Figure 1 presents a flow chart describing the selection of articles. Out of the 120 articles identified in our initial search in Medline, Embase, CINAHL, and PsycInfo databases, 14 were conference abstracts, 14 were beyond the scope and therefore irrelevant (e.g., articles on postnatal wards, homeless people, non-humans, etc.), and 18 were hospital-based post-disease/ -injury, which resulted in 74 relevant articles from the database search. We added another 12 relevant articles from reference tracking for a total of 86 eligible articles that were appropriate for the next stage of quantitative and qualitative analysis.
3.1 Qualitative Analysis
Based on the collected literature, we divided the conceptual shifts about reablement into the following categories: historical focus (pre-2000); the emergence of ‘restorative care’ for older people (2001–2005); the transition from ‘restorative care’ to ‘reablement’ (2006–2014); and the boom of reablement services (2015–2019).
3.1.1 Historical focus (pre-2000)
Our literature review indicated that the meaning and conceptualisation of ‘reablement’ has changed since the beginning of the 20th century; in practice, it has both run parallel to and deviated from its sister practice, rehabilitation. Notably, after World War II, the emphasis of clinical rehabilitation began to broaden from a patient’s recovery of ambulation to a focus on “the comprehensive restoration of an individual’s physical, mental, emotional, vocational, and social capacities” (Kottke and Knapp, 1988 in Brandt and Pope, 1997: 31; emphasis added). Around the same time, the word ‘reablement’ first entered the scholarly lexicon in an editorial published in Physiotherapy, which was simply titled “Disablement and reablement” (Nixon, 1947). The author argued that the word ‘rehabilitation’ must be discarded in favour of ‘reablement’, which should focus on “making a disabled person able-bodied again”, and restoring “a man to capacity for his former work, or, alternatively, what particular work he can be trained for” (Nixon, 1947: 173).
The publication of this editorial at the end of World War II suggests that the author’s conceptualisation of ‘reablement’ was inspired by the need to support and train ‘dis-abled’ patients – most likely injured soldiers returning from the frontlines – in restoring their functional abilities and ‘re-settling’ them both at home and in the workplace. The term ‘reablement’ also started to be used to describe physiotherapeutic training for patients suffering from specific health conditions or diseases, such as cerebral palsy and rheumatoid arthritis (Collis, 1947; Grenville-Mathers, 1949). The first mention of reablement associated with “the heavily handicapped patient” was found in the title of a British journal article on the principles of rehabilitation in 1962 (Grant, 1962), and an article from 1975 discussed reablement in relation to functional activities and “resettlement in work and home” (Nichols, 1975 :113).
Throughout the 1960s and 1970s, there was a continued emphasis on the restoration of functional ability and “resettlement in work and home” (Leplaideur et al., 1977); (Dupontreve, 1977); (Cooper, 1977) as well as ‘re-abling’ patients suffering from arthritis and other rheumatic diseases (Newton, 1978: 49). Few scholarly articles published in the 1980s and 1990s mentioned the term ‘reablement’, but a 1994 editorial in Reviews in Clinical Gerontology was the first to mention a focus on older people: “’We are trying to improve this patient's quality of life’ is the often stated goal of much therapeutic effort made for elderly people” (Ebrahim, 1994: 93), continuing that “the criteria for successful rehabilitation are often limited to independence in a limited range of basic activities of daily living. Reablement is most obviously concerned with reducing disability and the appropriate outcomes must be disability measures. ‘Resettlement’ is a more complex goal and implies the restoration of people to their own, or sometimes a new, environment” (Ebrahim, 1994: 93–94; emphasis added). This article suggests that the term ‘reablement’ was still linked to ‘rehabilitation’ while ‘resettlement’ was understood as a different approach that included a focus on the environmental ‘restoration’ of older people.
