Reablement, Rehabilitation, Recovery: Chapter two - Purpose and context
This chapter provides an overview of rehabilitation as a beneficial intervention for many older people living with frailty, and the current situation across the four nations of the UK.
Introduction
The importance of rehabilitation was highlighted in recommendation 7 of the BGS Blueprint: “Protect and preserve the right to rehabilitation for all older people who need it, in line with the principles outlined by the Community Rehabilitation Alliance.”1
Rehabilitation (or recovery) is a set of interventions designed to optimise functional ability, social participation, improve health and wellbeing and reduce disability in individuals with health conditions in interaction with their environment.5 Due to resource constraints within the NHS, rehabilitation packages are typically time-limited. Interventions include:
- Holistic assessment considering the social determinants of health and acknowledging multimorbidity
- A personalised rehabilitation treatment plan based on shared decision-making and goal- oriented personalised interventions
- Information, advice and education to build confidence and support self-management and participation
- Medication reviews and advice to ensure medicines are used to optimise rehabilitation
- Structured exercise (one-to- one, in groups, in person or online)
- Support with diet
- Psychological support
- Support with communication, adaptations, assistive technology and digital skills.
A European consensus statement defined geriatric rehabilitation as a multidimensional diagnostic and therapeutic approach which aims to optimise functional capacity, promote activity, preserve functional reserve and social participation in older people with disabling impairments.6 A systematic review of 42 European studies of integrated care for older people called for a more (integrated) holistic response, blending a chronic care approach with education, enablement and rehabilitation to optimise function, particularly at times of a sudden deterioration in health, or when transitioning between home, hospital or care home.7
Comprehensive Geriatric Assessment (CGA), a highly evidence-based approach that combines assessment and multidimensional interventions, tailored to modifiable physical, psychological, cognitive and social factors, improves outcomes for older people and is the cornerstone of an integrated approach to preventing and managing frailty.8,9 Rehabilitation should be considered a core element of CGA – not an optional add-on.
| Key message 1 Systems should invest in rehabilitation as a priority for more sustainable care. Rehabilitation for older people improves lives, delays escalation of dependency, reduces demand and costs for readmission to hospital and avoids premature long-term care. |
Rehabilitation is also a key component of proactive care as set out in NHS England’s new framework for proactive care for older people living at home with moderate or severe frailty.10 Average annual costs of primary and secondary care service are three to four times higher for individuals who have moderate to severe frailty, but overall system costs are highest for people with mild frailty as the largest population cohort.11 Many providers and health and care systems aspire to scale up proactive care for people with all levels of frailty to prevent escalation of health and care needs, delay onset of disability, and reduce demand for emergency department attendance or admission to hospital or care home.12 Rehabilitation capacity is critical for successful proactive care (sometimes known as pre-habilitation, as detailed in chapter three) and for scaling up intermediate care community alternatives to acute hospital care.13 For an individual with deteriorating health and wellbeing, rehabilitation goal-setting may overlap with future care planning or end-of-life care planning. It will be important to recognise trigger points where the goals of care may change, through shared decision-making with the individual supported by those who are important to them.
| Key message 2 Rehabilitation is an essential component of virtually all healthcare for older people and should be integral to care plans in all settings: at home, in hospital, ambulatory care, care homes and hospice. |
Why rehabilitation is needed now more than ever
Across the globe, the consequences of COVID-19 and deconditioning as a result of lockdown are driving new approaches to rehabilitation.14 This is in part to compensate for the loss of focus on rehabilitation during the pandemic due to the redeployment of staff and loss of physical space for rehabilitation, and to address the new challenge of long COVID where people are living with disabling symptoms such as breathlessness, communication and cognitive challenges, and fatigue, all of which are amenable to rehabilitation.15 The rise in deconditioning and dependency experienced by older people and their carers during the pandemic is increasing pressure on a social care sector already in crisis. Delays in access to rehabilitation further increase dependency and generate even more demand for an overburdened system.
