Reablement in Scotland

Susan Kelso

AHP Lead Early Intervention

Scottish Government

Social Care clients by service type (2017)

128,750122,220

59,640

83,770

18,940

6,390 8,290

Community Alarm/ Telecare

Social Worker /Support Worker ²

Home Care Self-DirectedSupport (alloptions) ²

Housing Support * Meals ** Direct Payments(SDS option 1)

Scotland's’ estimated population 5,404,700 at 30 June 2016

A rise of 31,700 (0.6%) 2015

http://www.gov.scot/Publications/2017/12/3849/downloads

Social Care Clients by age group and gender (2017)

120,000 100,000 80,000 60,000 40,000 20,000 0 20,000 40,000 60,000 80,000

Ages 0-17

Ages 18-64

Ages 65+

Number of clients

Male Female

Clients receiving social care services by care and age group

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Frail olderpeople

Dementia Physicaldisability

MentalHealth

Learningand

PhysicalDisability

LearningDisability

Other Not known All

65 andover

Under 65

Living arrangements for people receiving care at home (2017)

40%

55%

60%

45%

20,000 15,000 10,000 5,000 0 5,000 10,000 15,000 20,000

Ages 18-64

Ages 65+

Clients with known living arrangements

Living Alone Other

53%

47% Living Alone

Other

Overview (iHUB)

• The Reshaping Care for Older People: A Programme for Change 2011-2021: “optimise the independence and wellbeing of older people at home, or in a homely setting. This will involve a substantial shift in focus of care from institutional setting to care at home – because it is what people want and provides better value for money.”

• The Health and Social Care Delivery Plan December 2016 10% reduction in unscheduled bed-days (i.e. 400,000 bed-days), by reducing delayed discharges, avoidable admissions and inappropriately long stays in hospital.

• Intermediate Care services offer alternatives to emergency inpatient admission and deliver person centred outcomes for people whilst improving whole systems flow

Intermediate Care & Reablement Scoping Atlas 2017 (iHUB)

Reablement Benchmarking Project 2016

• Glasgow Partnership: “To maximize independence, allow people to remain at home safely for longer, to prevent admissions to hospital and to optimize the quality of life for the individual”

• Perth and Kinross: “The service helps people regain skills that will allow them to live as independently as possible in their own homes”.

• North Ayrshire: “To maximize independence to ensure service users can remain safely in their own homes, achieve their individual outcomes/goals and where possible no longer require service intervention”

Reablement Benchmarking Project

• National agreement on what reablement is

• Common data and measurement

• National evaluation and training

• National costing model

http://www.audit-scotland.gov.uk/uploads/docs/report/2016/nr_160310_changing_models_care_supp1.pdf

Enhanced Community Support –changing context for reablement• Delivered by a multidisciplinary team (MDT) at GP practice level.

• MDT includes: nurses, community pharmacists, allied health professionals, community mental health staff and social workers

• Persons’ assessment is led by the GP

• Enhanced care coordinated by advanced nurse practitioner specialising in medicine for the elderly or a senior district nurse with time protected for the assessment of frail people and care coordination.

• Meet weekly to discuss patients currently receiving the enhanced service and to identify others who could benefit from the service.

• Links with the voluntary sector

http://www.audit-scotland.gov.uk/uploads/docs/report/2016/nr_160310_changing_models_care_supp1.pdf

Oban Frailty Project

A collaboration of 3 projects

Rationale

One in 10 people over 65 are likely to be living withfrailty, rising to up to half the population aged over85 years.Early diagnosis of frailty in primary care andproactive interventions can potentially keep peopleliving independently, reducing reliance on healthand social care resources.By identifying levels of frailty in our patientpopulations we can target resources moreeffectively, provide a more responsive and patientcentred approach and reduce duplication acrosshealth and social care services.

Patient Presentation/level of Frailty

Appropriate Service/Project Core services Referral route

Patient has chronic long term condition or at risk of developing long term condition which could be improved with exercise. Motivated to improve health Edmonton Frailty Score of 0 – 5 Not Frail

LORN AND OBAN HEALTHY OPTIONS (LOHO) HealthyTown/Villages project. A community enterprise initiativedesigned to take a holistic approach to improving healthusing exercise delivered by qualified instructors. LOHOact as a link to other 3rd Sector groups in Oban includingcarers support, housing services and voluntary groupsand also have close links with health services sharingresources where appropriate

Qualified exercise professionals. (Support from GP’s, Physiotherapy and other third sector groups )

Well established referral route using LOHO referral form via GP practice from health and social care professionals