3.1.2 The emergence of ‘restorative care’ for older people (2001–2005)
By the turn of the millennium, this idea of ‘resettlement’ and ‘restoration’ as a specific intervention for older people receiving homecare had transitioned into ‘restorative care’. In 2002, Tinetti et al. published what could be considered a landmark paper in the Journal of the American Medical Association (JAMA) titled: “Evaluation of restorative care vs usual care for older adults receiving an acute episode of home care”. The authors suggest that “a primary goal of health care for older, particularly multiply and chronically ill, persons should be to optimize function and comfort rather than solely to treat individual diseases” (Tinetti et al., 2002: 2098). The restorative-care model that the authors described was based on principles adapted from geriatric medicine, nursing, rehabilitation, and goal attainment, which refers to the belief that people “are more likely to adhere to treatment plans if they are involved in setting goals and in determining the process for meeting these goals” (Tinetti et al., 2002: 2100).
The intervention included training relevant health professionals (i.e., homecare nurses, therapists, and home health aides) as well as reorganising this home-care staff “from individual care providers into an integrated, coordinated, interdisciplinary team with shared goals”, which required a “reorientation of the focus of the homecare team from primarily treating diseases and ‘taking care of’ patients toward working together to maximize function and comfort” (Tinetti et al., 2002: 2100). Furthermore, it was built upon “the establishment of goals based on input from the patient, family, and home care staff, and agreement among this group on the process for reaching these goals” (Tinetti et al., 2002: 2100).
Although the authors cite several studies from the 1990s that focused on goal-setting in clinical medicine for the so-called ‘frail elderly’, this intervention appears to be the first well-defined programme that reflects the central aims of reablement as it is presently being operationalised and implemented worldwide; in other words, while the restorative-care model was not explicitly called ‘reablement’, it contained similar features and aims, and seems to have provided the philosophical foundation for many of today’s reablement programmes. Tinetti et al.’s research also built its findings on their earlier study, “The design and implementation of a restorative care model for home care” (Baker et al., 2001) as well as several previous articles that examined older people’s self-care and functionality with regards to performing activities of daily living (ADLs) in both hospital and home settings.
During this period, researchers in the United Kingdom also published a report that described 33 services that were part of the NHS Modernisation Agency’s Changing Workforce Programme project (Nancarrow et al., 2005). These services were “designed to prevent inappropriate hospital admissions, facilitate hospital discharge, and prevent premature or avoidable admissions to long-term care” (Nancarrow et al., 2005: 338) – and this included what the authors called ‘reablement services’. The summary of care roles outlines that this service focuses on providing “personal care, daily living skills, mobility and financial management (…); enablement rather than ‘doing’ for their services users; dedicated home workers providing personal care from an enabling perspective with rehabilitation skills; reablement to promote independence” (Nancarrow et al., 2005: 343).
3.1.3 The transition from ‘restorative care’ to ‘reablement’ (2006–2014)
The foundational aims of ‘restorative care’ services for older people seem to have transitioned to being called ‘reablement’ more broadly in the late-2000s, and our search identified 24 relevant articles from this time period. In the United Kingdom, this transition was reinforced by a retrospective longitudinal study of ‘homecare re-ablement’, “Research into the longer-term effects of reablement services”(Newbronner et al., 2007), which was undertaken for the Care Services Efficiency Delivery (CSED) Programme at the Department of Health. In the Journal of Integrated Care, it was stated that homecare reablement had been widely accepted in the UK, and referred to “services for people with poor physical or mental health to help them accommodate their illness by learning or re-learning the skills necessary for daily living” (Petch, 2008: 38).
