This chapter looks at the workforce, training and physical space requirements for the delivery of rehabilitation, and considers some solutions to existing barriers.
Proactive and integrated workforce model
Many staff from different healthcare disciplines, social care and housing providers, community and third sector partners work alongside unpaid carers to support older people to achieve their rehabilitation goals.
Family carers provide valuable support for recovery and need to be supported as equal partners in care, albeit recognising their capacity may be limited due to their own health or other constraints. Which practitioners should be involved in rehabilitation should be based on holistic assessment of need and individualised goals. Multidisciplinary teams are varied in composition and the leadership of the team should not be based on an idea of ‘seniority’ but on which team member has expertise in the priority concern of the individual.
Integrated workforce planning is required to meet the growing demand for rehabilitation in an ageing population. NHS England suggests education and training places for allied health professions will need to grow by as much as 25% by 2030-31 to meet demand.84
Workforce models that optimise skill mix and enable people to work at the top of their licence can increase system capacity and extend the reach to older people who are currently excluded from access to rehabilitation. A strategic and integrated approach can be facilitated by appointing a rehabilitation director operating at executive level within the system and establishing a local network of providers who consider existing services and collaborate to improve access, ensure equity of provision, reduce fragmentation and make best use of collective workforce capacity. Capacity planning involves assessing needs of individuals and aggregating at a neighbourhood level. There are models to help in planning required capacity.85 Population segmentation and risk stratification have been applied over recent decades to better understand levels of need within a neighbourhood and plan capacity of teams accordingly.
Many rehabilitation programmes are for specific conditions (eg stroke, heart failure, respiratory disease) but often have common elements and shared resources that are useful for people with multimorbidity or frailty. Flexible delivery may enhance interdisciplinary learning and service efficiency as illustrated by the generic Healthy and Active Rehabilitation Programme developed in Ayrshire in Scotland, working with leisure service partners.86
The Collaborate Don’t Compete project87 describes how different exercise professionals can work together to promote stronger rehabilitation outcomes, including for older people.
| Key message 8 Rehabilitation is a multi-agency endeavour involving many health and social care disciplines, voluntary sector, volunteers, unpaid carers, housing and community leisure services. Systems should work with all partners to offer rehabilitation for older people as a key component of health and social care within age-friendly communities. |
Case study examples
NHS Fife Intermediate Care Service
The NHS Fife Intermediate Care Service provides rehabilitation to people within their own homes. This community rehabilitation initiative aims to ensure patients have the best chance of achieving their personal goals, improving independence, general health and wellbeing, whilst in their home or homely setting.
Working together to improve outcomes for Pat in St Andrews, Fife: Following initial inpatient rehabilitation after a stroke, Pat was referred to the local intermediate care team for Early Supported Discharge rehabilitation at home with a personal goal to be able to walk outside again with a stick. Rehabilitation support workers visited Pat daily, encouraging her to regain independence with personal care, and developed a personalised exercise programme to promote balance, mobility, self-management, independence and wellbeing. Pat progressed to walk with a stick indoors then outside with support workers. She started an out-patient rehabilitation class at the local community hospital and was motivated by exercising with others. She then moved on to Active Options, a community exercise group. A local area co-ordinator helped Pat identify a social group that could support her to get out and about, be active and socialise.
Read more about community rehabilitation in NHS Fife at www.nhsfife.org/services/all-services/icass-integrated-community-assess…
Education and training support
Professionals engaged in rehabilitation need core competencies in communication, shared decision-making, goal-setting and collaborative practice. They also need skills in assets-based approaches, supporting self-management, identifying and escalating potential medication-related problems, and identifying and signposting carers to support for wellbeing.
Education should include raising awareness of human rights duties such as challenging ageism and ageist stereotypes; confidence in tolerating risk in encouraging mobility; understanding how to create a safe and enabling physical environment; and support for motivational coaching and behaviour change to sustain the gains. Student placements, simulations and rotational posts that offer experience in different settings are valuable. Non-registered members of staff are critical in delivering programmes of rehabilitation and need training to equip them to have the right skills.
