivation was the driving force behind reablement interventions.
Homecare helpers as most important team players
All informants mentioned the home care provider as the most important collaborator because home care helpers play an important role in reablement by making observations and training with clients. The informants emphasized home care helpers as the largest employee group, and home care helpers must be prepared to carry out reablement in practice. Home care helpers were typically also closest to the clients and mutual trust was already established between them. Initially, this trust was often not present between the clients and reablement professionals. One informant stated:
Most clients keep up a façade when a reablement professional arrives, but do not necessarily keep up that façade with their regular home care helpers.
The informants described the relationship between home care helpers and clients as beneficial as the home care helpers’ regular visits contributed to them knowing the clients’ needs. Therefore, the informants felt a stronger collaboration when the home care providers were involved early in the process – typically during the first visit. The informants mentioned that during the first visit, it is possible to observe the home care helper’s interaction with the client. Based on these observations, the client, home care provider, and reablement professionals jointly discuss the client’s goals and the specific content of the reablement intervention. Subsequently, the home care helper receives instructions from the reablement professional on how to train with the client in his or her own home during routine visits.
Motivation among home care helpers could also be challenging due to limited time resources. The informants highlighted that some home care helpers considered reablement to be an extra workload. The older and most experienced home care helpers in particular could get stuck in old habits and be critical of reablement. This critical attitude could lead to lack of motivation, possibly affecting some clients negatively.
However, the informants mentioned that a paradigm shift was slowly happening, with home care providers changing their mindset from providing direct physical care to providing more rehabilitative care as illustrated by the following quotations:
I think it is getting better and better! The more it gets rooted. It reflects a paradigm shift in home care. They change their mindset from thinking of themselves as “warm hands” to rehabilitating employees.
I can feel that there is a difference, and people are beginning to understand the rehabilitative approach or thinking that is involved. I think we are getting closer to a common mindset, but it has taken a long time.
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