Other British researchers emphasised progress in developing “outcomes-focused services for older people and the factors that help and hinder this” (Glendinning et al., 2008: 54). The authors also described two small-scale, exploratory studies that examined the impact of home-care reablement on subsequent service use (Glendinning and Newbronner, 2008). These articles distinguish ‘reablement’ as its own unique approach, describing it as a service that “aims to help people ‘do things for themselves’, rather than ‘having things done for them’. Home care reablement services therefore provide personal care, help with mobility and other practical tasks for a time-limited period” (Glendinning and Newbronner, 2008: 33). The authors further stated that user-identified outcomes are central to the reablement process, particularly with regards to personal care, daily living tasks, or social activities. They also pointed out that reablement services can be offered to adults of all ages in the UK, although they suggested that “even very elderly…users may regain skills and attitudes to help sustain them for a relatively long period” (Glendinning and Newbronner, 2008: 36–7). The same authors published a prospective longitudinal study and working paper that investigated the longer-term impacts of “home care re-ablement services” (Glendinning et al., 2010).
During this time period, a greater focus on professional practice was beginning to develop (Samuel, 2010), and a professional column in British Journal of Community Nursing stated that reablement is “generally provided by local authorities as part of adult social care provision with a focus upon promoting self-care skills and rebuilding confidence” (While, 2011: 102). Reablement services targeted specifically at older people was also beginning to emerge in northern Europe – particularly, Finland. However, such programmes were termed “geriatric rehabilitation’ (Wallin et al., 2009) and did not take place within the home setting. But, other than this difference, the Finnish intervention has aims similar to other reablement programmes; e.g., the goal was “to achieve and maintain functional independence, and to enable older people to remain community-dwelling” (Wallin et al., 2009: 145).
By 2011, British experts reiterated the burgeoning ‘reablement philosophy’, which states that “the focus is on restoring independent functioning rather than resolving health care issues, and on helping people to do things for themselves rather than the traditional home care approach of doing things for people that they cannot do for themselves” (Francis et al., 2011: 2). Other researchers claimed that “home-care re-ablement or ‘restorative’ services” should enable older people to live independently in the community, writing that “the assumption underlying re-ablement is that enhancing independence and practical skills reduces needs for ongoing service support” (Rabiee and Glendinning, 2011: 496). However, there remained a lack of consensus about the definition, organisation, and practices related to the overall concept of reablement. For example, a 2011 Taiwanese article discussed community hospital-based post-acute care (PAC) to improve functional ability amongst frail older patients (Lee et al., 2011), which is the first time the term is mentioned by East Asian researchers.
A 2012 British article – which claimed to be the first in-depth study of the experiences of home-care reablement service users and carers – described reablement as “a short-term, intensive service that helps people to (re-)establish their capacity and confidence in performing basic personal care and domestic tasks at home, thereby reducing needs for longer term help” (Wilde et al., 2012: 583). The authors noted that similar programmes were also being implemented in Australia and New Zealand. In Australia, the term ‘restorative care’ was being used to describe interventions with aims similar to many current reablement programmes. For example, the provision and nature of home-care services had developed a “new focus on activity, independence and successful ageing” and concluded that “a restorative approach to home care has significant advantages over the traditional approach aimed at maintenance and support only” (Ryburn et al., 2009: 232). However, the National Development Manager–Care and Communities for Age UK argued that reablement is “nowhere near as effective as it could be” because it lacks personalisation and “fails to appreciate what motivates people to make the substantial effort involved in regaining lost skills and abilities” (Newton, 2012: 117).
By 2013, Australian researchers began to describe restorative home care services as “short-term and aimed at maximizing a person’s ability to live independently. They are multidimensional and often include an exercise program to improve strength, mobility, and balance” and “the intervention should ultimately “create independence, improve self-image and self-esteem, and reduce the level of care required through the delivery of an individualized program” (Burton et al., 2013: 1591–2). The linguistic transition from ‘restorative care’ to ‘reablement’ in Australia is clearly seen in a study that aimed “to determine whether older individuals who participated in a reablement (restorative) program rather than immediately receiving conventional home care services had a reduced need for ongoing support and lower home care costs” (Lewin et al., 2013: 1273; emphasis added). These authors also provided a straightforward definition of reablement in Australia; i.e., “an emphasis on capacity building (…) to maintain or promote a client’s capacity to live as independently as possible, with an aim of improving functional independence, quality of life, and social participation, (…and) an emphasis on a holistic, person-centered approach to care, which promotes clients’ wellness and active participation in decisions about care” (Lewin et al., 2013: 1274).
