“Reablement is a new way of working, with the aim of improving elderly people’s independence.”
Tine Rostgaard is a lecturer on Citizenship and Elderly People at the University of Aalborg in Denmark. Her research focuses on social care policies for elderly people, and she has special interest in understanding care practices and their implications for care quality. She chairs the Danish Gerontology Society and is also editor of Elderly and Society.
Reablement is a re-learning process designed for people with moderate dependency, its aim being to help them to perform the activities of their daily life independently so that they can remain in their homes for the longest time possible. The programmes are run prior to the person concerned being assigned an assistance resource (home help service, day centre, long-term care home, etc.). Recently, the European Commission has highlighted Denmark’s efforts to implement reablement policies as an innovative initiative that reduces the challenges that care systems must tackle. Tine Rostgaard is a co-creator and one of the foremost promoters of this programme, which is being applied with notable success in several northern European countries, Australia and New Zealand.
In recent years, the sustainability of care systems for dependency has been thrown into question and there is talk of a future care crisis. What, in your opinion, are the factors that may endanger the current system?
The real challenge is ageing. Demographic changes – fewer children are being born and people’s lives are getting longer – mean that there will be more people needing care during the last stages of their lives. We calculate that by the year 2060, the cost of caring for elderly people will have increased by 100% with respect to the cost today. This is a notable increase that represents a major challenge.
We also have a challenge with regard to who should be caring for elderly people. Ageing also affects the sector’s workers, whether formal (professional care staff) or informal (families who are carers for their elderly members). We have to improve staff recruitment and retainment. Few young people are seeking work in this sector and those who do so rarely remain in their position for long, as this work is not attractive to them, even in countries with an efficient dependency care system.
There has been a sea change in the mindset of women and of elderly people. Traditionally women have taken on the burden of caring for elderly family members. But today it is no longer as common for families to live together: young people leave home earlier and emigrate or move to other cities. Meanwhile elderly people frequently prefer to look after themselves and not depend on other family members. This is a common finding in all cultural systems.
So in summary, yes, we do have a lot of challenges.
Which are the policies that we should be prioritising today in order to be able to tackle future situations?
The policies that we must concentrate on are along the lines of reablement (time-limited home rehabilitation policies). To prevent dependency, it is necessary to invest in elderly people so that they are capable of managing their life situations during the longest time possible. It is also necessary for informal carers to be able to care for their loved ones but at the same time keep their jobs. For this, new work policies must be promoted that allow people to take a few hours or even a whole day off to care for their parents or grandparents. And formal carers must receive a fair wage and obtain greater social recognition for the work that they do.
What is reablement? In what sense is it an innovative policy with respect to more consolidated practices in this sphere?
Reablement is a new form of working whose main aim is to improve the independence of elderly people. Along the traditional lines of providing care within the home, a social worker visits the elderly person at home and assists them with basic needs: getting out of bed, washing, dressing and cleaning the house. With reablement policies, the first thing is to ask the elderly person what their needs and goals are and what they would like to achieve: Would you like to be able to leave the house? Go shopping? How can we assist you in managing your daily tasks, in such a way that you do not have to depend on someone coming to help you? It is a programme aimed at achieving objectives.
What does reablement consist of ? How is it applied technically?
The programme consists of an intervention that lasts 12 weeks. We keep the figure of a carer who travels to the person’s home, but in this case it is an occupational therapist. The physical condition of the elderly person is worked through muscle-strengthening exercises. At the same time, they are shown how to use personal assistive devices (walkers, bed hoists and other ergonomic objects). We are not talking about digital devices but about very simple technologies actively used by elderly people. In contrast, they reject more complex devices because they believe they will not be capable of using them.
The programme’s focus is on doing things differently: learning routines, doing tasks according to the resources available and, in short, going one step beyond the traditional form of providing home care, which basically consists of having another person do things for you.
What are the benefits of reablement? What advances does it offer with respect to rehabilitation, which is practised at day centres and residences?
It is oriented towards specific objectives. One of the people that I talked with told me that her daughter’s family lived on the second floor of her building, but that she could not climb the stairs to visit them. Improving her physical fitness paved the way to ensuring that she could fend for herself and also be able to visit her grandchildren more often. We also ensured that she was capable of performing personal hygiene and household tasks on her own.