Patient likely to have at least onechronic condition starting to impacton ability to fully self care – starting toneed social or increased familysupport for activities such asshopping/ housework or activitiesrequiring a degree of balance and/orstrength.Edmonton Frailty Score of 6-7 Vulnerable or 8-9 Mild frailty

PHYSIOTHERAPY/LOHO REABLEMENT TEAMA physiotherapy led project which includes OT aimed atthose people who would benefit from a period oftargeted strength and/or balance exercises to maximisefunctional ability to fully self care as well as educationdesigned to help people thrive at home. Assessment byphysio and/or OT with exercise programme delivered byLOHO staff. Onward referral to LOHO or escalation toOban Frailty Team service if required

PhysiotherapyOccupational TherapyQualified exercise professional(Support from Oban Frailty Team & Third sector services)

Via SCI gateway from GP practices to Physio ObanShort referral form from health and social care professionals not using SCI – All referrals to be marked ‘ICF Frailty project’

Self generated referrals from interrogation of practice data (eFI)Referrals from other health and social care professionals via MDT meetings

Patient with more than onechronic condition impacting onsimple ADL’s likely to already be inreceipt of social care and at risk ofrecurrent hospital admissions/increased dependence on healthand social care servicesEdmonton Frailty Score of 10 – 11 Moderate Frailty(Patients scoring as severe frailty12-17 on the EFS will receive thesame approach but not beincluded in pilot data)

OBAN FRAILTY TEAMPractice led MDT service aimed at regular review andholistic management of complex patients presentingwith significant issues due to frailty. Based onanticipatory, person centred approach and utilising awide range of professionals in a co-ordinated mannerto minimise repetition of tasks in order to supporteven the most frail and complex patients at homewherever possible.

GPPractice & community nursingOccupational TherapyPharmacyDieteticsCPN/Dementia TeamSocial Services(Support from, physio, ECCT & 3rd sector groups)

LEVEL 3 4000+ 10%

LEVEL 2 600+ 20%

LEVEL 1 100+ 40%-70%

Unscheduled Care

LOW

HIGH

Risk of requiring unscheduled care

Patient numbersLevel of CareCost of

management

Demographics

Aims• Reduce dependence on unscheduled care

services across all levels.

• Reduce demand for social care support

• Reduce levels of frailty in levels 2 and 3 or prevent/delay deterioration to level 1

• Target HSCP resources in most effective manner

• Maximise value of each patient contact

• Reduce duplication

• Speed up referral processes

• Improve MDT communication

• Link and co-ordinate disparate services

Frailty - a loss of physiological reserve

FUNCTIONAL ABILITIES

Independent

Dependent

“Minor illness” eg UTI

People usually present in crisis

If people are that close to their threshold they can easily cross it again

with deconditioning.

Need effective supervision if frail.

Need to remember that when they stop

exercising they will

decline in function.

(Clegg, Young, Rockwood Lancet 2013)

Dawn Skelton 2017

Rebuilding reserves - role of exercise in care homes

• A 12 week Strength Training programme in

90+ year old nursing home residents

doubled their leg strength (Fiatarone, 1990)

• Over 75s rejuvenated 20 years of lost

strength in 12 weeks of seated strength

exercises (Skelton, 1995)

• High Intensity Functional Exercise for Care

home residents with dementia (12 wks)

improved strength, balance and ADLs

(Littbrand, 2011)

Dawn Skelton 2017

Who Duration Type Frequency

Time

Aged 70-85 Mobility Limited (Chale et al. 2013)

6 months Strength, supervised and progressive

3 x p/w 45-60 mins

Sarcopenic women (Kim et al.

2012, 2013) (Shahar et al. 2013)

3 months Multi-component, progressive 2 x p/w 60 mins

Sarcopenic men (Zdzieblik et al.

2015)

3 months Multi-component, progressive 3 x p/w 60 mins

Retirement Village (Daly et al.

2014)

4 months Multi-component, progressive 2 x p/w 60 mins

Retirement Care (Oesen et al.

2015)

6 months Strength, progressive 2 x p/w 45-60 mins

Frail women (Kim et al. 2015) 3 months Multi-component, progressive 2 x p/w 60 mins

Frail (Tieland et al. 2012) 6 months Strength, progressive 2 x p/w 45-60 mins

Care homes (Rosendahl et al.

2006)

3 months Multi-component, progressive 5 x per fortnight

60 mins

Care homes (Bonnefoy et al. 2003) 9 months Multi-component, progressive 3 x p/w 60 mins

Hospitalised men (Miller et al.

