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We hear from Zoe Betts, Adult Social Worker and Owner of iamsocialwork, who gives us a detailed insight into reablement. 

The transition from hospital to home can create much anxiety, for families as much as for the patient. It can be new territory for people and often the longer the admission the greater those worries can become. The list of questions can be endless.

Having discharge planning meetings early in the process with the patient and their family whilst in hospital, can hugely alleviate many worries.  They are often understandably fearful that the support will stop as soon as someone leaves hospital, but as I discover, when talking to physiotherapists and a senior occupational therapist at a large London Trust, reablement pathways are helping to address these very real concerns. 

Working within a hospital environment myself, I know what a great job the staff do there, but I absolutely understand the reasoning behind founder of the Institute for Healthcare Improvement, Don Berwick’s assertion that “the hospital shouldn’t be the centre of healthcare, it’s a repair facility, it’s not the source of health. Home is the source of health”. 

More and more Trusts, CCGs and local authorities are in agreement with this; that support can be implemented – and more successful - at home. This can include a combination of health and social care services. Particularly from a functional rehabilitation point of view, many boroughs are accepting that the rehab journey can be continued at home and no longer requires a hospital admission.  

Confusingly, the pathway for consideration of support at home can differ between each local authority. One model followed by those I spoke with for the purpose of this article, commonly referred to as a reablement pathway, offers care free of charge alongside an intense programme of therapy. Care is brokered out via the local authority to a care agency and therapy will be in place with either the local authority as well, or with a more specialist health-led therapy team. This can include speech and language therapists as well as physiotherapists and occupational therapists, depending on the reason why therapy is needed. 

The level of care and therapy is discussed and recommended by the hospital multi-disciplinary team, and then discussed with the patient and their family to understand how much support they will accept and what works best for them. Both aspects are usually in place free of charge for a period of six weeks, to allow a long enough period of time to improve and achieve the goals set. 

The criteria is goal orientated, which can be very minor such as washing your body using both hands or maintaining a sitting balance, completing a transfer consistently; as well as having no previous package of care or having newly identified goals after a new admission.

As this is such an integrated pathway, working closely with the therapy teams is a must. The social worker completes an assessment of needs and the physiotherapists and/or occupational therapists provide the therapy goals from the outcome of their hospital sessions. 

It can be a huge relief for people and their families to know that this intense level of support will be in place to help at home so frequently.

To find out what the specific benefits and challenges are with the reablement pathway, Nicole, a Senior Occupational Therapist at the Trust, shared her thoughts with me. 

What are the main benefits of the reablement pathway for the patient?

“We often find people make much better progress once they are back in their own home. Therapists can visit a patient at home anything from three times a week to once a day, depending on someone’s goals and their own motivations. This works alongside a care package sourced by the local authority or by the person directly and ensures a person gets a good balance of care and therapy and really gives them the best chance to get back to where they were before their admission”.

What do you consider when recommending a reablement pathway? 

“We consider whether the patient has a condition that has the potential to improve, whether the patient wants to become more independent and if they have rehabilitation goals.” 

What are the main challenges you face?

“It’s often motivation, low mood and any cognitive impairment. I work on stroke rehab ward and following a stroke there is a high incidence of depression and cognitive impairment, which can influence engagement in rehabilitation and a patient's ability to improve.” 

How do you find the transition to community therapy teams?

“We are fortunate to have close working relationships with community services with regular meetings, handovers and a clear referral process. We try, where possible, to get rehabilitation teams to come and assess patients in hospital first, as a means of handing over the patient. It is important where possible for community therapists to work alongside reablement carers to ensure they are both working on similar rehabilitation goals so we try and get them to have a session together when we know the carers will be there too. This is particularly important when there are any manual handling risks involved.

What's the most rewarding part of your job?

Working with amazing patients, carers and their families and being part of a proactive, hardworking multidisciplinary team. It’s very rewarding! 

Author profile

Zoë runs iamsocialwork which supports students and qualified social workers to network with one another and learn from academics via a variety of national events and forums. She is a judge for the Social Worker of the Year Awards and works full-time as a social worker, addressing process improvements as part of an integrated hospital discharge team in London. 

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