This improvement in the beneficiary’s capabilities, rather than an advantage, might seem to be a drawback…
Yes, that’s true. On this point the system may be too ambitious and it receives some criticism. The programme’s beneficiaries often say to me: “I can appreciate the benefits of getting out of bed on my own, getting dressed, washing, etc., but what is the benefit for me of cleaning the house again like I used to?” I understand that stance, it is normal to find it rather odd.
The truth is that the fact that municipal services aspire to the system’s beneficiaries being able to do their own household cleaning, although generating controversy, is important with regard to the sustainability of dependency care systems. If elderly people are capable of performing these tasks through their own means, then the municipal services will save money. Thus, ideally, these policies provide a dual benefit: firstly, achieving elderly people who are more independent and have a better quality of life; and secondly, serving to save money in public services.
Is there any proof of the efficiency of launching reablement policies with respect to quality of life and gaining control and independence?
We know that the programme has a major effect in terms of gaining in quality of life. People gain independence and feel more confident about performing tasks autonomously. This is shown by the results of some Norwegian research studies.
In Denmark, we do not yet have specific results because we are still at a very early phase of implementation of the programme on a national level, but we have indicators that show that these systems help people to become more independent and, therefore, they need less help once the programme has concluded.
Is there any evidence available on the effects of the programme in terms of the costs of care systems?
Some provisional results suggest that 20% of the elderly people who have benefited from reablement programmes require no other service after the 12-week intervention. This allows us to get an idea of the saving that it represents in social services costs.
However, it will be important to calculate properly what the return on investment is and the costs of re-implementing the programme. Initially it costs a lot of money because it is quite intensive. Therefore we must be meticulous when it comes to evaluating whether the programme continues costing as much in the subsequent phases of implementation, or alternatively whether it is costly at the start then subsequently expenditure decreases. This analysis will give us the key to knowing whether reablement represents savings for government or not.
What is the typical profile of reablement beneficiaries?
The standard user is a person suffering from a moderate degree of dependency. In other words, they are not people with severe problems or serious disabilities, nor people with early dementia, but people who live in their own homes and are in need of intermittent support or have other limitations affecting their personal autonomy.
What happens if the person reaps no benefit from the reablement programmes or cannot participate in them?
It is problematic applying these programmes to people suffering from senile dementia or another type of cognitive disability, because an essential part of reablement consists of talking to them and finding out their objectives. The person must be capable of fulfilling their daily routines and of being committed to cooperating with their carers. And this requires a certain level of cognitive competencies.
However, we are trying to expand the programme to include people suffering with dementia. And we have even started to use it quite successfully with terminally ill patients, helping them to improve their quality of life in the last days of their lives.
Since when have these reablement programmes been applied in Denmark?
By 2007, the system was already up and running in 98 municipalities in Denmark. But since 2015, all Danish municipalities have been obliged to use it. Now it is included in the legislation.
In which other countries has the programme been applied? Are there similar experiences in countries in the Mediterranean area?
Norway has quite a lot of experience in the use of reablement; it is also applied in England, Scotland, the Netherlands, New Zealand and Australia.
As for Southern European countries, it is worth highlighting that quite a large divide exists with respect to the Scandinavian countries, not only with regard to the use of these programmes, but to the way of organising dependency care systems in general. In countries in the north of Europe, we have a more solid formal structure of the care system. We trust that our Government will contribute solutions for our wellbeing. That is the reason we pay taxes. We have much more generous social services: around 14% of people aged over 65 years receive home care, free of charge. This does not occur in many countries in Southern Europe.
Is this attributed to cultural or economic reasons?
I would say it is a combination of both. I don’t know which came first, the chicken or the egg. Moreover, we live in more individualised societies. We do not expect families to look after their elderly. This does not mean that they do not matter to us. In fact, in some of the research that I have conducted on loneliness among elderly people, I have observed that, although in countries of the North elderly people live alone more often, there are higher rates of loneliness in countries of the south, including Spain.
Living with the family does not always imply that you feel like a participant in affective relations that are significant for you….
Of course. Another factor that contributes to loneliness is that in countries like Spain there are many people of advanced age obliged to care for their spouses, who are often ill. These people feel lonely because they cannot leave their homes nor have a life of their own.
In your opinion, what strategies can we follow to humanise care?
I believe that reablement is a very good strategy, because it puts the person at the core of the care process. We focus on people’s preferences and goals, thus we offer them the possibility of making decisions relating to their lives. It is a system with a highly individualised focus, which is the best way of dignifying people care.
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