However, it appears that a semantic debate was still occurring in Ireland and the UK. An Irish intervention protocol described ‘reablement’ (in scare-quotes) as “an innovative approach to improving home-care services for older adults in need of care and support or at risk of functional decline” (Cochrane et al., 2013: 2), and the authors identified five essential defining criteria for an intervention to be called ‘reablement’: 1. participants must have an identified need for formal care and support, or are at risk of functional decline; 2. the intervention must be time-limited (typically 6–12 weeks) and intensive (e.g., multiple home visits); 3. the intervention must be delivered in the older person’s own home; 4. the intervention must focus on maximising independence; and 5. the intervention must be person-centred and goal-directed (Cochrane et al., 2013: 3–4). A 2013 British article described such programmes as “re-ablement or restorative homecare services that provide time-limited input aimed at reducing dependency in personal activities of daily living, and preventing or delaying the need for further homecare support” (Whitehead et al., 2013: 1; emphasis added) while a 2014 Australian paper made the distinction between terminology in the different countries: “Restorative home-care services, or re-ablement home-care services as they are now known in the UK, aim to assist older individuals who are experiencing difficulties in everyday living to optimise their functioning and reduce their need for ongoing home care” (Lewin et al., 2014: 328).
Nearly all of the articles during this time period also cite a growing political interest in cost-savings. For example, although the emphasis in the UK remained on providing services to adults of all ages (not specifically older adults), the white paper, Caring for Our Future: Reforming Care and Support, provided a definition of reablement in which “users receive home-care but are supported to increase their ability to manage tasks independently, in order to reduce the amount of homecare they will require in the longer term” (Whitehead et al., 2014: 2), and further distinguished reablement from rehabilitation, stating that reablement services “adopt a social model of recovery rather than a medical model” (Whitehead et al., 2014: 2). During this time, there is also increased emphasis on developing professional practice; e.g., a critical literature review analysed evidence on the effectiveness and cost-effectiveness of occupational therapy interventions for older people in social-care services, including rehabilitation and reablement (Boniface et al., 2013).
In Scandinavia, reablement programmes started to be offered in the 2000s; the first was established in Östersund Municipality, Sweden, in 1999 and – based on the Swedes’ positive experiences – soon began to develop in neighbouring Denmark (2008) and Norway (2012) under different names. The study protocol for a randomised controlled trial (RCT) of reablement in community-dwelling adults described it as “an approach to improve home-care services for older people needing care or experiencing functional decline. It is a goal-directed and intensive intervention, which takes place in the person’s home and local surroundings with a focus on enhancing performance of everyday activities defined as important by the person” (Tuntland et al., 2014: 1). A subsequent Danish article referred to the Nordic concept of ‘help to self-help’, which is based on “ways of providing help that involves the activation of older people, the aim being to enable them to manage as much as possible themselves” (Dahl et al., 2015).
3.1.4 The boom of reablement services (2015–2019)
Our search identified 56 articles from this time period; the majority were published by researchers from Norway (n=19) and the United Kingdom (n=12), and they include both quantitative and qualitative studies conducted in these countries as well as a few collaborative studies conducted by researchers from different countries. There are no articles from Asia, South/Central America, or Russia and only one from continental Europe. If reablement-like programmes have been or are currently being offered in these regions, they are most likely called another name. We have summarised the regional studies and organised these results alphabetically by region in Table 1.
