Embedding Outcomes in Homecare Re-ablement for Older People in North Lanarkshire

This project aims to investigate the potential for and most effective means of implementing evidence (formal research studies, practitioner wisdom and user and carer perspectives) about outcomes in the context of home care re-ablement. While there has been some attempt to consider outcomes in homecare more broadly (Sawyer, 2005), progress remains patchy. There is also a need to develop outcomes in re-ablement services, which are being promoted throughout the U.K (CSED, 2007). Re-ablement has been recognized as achieving significant savings for local authorities; however initial costs of re-ablement appear to negate long-term savings (PSSRU, 2010). Embedding an outcomes approach within re-ablement may assist in providing effective home care services within a context of diminishing resources and an ageing population.

Emerging evidence of outcomes approaches show that they are both person-centred and enabling and can be implemented without additional resources (Miller, 2010). Evidence from re-ablement is largely positive, suggesting that home care re-ablement can reduce commissioned hours of home care, and offer sustained benefits to service users by increasing their skills and ability to live independently, (MacIntyre and Stewart, 2011). However, (Slasburg, 2009) suggests that establishing a re-ablement culture for all rather than a specific service for some will ensure benefits to all rather than to a small minority of hand picked service users.

This project will build on an established knowledge exchange initiative in Scotland, Talking Points (Scottish Government, 2009). It will work directly with a partner local authority, North Lanarkshire Council, to investigate how an outcomes-based approach to assessment has been embedded within two home care re-ablement teams. The project will enable existing evidence on both outcomes and re-ablement to be mapped across current practice in North Lanarkshire and this iterative process will facilitate knowledge exchange.

Guidance and associated tools will be produced for the local authority as well as digital stories for broader dissemination and training purposes. It is expected that the key messages from this knowledge exchange process will have applicability for other home care services who are working to embed outcomes in re-ablement across the U.K. and internationally. In addition, if funding is secured, this project will be the first stage in the development of the exploration of a re-ablement approach being introduced throughout home care services both within the council and in the contracted private sector services. Key stages of the project are summarised below.

Stage 1 will establish key messages from the literature as they relate to outcomes and re-ablement. In addition a small number of strategic staff within the local authority and other providers will be interviewed to establish a baseline for current practice.
Stage 2 will test out via focus groups the relevance and applicability of the key messages identified in stage 1 with practitioners and managers across two re-ablement teams in North Lanarkshire
Stage 3 will synthesise the messages from research, the practice experience and potential challenges to implementation via an Expert Group comprising; relevant practitioners, researchers and external advisors including Partnership4Change. Stage 4 - Detailed guidance on the optimum model of practice, including relevant tools to ensure outcomes are embedded in the re-ablement model in North Lanarkshire will be produced.
Stage 5 - guidance and tools disseminated via a 2nd focus group to consider any challenges concerns from the practitioners.
Stage 6 - second Expert Group meeting to finalise the model to be developed within North Lanarkshire. A further output of this event will be detailed guidance for dissemination
Stage 7 - implement model across North Lanarkshire
Stage 8 - dissemination of project outcomes across Scotland via IRISS.

Beneficiaries of the research will include users of services and their carers, particularly in health and social care and housing, which are moving towards outcome based working. Where outcomes are embedded, service users benefit from approaches that more actively involve them in identifying their outcomes, building on their strengths and capacities. Carers benefit from improved communication and a greater sense of clarity about the purpose of services and support. While homecare re-ablement also explicitly aims to maximise independence, there has tended to be an almost exclusive focus on functional outcomes with less attention to the quality of life of service users. Embedding outcomes will mean that quality of life outcomes are taken into consideration, so that factors like social isolation are considered and addressed.

In general, staff have reported benefits from outcomes based working in that it restores relationship based approaches to practice and promotes more meaningful engagement, rather than prescriptive tick box approaches. Re-ablement home care staff within North Lanarkshire have identified that they enjoy the new way of working, gaining satisfaction from the positive changes in service users, they have identified 'backlash' as an issue. This means that staff have encountered resistance from some service users and carers who have grown accustomed to traditional home care which performs tasks and does things to people rather than working with people to enhance their skills and capacities. Outcomes based working offers some potential to manage these tensions, involving a negotiated process of assessment and planning with the person and their carer, to agree what is to be achieved and how that will happen. There is also real potential to include staff from more traditional home care services to work in a more enabling way with service users, and outcomes based planning can support this.

There is potential for homecare re-ablement services to benefit from embedding outcomes in so far as there is increasing pressure on providers to be able to demonstrate the effectiveness of their interventions from the perspective of service users and carers (see e.g. Glendinning et al, 2008). Outcomes based working not only provides a means of more constructive engagement with individuals, but in addition, the records which are produced from individual planning and review can be collated and aggregated up to demonstrate impact, fulfilling a range of requirements including service planning, commissioning and accountability and scrutiny.

At a wider level, there is potential for local authorities and the public sector generally to benefit from this approach. Outcomes based working improves communication between individuals at the frontline and provides clarity of purpose about the role of services, which in turn improves their efficacy and relevance. The focus on supporting people to be active in achieving the outcomes they have identified as important also means that there is less reliance on providing services, and that consideration is also given to the person's role as well as the role of natural and community based supports. In the face of budgetary constraint and demographic pressures, this shift will be critical in sustaining public services. Local councils are also under pressure to demonstrate outcomes for accountability, scrutiny and performance management purposes. While North Lanarkshire is en route to being able to demonstrate outcomes from care management, it will be necessary for different parts of the system to be outcomes focused to achieve full benefits. It is envisaged that the focus on re-ablement in this project will be the first stage in bringing on board the wider home care service. As many local authorities throughout the UK are currently introducing, embedding or extending homecare re-ablement, there will be considerable interest in the outputs from this project.