Rehabilitation is central to the ambitions of the UN Decade of Action on Healthy Ageing.16 The purpose of rehabilitation is to optimise functional ability in essential everyday activities and enable participation in education, work, life roles and the things that bring meaning, purpose and happiness to the individual. It supports people to overcome difficulties with thinking, seeing, hearing, communicating, eating and moving around, and helps them to regain the specific skills and confidence required to resume or maintain participation in their work, hobbies or interests and social network. This is sometimes described as a recovery-based approach, supporting people to regain control of their lives and work on things that enable them to lead good lives.
A rights-based approach is particularly important for older people and people with disabilities who are at risk of being marginalised in access to healthcare. Access to rehabilitation is enshrined in the Convention on the Rights of Persons with Disabilities17 and high-level actions to improve access and equity of rehabilitation provision are set out in the World Health Organization’s ‘Rehabilitation 2030’ work programme.18 Rehabilitation must be flexible and cater to the specific needs of the individual. For older people in particular, this may mean adapting aspects of the rehabilitation offer to meet the needs of individuals experiencing delirium, dementia, depression, sensory or communication impairments.
| Key message 3 Every older person can benefit from rehabilitation in some way: age alone should not bar access. The approach, intensity and pace of rehabilitation should be flexible and may need to be adapted for people with delirium, dementia, depression, sensory or communication impairments. |
State of rehabilitation: Reflection on policy, capacity and access in each of the four nations
BGS members across the UK report differences in access to rehabilitation for older people in their area. Variations range from different provision for reablement and community rehabilitation at home to whether or not older people can access rehabilitation in hospitals or in care homes.
England
There is considerable variation in the quality of and access to rehabilitation services across England. There are some key guidance documents targeted at commissioners and providers, which aim to reduce this unwarranted variation. Importantly rehabilitation services need to be given the same level of priority, resource and funding as other aspects of the healthcare system such as urgent and emergency care. Until this happens, Integrated Care Systems will find it challenging to provide consistent high-quality rehabilitation services for their local population, particularly given the multidisciplinary workforce and budgetary restraints many currently face.
NHS England’s Intermediate Care Framework13 focuses on intermediate care services delivering rehabilitation following hospital discharge and identifies four key priority areas. Firstly, improving demand and capacity planning with better utilisation of data metrics. Secondly, improving workforce utilisation through new ways of working such as blended roles. Thirdly, implementation of effective multidisciplinary team care transfer hubs. Finally, improving data quality and overcoming the information governance barriers, which often impede this.
NHS England have also published a community rehabilitation and reablement model19 and NHS RightCare have published a community rehabilitation toolkit.20 Both documents focus on recommendations pertaining to community rehabilitation more generally. Several key aspects of the patient journey are covered including maintaining independence, preventing deterioration, the need for integrated care, the community-hospital interface, adequate workforce, and improving data quality, all of which should incorporate experience of care, timely access to services, and ensuring person-centred care is at the heart of rehabilitation. This should all be underpinned by strong leadership at all levels of the health and social care system to drive the necessary changes in behaviour and culture required for high-quality rehabilitation for all.
The Community Rehabilitation Best Practice Standards developed by the Chartered Society of Physiotherapists (on behalf of the Community Rehabilitation Alliance) is another useful reference guide in how to run high-quality rehabilitation services.2 It neatly describes what the expectations of different stakeholders should be and what is needed to deliver on the key recommendations. These include the patient, clinician, rehabilitation lead, network, commissioner and social care provider.