2006)

3 months Strength, progressive 3 x p/w 45-60 mins

Beaudart et al. Osteoporos Int. 2017

Exercise for Sarcopenia – Frailer older people

Dawn Skelton 2017

Achieving activity guidelines

MovingMoving More Often

Moving regularly

and frequently

Sedentary

Meeting the guidelines

Increased physical activity

Increased benefits

Dawn Skelton 2017

NHS Physical Activity ProgrammeKey factor for resilience is level of activity not less time sitting

Something is better than nothing

Adults 30 minutes. (39%)

Children 60 minutes (72%)

1:4 will have mental health difficulties

AHP Active and Independent Living Programme

AILP VISIONAHPs will work in partnership with the people of Scotland to enable them to live healthy, active, and independent lives, by supporting personal outcomes for Health and Well Being.

H&SC DELIVERY PLANOur aim is a Scotland with high quality services that have a focus on prevention, early intervention and supported self management.

• Unique to Scotland and AHPs • Linked to health and social care data• All AHP professions • All Adult Services• Cost of services, profile of people using

services and people providing services at each stage on the Lifecurve

• 15,000 surveys returned – 60% with useable CHI numbers – access to ISD data

Lifecurve score across Scotland

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15Greater Glasgow and Clyde 29 3 1 1 2 14 3 3 3 1 8 6 8 13 2 4

Grampian 23 5 0 2 2 14 3 5 3 1 8 7 5 16 2 4

Fife 28 3 1 1 3 14 3 4 3 1 7 6 7 13 2 4

Tayside 27 4 1 1 2 12 4 5 2 1 9 8 5 14 2 5

Lothian 27 2 1 1 2 15 3 4 3 1 7 5 6 13 1 6

Lanarkshire 27 2 1 1 2 12 2 5 4 1 7 6 9 14 2 5

Highland 32 2 0 1 2 12 3 4 3 1 7 5 7 13 2 5

Forth valley 21 4 1 2 2 10 1 4 2 1 8 6 11 18 2 6Dumfries & Galloway 24 4 1 1 2 10 3 4 5 2 8 8 6 16 3 2

Borders 31 4 0 0 2 16 3 3 4 3 6 3 6 12 1 4

Ayrshire & arran 12 2 1 3 3 10 4 5 5 0 8 15 8 18 3 3

Western Isles 33 7 0 1 2 17 2 2 0 0 11 8 3 8 3 3

Shetland 20 0 0 0 5 11 5 2 0 0 9 5 11 27 2 2

Orkney 38 0 4 0 4 13 0 0 4 0 8 8 4 8 4 4

life curve score 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Physiotherapist 27 2 1 2 2 15 3 3 4 1 8 6 7 13 1 4

Occupational Therapist 13 2 1 1 1 10 3 5 3 1 9 11 9 22 3 6

Podiatrist 26 10 0 1 4 18 2 3 3 1 8 3 6 10 1 3

Radiographer (diagnostic) 65 3 0 0 1 13 2 1 2 1 2 1 3 5 0 1

Dietitian 34 3 1 1 4 17 3 5 1 0 9 3 5 6 3 4

Speech and Language 23 3 2 1 2 14 3 6 1 2 7 2 8 13 5 9

Prosthetist/Orthotist 32 2 0 3 3 13 5 2 3 2 10 3 6 12 1 2

Radiographer(theraputic) 73 1 0 0 3 11 1 1 1 0 4 0 2 1 0 4

Orthoptist 52 4 1 2 1 16 4 5 2 0 0 3 2 8 1 1

Lifecurve Score by Profession (heat map)

Some Early Lifecurve applications to practice

• Aberdeen Health and Social Care Partnership –increase in identifying people for reablement services leading to improved independence

• Lanarkshire GP practice – occupational therapy using as part of a ‘good conversation’ to identify early reablement goals

• Forth Valley Podiatry – better conversations about the persons’ wellbeing and signposting for self management

What should reablement include?“Progressive Resistance plus balance training

• Brisbane based trial with 245 people aged 65 yrs +• All receiving care at home• Worked out twice a week• 24 week exercise programme doubled their upper and

lower body strength• Benefits included people falling less, reduced anxiety

and depression, less care at home required, people living independently for longer in their own home

• $1.4M for programme – would pay for itself• Convert to UK costs: £80,000 - £326/person

Ref: Herald Sun, Australia 28th January 2018

Thank you!

Susan Kelso

AHP Lead Early Intervention

Scottish Government

Susan.kelso@nhs.net

0794 308 3735

@susankelsoAHP