3.2 Quantitative Analysis
We created a term map based on text mining the abstracts of the final eligible articles. Figure 2 shows a term map based on the most relevant terms from the abstracts of all 86 final eligible articles. Out of 2,238 terms, 220 met the threshold of five occurrences. Here, we visualised 60% of the most relevant terms, which amounted to 132 terms with 3,315 links between the terms. Each circle represents a term from the various abstracts, and the lines connecting the circles represent the interrelatedness of different terms. The size of the circle represents the number of occurrences of the term. The closer the circles are to each other indicates a high co-occurrence of terms representing a topic. The term map is coloured according to publication year, with dark blue/purple circles indicating terms from the earliest publication in 1947 until 2012 transitioning to teal in year 2013–2014, then turquoise/green in 2015–2017, and thereafter yellow indicating terms from the most recent publications in year 2018–2019.
Based on the number of occurrences of terms emerging in Figure 2, we can see the central concepts that have been emphasised in the literature throughout the years as listed in Table 1. In the earlier papers from 1947 until 2012, the core principles of reablement had already been conceptualised as a form of rehabilitation for hospitalised patients with disabilities and/or a need for homecare and social care services. In 2013–2014, there appears to be a shift of the target group from ‘patients’ to ‘users’. There was also an emphasis on developing specialised staff training that could create an impact by improving cost-effectiveness, and these programmes were offered as an alternative treatment to usual care. In 2015–2017, there appears to be another shift from ‘users’ to ‘participants’, with special attention to their goals and satisfaction with the programmes. This period also underlined the importance of assessing the performance of reablement services, particularly regarding the health professionals’ and carers’ roles, skills, knowledge, and experience (specifically, nurses and occupational therapists). In the most recent publications from 2018–2019, the focus shifted towards how to organise reablement teams and the programme’s overall approach, particularly on improving user involvement and collaboration between healthcare professionals, homecare personnel, and family members. The literature also highlighted an increased interest in making reablement programmes more inclusive to accommodate participants with dementia.
Figure 1 presents a flow chart describing the selection of articles. Out of the 120 articles identified in our initial search in Medline, Embase, CINAHL, and PsycInfo databases, 14 were conference abstracts, 14 were beyond the scope and therefore irrelevant (e.g., articles on postnatal wards, homeless people, non-humans, etc.), and 18 were hospital-based post-disease/ -injury, which resulted in 74 relevant articles from the database search. We added another 12 relevant articles from reference tracking for a total of 86 eligible articles that were appropriate for the next stage of quantitative and qualitative analysis.
3.1 Qualitative Analysis
Based on the collected literature, we divided the conceptual shifts about reablement into the following categories: historical focus (pre-2000); the emergence of ‘restorative care’ for older people (2001–2005); the transition from ‘restorative care’ to ‘reablement’ (2006–2014); and the boom of reablement services (2015–2019).
3.1.1 Historical focus (pre-2000)
Our literature review indicated that the meaning and conceptualisation of ‘reablement’ has changed since the beginning of the 20th century; in practice, it has both run parallel to and deviated from its sister practice, rehabilitation. Notably, after World War II, the emphasis of clinical rehabilitation began to broaden from a patient’s recovery of ambulation to a focus on “the comprehensive restoration of an individual’s physical, mental, emotional, vocational, and social capacities” 10,11. Around the same time, the word ‘reablement’ first entered the scholarly lexicon in an editorial published in Physiotherapy, which was simply titled “Disablement and reablement” 12. The author argued that the word ‘rehabilitation’ must be discarded in favour of ‘reablement’, which should focus on “making a disabled person able-bodied again”, and restoring “a man to capacity for his former work, or, alternatively, what particular work he can be trained for” 12.
The publication of this editorial at the end of World War II suggests that the author’s conceptualisation of reablement was inspired by the need to support and train ‘dis-abled’ patients – most likely injured soldiers returning from the frontlines – in restoring their functional abilities and ‘re-settling’ them both at home and in the workplace. The term ‘reablement’ also started to be used to describe physiotherapeutic training for patients suffering from specific health conditions or diseases, such as cerebral palsy and rheumatoid arthritis 13,14. The first mention of reablement associated with “the heavily handicapped patient” was found in the title of a British journal article on the principles of rehabilitation in 1962 15, and an article from 1975 discussed reablement in relation to functional activities and “resettlement in work and home” 16.