In his annual report in 2023, the Chief Medical Officer for England, Professor Sir Chris Whitty, highlights the provision of rehabilitation as a key component of a coordinated treatment plan for older people which should be developed as a result of comprehensive geriatric assessment: ‘CGA is based on the premise that a full evaluation of an older adult living with frailty by a team of healthcare professionals from multiple disciplines may identify a variety of treatable health problems, resulting in a co-ordinated plan and delivery of health care, social care and rehabilitation care leading to better health and wellbeing outcomes.’21
Scotland
The Scottish Government’s Once for Scotland Person-Centred Approach to Rehabilitation22 builds on their earlier Rehabilitation Framework published during the pandemic.23 The 2022 document sets out six principles that should underpin all rehabilitation services: Easy to access for every individual; Provided at the right time; Realistic and meaningful to the individual; Integrated; Innovative and ambitious; Delivered by a flexible and skilled workforce. While these principles are laudable, there is no clear roadmap for delivery. Healthcare professionals report that rehabilitation services are struggling across Scotland, due to lack of workforce capacity and a backlog of maintenance issues within healthcare facilities. Specialist medical supervision for rehabilitation services for older people has traditionally been provided by geriatricians who are now being redeployed into services such as Hospital at Home, Frailty Units and Perioperative services, along with advanced practitioners from allied health professions and nursing. While these services provide good outcomes for patients who can access them, without a significant increase in staffing, these good outcomes for some patients will be at the expense of adverse outcomes for the increasing number of older people needing rehabilitation. Community rehabilitation services are understaffed and repeated realignments of these services have eroded the previously strong links between primary care and community services. Rehabilitation for older people with frailty is often provided in community hospitals which are impacted by the primary care and community workforce crisis. The ongoing crisis in social care compounds these challenges as older people experience a delay in being discharged from hospital and in starting their community rehabilitation.
Wales
In 2022, the Welsh Government published the All Wales Rehabilitation Framework: Principles to achieve a person-centred value-based approach.24 This document sets out principles of rehabilitation, using the acronym of WALES:
- Wellbeing – investment in the workforce to provide a holistic, person-centred, needs-based approach.
- Accessible – co-produced services that are equitable and inclusive to all.
- Living happier, healthier, longer – healthy living, prevention, supported self-management and optimisation.
- Everyone’s business – a collaborative whole workforce and stakeholder ethos.
- Sustainable – long term service planning, embracing digital innovation for societal benefit and greener ways of working and living.
This framework is supported by Health Education and Improvement Wales’s community rehabilitation standards, published in late 2023.25 This document provides seven best practice standards designed to improve the quality and experience of rehabilitation:
- Co-produced community rehabilitation must be built around the needs of patients and their support network, delivering personalised rehabilitation to ensure people have choice and control over the way their rehabilitation is planned and delivered.
- Effective rehabilitation adopts a biopsychosocial approach due to the diversity of needs of the person.
- Effective partnerships and good communication are central to providing seamless rehabilitation in the right place for everyone.
- Good data is essential to drive improvement in the quality and value of community rehabilitation services.
- A core part of community rehabilitation is supporting people to stay well, take control of their lives, maintain independence, and support self-management as part of a sustainable health solution for Wales.
- Rehabilitation services need to be accessible to people when and where they need so that longer term issues can be minimised, resulting in better health and wellbeing for the individual and a reduced burden on society.
- Rehabilitation requires a motivated, engaged and valued health and social care workforce, with the capacity, competence and confidence to meet the needs of the people of Wales.
BGS members in Wales report that additional resources are needed to realise this vision including a focus on ensuring care is provided in the right setting with rehabilitation starting as early as possible to prevent deconditioning. Strong leadership and an understanding of rehabilitation are needed to ensure that rehabilitation services are coordinated and effective. Without this we risk extending length of stay in hospital, protracting the rehabilitation journey in the community and adding to the care pressure on social services and on friends and families who provide so much of the care at home.
The Right to Rehab campaign26 in Wales is led by the Chartered Society of Physiotherapy with input from other organisations in Wales interested in rehabilitation. The campaign considers the publication of the above standards as a campaign win, along with investment in the allied health professional workforce for reablement and a ministerial commitment that rehabilitation space lost during the COVID-19 pandemic should be reclaimed or a suitable alternative provided. The campaign is currently calling for consistent delivery of the rehabilitation standards across every health board in Wales, the appointment of a rehabilitation lead in every hospital and the appointment of rehabilitation voices in every Regional Partnership Board to promote integration of services in the community.