The BGS offers an online educational module on frailty88 that can support practitioners contributing to rehabilitation to develop these important competencies. NHS England also offers a frailty e-learning module for the public and for generalist professionals that includes a sub-section on rehabilitation.89 Additional required rehabilitation competences include skills such as case management and care coordination as reflected in a new capability framework for virtual wards and hospital at home services in England.90
| Key message 9 Rehabilitation is everyone’s business – older people themselves, carers and all health, social care, housing and voluntary sector workforce need to understand how to motivate and support enablement in later life. Systems should work with education providers to support everyone involved to work together and at the top of their licence to increase collective capacity for reablement and rehabilitation for older people. |
Case study examples
Bevan Exemplar project
A Bevan Exemplar project in a community hospital in Wales upskilled healthcare support workers as Rehab Champions to reduce delays between purposeful therapy contacts and to help the MDT adopt a 24-hour approach to implementing rehabilitation plans for patients. Patients were discharged with lower dependency, smaller packages of care than anticipated, reduced manual handling equipment needs and had a shorter length of stay than the previous average.
Read the case study at https://bevancommission.org/wp-content/uploads/2023/08/Rebecca-McConell…
Occupational therapists and physiotherapists in integrated community services at Guy’s and St. Thomas’ NHS Foundation Trust
Occupational therapists and physiotherapists in integrated community services at Guy’s and St. Thomas’ NHS Foundation Trust complete an enhanced Level 1 Medicines Reconciliation as part of the patient’s initial assessment. This facilitates timely identification of issues relating to medicines, and prompts consideration of the impact of medicines on rehabilitation goals (e.g. on pain management). Where required, therapists refer to a team of pharmacists and pharmacy technicians to support the optimisation of medicines.
“The occupational therapist checked the medication that I had been given by the Hospital and noticed missing medication and contacted my GP to arrange for it to be re-prescribed. They also supported me in contacting my GP, as I wanted a lower dose of pain killers (that I was not allergic to). My GP, encouraged by their email, acted quickly but I still did not have my newly prescribed medication, and the pharmacy were not answering when I tried several times to enquire by phone. The occupational therapist telephoned directly and got through and by that evening the newly prescribed medication had been delivered to my home.”
- Patient at Guy’s and St Thomas’ NHS Foundation Trust
Physical environment
The optimal environment for rehabilitation is generally the individual’s home but this may not be feasible for some people due to lack of space, lack of equipment, or challenging circumstances, particularly for older people who live alone and need support to engage in rehabilitation.
Provision of simple equipment can be crucial in ensuring that an individual is able to rehabilitate in their own home. In all settings, the physical environment should be able to support older people who require specific support for sensory, functional or cognitive impairments or to help them engage with the rehabilitation process.
Physical space for rehabilitation in hospitals has diminished in recent years, exacerbated by the pandemic and by a spiralling maintenance backlog resulting in closure of some areas for extended periods of time. In some hospitals, the function of former rehabilitation spaces has changed to accommodate patients with acute medical needs. In a survey by CSP at the end of 2022, physiotherapists reported a loss of rehabilitation space in more than 100 areas across the UK. In a follow-up survey in May 2023, 96% of respondents said the situation had stayed the same or worsened. Rehabilitation needs the appropriate space, facilities and IT infrastructure.
On the Occupational Therapist’s first visit to my home, she noticed that my raised toilet seat was not fitted correctly as my toilet seat underneath was broken. It had caused a few scary moments when it kept slipping when using it. She immediately securely fitted the raised toilet seat, and it was wonderful to have a safe toilet to use. When she saw I was struggling to move my meals from the kitchen to my table, she arranged a trolley, which has been a real life saver as there were many things I could not carry due to being on two crutches. The trolley has helped improve my daily living considerably. She was excellent in helping me with Adult Social Services to get installed bathroom aids, a bed rail and grab rails at my front door. All have helped in my daily living needs and will continue to be of help, as I have a permanent issue with my right knee.” - Patient at Guy’s and St Thomas’ NHS Foundation Trust
| Key message 10 Rehabilitation needs the appropriate space, equipment, facilities and IT infrastructures, including access to care records that can be shared across providers in all care settings. Systems should commission a menu of options from a range of partners in environments that are fit for purpose. Services should be of sufficient duration to enable older people to achieve their social goals as well as undertake activities of daily living at home. |
Digital solutions
How patients receive their rehabilitation is important.