Northern Ireland
There is currently no national framework guiding rehabilitation services for older people in Northern Ireland. It is therefore up to individual Trusts to determine how rehabilitation is provided. BGS members in Northern Ireland report that all Trusts offer a number of rehabilitation pathways to facilitate discharge for older people. However, chronic staff shortages and competing priorities between acute and community care result in ongoing challenges for Trusts providing rehabilitation for older people with frailty. The lack of gold standard and key performance indicators for general rehabilitation has an impact on budget and resource allocation. All Trusts promote the ethos of ‘home first’, which includes discharge to the individual’s own home including residential homes, with follow-up from an acute assessment team or community rehabilitation team. While this approach is advisable, there is concern that this pathway cannot always meet the needs of patients, particularly those with complex needs or requiring intensive rehabilitation. Community rehabilitation teams often hold waiting lists of two to three weeks to response. Therapy staff are supported by care staff or rehabilitation assistants. However, input can be as infrequent as once a week.
Many acute wards, with the general exceptions of orthopaedics and stroke, struggle to provide responsive rehabilitation and deconditioning is an ongoing concern despite widespread knowledge and local endeavours. Further education and a focus on creating a culture which promotes rehabilitation as everyone’s business is required to prevent the consequences of higher dependency, higher frailty levels and increased rehabilitation resources to support patients to regain function.
Due to inherent pressures within all Trusts, the need to maintain flow continues to influence decision-making for discharge planning and rehabilitation pathways. Unfortunately there is disparity in access to comprehensive geriatric assessment for older people across Trusts. This has been further impacted by decisions to redirect geriatrician input, hence removing geriatricians from a number of rehabilitation inpatient and intermediate care facilities across Trusts.
There is widespread concern regarding the lack of integrated delirium pathways, and access to suitable rehabilitation environments for patients with delirium and dementia. These patients often have complex needs and take time to rehabilitate. However, decisions to withdraw rehabilitation can be made too early, having a significant impact on quality of life and use of Trust resources. Intermediate rehabilitation facilities are often unsuitable for these patients and as a result, patients can be subject to lengthy waits to access inpatient rehabilitation. They often remain in acute wards and are at high risk of deconditioning and decompensation. Alternatively they may be discharged to interim nursing care facilities which vary in culture regarding rehabilitation and may provide only limited rehabilitation services due to pressures within community rehabilitation services.
What matters to older people receiving rehabilitation and those who provide it
There is limited peer-reviewed evidence about what matters to older people receiving rehabilitation but many presentations at BGS conferences have highlighted experiential evidence and some charities have published qualitative research and case studies.
Future research should address gaps in the evidence and ensure that people who have traditionally been excluded from research, such as those with cognitive impairments, are included. Common themes highlighted are:
Autonomy and independence
Older people value autonomy and independence above all else when receiving rehabilitation. Autonomy and independence look different for each individual and apply whether they live in their own home or in a care home. Everyone has something to gain from rehabilitation so goals must be personalised to what matters to the individual with the overall aim of promoting dignity, choice and control, improving their sense of wellbeing, and enabling them to live the life they would like, including taking part in activities and hobbies that they enjoy. Physical functional ability has a huge influence on an older person’s ability to do the things they love, and its decline can have negative impacts on their mental health.
It is so uplifting, there is tremendous psychology involved in improving one’s aged body. If somebody tells you, you can do it, you’ll do it, you’ll try.” - Dance programme participant27
Wellbeing, confidence and choice
Rehabilitation, particularly group programmes, helps to reduce loneliness and isolation as many participants appreciate the opportunity to socialise with people in similar circumstances. Case studies illustrate the importance of offering a choice of meaningful activities and nurturing a sense of pride and achievement to counter levels of anxiety and low confidence that often prevail. For example, participants in rehabilitation programmes to prevent falls frequently speak of psychological benefits from reducing their fear of falling and restoring energy and confidence to get out and about.