In a study by the British Heart Foundation, while a majority of people expressed a preference for face-to-face support, others commented that they felt that they were able to get the same experience from a telephone or video call.91 In a recent interview study within a trial of remote physiotherapy for early stage Parkinson’s disease, participants found remote consultation with a physiotherapist acceptable and liked the convenience of not having to travel to the clinic.92 However technical difficulties included positioning of the camera and limitations of internet connectivity. If these challenges can be overcome, telerehabilitation has potential to make rehabilitation more accessible. Other considerations are lack of equipment, limited digital infrastructure, difficulty in establishing a therapeutic relationship online, a need for more training and support and simpler technologies that can be personalised.93
An overview of technologies used to facilitate remote rehabilitation in adults with deconditioning, musculoskeletal conditions, stroke, or traumatic brain injury, was unable to draw firm conclusions.94 Targeted digital solutions for physical activity are more promising. A review of digitally enabled physical activity and exercise interventions for older residents in long-term care facilities reported increased function and activity.95 A recent qualitative study which explored remote delivery of a programme of physical activity and exercise for people with early dementia or mild cognitive impairment during COVID-19 found that remote delivery could be challenging for carers, people with dementia and therapists.96 However, creative approaches to address these issues were identified.
Digital solutions are also required to enable continuity of information between providers and at transitions between settings or services. These are a key aspect of an integrated approach to rehabilitation. For example, a care plan should be able to be shared across interoperable systems and accessed and added to by key staff involved in rehabilitation and support.
National IT solutions, such as the Summary Care Record application, may be useful but most areas have much work to do in information governance and interoperability of systems to improve access to data for the range of providers of rehabilitation and intermediate care.
The National Institute for Health and Care Research has produced guidelines for the use of virtual home assessment tools.97
Measuring what matters
As health and care systems implement new models of rehabilitation, there is a need to understand and communicate the benefits for patients, carers, professionals, organisations and systems.
Multi-dimensional interventions for older people often prove challenging to evaluate. Analysis of rehabilitation service data is critical for planning, commissioning and monitoring their performance. Good quality data is a prerequisite for continuous quality improvement and benchmarking of rehabilitation services. However, we lack standard national datasets and there is often limited interoperability between the local datasets that exist in different care settings. A recent report by the Community Rehabilitation Alliance offers recommendations for addressing these issues.98
Thoughtful consideration of different professional values, cultures and approaches is required when introducing tools to measure quality and outcomes of multidisciplinary rehabilitation interventions.99
Monitoring and evaluation of complex rehabilitation interventions will require a range of mixed methods approaches, depending on the maturity of the service. Ideally there should be a continuous quality improvement approach using small-scale local data to drive improved practice and outcomes at point of care. Periodic reviews of activity, case-mix and patient and carer feedback will support assessment of reach, inclusion and experience. More detailed evaluations should consider interdependencies through contribution analysis and assess both cost-effectiveness and social value.
Considering wider outcomes beyond health, longevity and Quality Adjusted Life Years (QALY) will enable commissioners to have a broader understanding of effectiveness and value from investment in new ways of working.100,101
Examples of monitoring and evaluation tools:
- The Measure Yourself Concerns and Wellbeing Tool from Meaningful Measures has been adopted by the Gloucestershire complex care at home service.102
- The International Consortium on Healthcare Outcomes has developed numerous tools for patient-centred outcome measure.103
- The Welsh Government have published a rehabilitation evaluation framework to assist Health Boards, local authorities and third sector partners to understand the demand for and to evaluate the impact of rehabilitation.104
- Akpan and colleagues published a standard set of health outcome measures for older persons.105
- A reablement team in Dumfries and Galloway, Scotland used the community IoRN2 tool (Indicator of Relative Need) to measure impact and as a catalyst for outcomes focused conversations and collaborative practice.106
- The Patient-Reported Outcomes Measurement Information System (PROMIS) is a short form designed to measure physical function in geriatric rehabilitation patients.107
- The BEPOP (Benchmarking Exercise Programme for Older People) national benchmarking first wave seeks to determine and promote exercises associated with positive outcomes for older people living with, or at risk of, sarcopenia or physical frailty.108
| Key message 11 The quality of rehabilitation services should be monitored, tracking changes in health and functional outcomes, patient and carer experience, and considering coverage and cost-effectiveness. This intelligence should be used to continually improve services. Quality indicators should acknowledge personalised goals and outcomes, and that delay of further functional decline may be a more realistic outcome than recovery of independence for people who have progressive life-limiting illness or are at the end of life. |