I hadn’t got proper balance, so they asked me to go to physiotherapy and when they explained what they wanted me to do I was completely honest and said, “I won’t do them”. And then they said, “would I like to join a dance class?” which has been absolutely brilliant. I have loved it and I really look forward to coming every week and I haven’t looked forward like that to anything.”- Dance programme participant27
Prevention of further ill health/injury
Many patients value the role of rehabilitation in preventing further pain, ill health or injury, reducing their need for surgery, for home care support, or admission to hospital or care home. This is also the most obvious system benefit – providing good quality rehabilitation prevents ill health, injury and more intensive use of health and care services, thus avoiding system costs. At a time when statutory services are under extreme pressure, investment in high-quality rehabilitation is a clear ‘invest to save’ action.
“I’m feeling much more confident now. I feel I am able to do things for myself. I can say to the staff ‘stop, I can do that for myself. I don’t need your help.’ I really wasn’t sure about trying that at first because my knees used to be really stiff but now they feel great. I feel like I can’t stop moving my legs.” - Participant in care home rehabilitation28
What matters to carers
Resource limitations and time restrictions are key considerations for care workers and unpaid carers supporting the rehabilitation goals of older adults they care for. Their critical role in promoting participation and carry-over of rehabilitation interventions requires support from education and training and digital tools that enable their participation as a full partner in the rehabilitation programme.
The carers noticed a massive difference with how much they were doing for themselves, how much confidence they had because it was given back to them. I think the family had seen a big difference as well.” - Care Home Activity Coordinator28
What matters to rehabilitation professionals
Healthcare professionals often speak about ‘rehabilitation potential’ – the perceived likelihood of a patient responding to rehabilitation. We challenge the term ‘no rehabilitation potential’, all too often applied to older patients, limiting their access to rehabilitation services. Cowley’s research29,30 identified three questions for healthcare professionals to consider when assessing rehabilitation potential: ‘will it work?’, ‘is it wanted?’ and ‘is it available?’ It is important to ensure rehabilitation goals are tailored to the individual, so that they are meaningful, achievable and more likely to meet the desired outcome even if that is seemingly small gains in independence and quality of life. Critical to this is understanding the motivation of people taking part in rehabilitation programmes, and how this can be supported, particularly in the presence of cognitive impairments. It is also important to ensure finite resources are used wisely. Clinicians need to carefully balance the principle that all older persons can achieve some tangible benefits from rehabilitation with the reality of targeting limited resources to make the greatest population impact. Realising the value of rehabilitation requires a personalised approach to engage and motivate older people to participate and a tiered, multi-agency model with a mix of skills to optimise collective workforce capacity and capability, as described in NHS England’s good practice guidance on community rehabilitation and reablement.19
We found this improved mental wellbeing. Patients were smiling, they were more engaged with the therapy afterwards and they were more engaged with ward staff…” - Occupational Therapist31
One of the key challenges for older people in hospitals is loneliness and also inactivity. Some of the key benefits I see when patients engage in hospital activities are greater positivity and improvement in mood, eating more, and being more concordant and engaging with the treatment plan that they are having and also subtle other improvements such as improved sleep and more engaged in the discussions when it comes to planning their discharge.” - Consultant Geriatrician31
As a physio, I know that movement matters and it matters so much in hospital when you spend so much time being sedentary or in bed. I know how quickly people can lose their independence through lack of activity…” - Clinical Specialist Physiotherapist31
| Key message 4 The business case for rehabilitation in older people is compelling. Future research should address the evidence gaps around older people who have been excluded from studies due to cognitive impairment or socio-economic or cultural inequalities. |