Throughout the 1960s and 1970s, there was a continued emphasis on the restoration of functional ability and “resettlement in work and home” 17,18,19 as well as ‘re-abling’ patients suffering from arthritis and other rheumatic diseases 20. Few scholarly articles published in the 1980s and 1990s mentioned the term ‘reablement’, but a 1994 editorial in Reviews in Clinical Gerontology was the first to mention a focus on older people: “’We are trying to improve this patient's quality of life’ is the often stated goal of much therapeutic effort made for elderly people” 21, continuing that “the criteria for successful rehabilitation are often limited to independence in a limited range of basic activities of daily living. Reablement is most obviously concerned with reducing disability and the appropriate outcomes must be disability measures. ‘Resettlement’ is a more complex goal and implies the restoration of people to their own, or sometimes a new, environment” 21. This article suggests that the term ‘reablement’ was still linked to ‘rehabilitation’ while ‘resettlement’ was understood as a different approach that included a focus on the environmental ‘restoration’ of older people.
3.1.2 The emergence of ‘restorative care’ for older people (2001–2005)
By the turn of the millennium, this idea of ‘resettlement’ and ‘restoration’ as a specific intervention for older people receiving homecare had transitioned into ‘restorative care’. In 2002, Tinetti et al. published what could be considered a landmark paper in the Journal of the American Medical Association (JAMA) titled: “Evaluation of restorative care vs usual care for older adults receiving an acute episode of home care”. The authors suggest that “a primary goal of health care for older, particularly multiply and chronically ill, persons should be to optimize function and comfort rather than solely to treat individual diseases” 22. The restorative-care model that the authors described was based on principles adapted from geriatric medicine, nursing, rehabilitation, and goal attainment, which refers to the belief that people “are more likely to adhere to treatment plans if they are involved in setting goals and in determining the process for meeting these goals” 22.
The intervention included training relevant health professionals (i.e., homecare nurses, therapists, and home health aides) as well as reorganising this home-care staff “from individual care providers into an integrated, coordinated, interdisciplinary team with shared goals”, which required a “reorientation of the focus of the homecare team from primarily treating diseases and ‘taking care of’ patients toward working together to maximize function and comfort” 22. Furthermore, it was built upon “the establishment of goals based on input from the patient, family, and home care staff, and agreement among this group on the process for reaching these goals” 22.
Although the authors cite several studies from the 1990s that focused on goal-setting in clinical medicine for the so-called ‘frail elderly’, this intervention appears to be the first well-defined programme that reflects the central aims of reablement as it is presently being operationalised and implemented worldwide; in other words, while the restorative-care model was not explicitly called ‘reablement’, it contained similar features and aims, and seems to have provided the philosophical foundation for many of today’s reablement programmes. Tinetti et al.’s research also built its findings on the authors’ earlier study, “The design and implementation of a restorative care model for home care” 23 as well as several previous articles that examined older people’s self-care and functionality with regards to performing activities of daily living (ADLs) in both hospital and home settings.
During this period, researchers in the United Kingdom also published a report that described 33 services that were part of the NHS Modernisation Agency’s Changing Workforce Programme project 24. These services were “designed to prevent inappropriate hospital admissions, facilitate hospital discharge, and prevent premature or avoidable admissions to long-term care” 24 – and this included what the authors called ‘reablement services’. The summary of care roles outlines that this service focuses on providing “personal care, daily living skills, mobility and financial management (…); enablement rather than ‘doing’ for their services users; dedicated home workers providing personal care from an enabling perspective with rehabilitation skills; reablement to promote independence” 24.
3.1.3 The transition from ‘restorative care’ to ‘reablement’ (2006–2014)
The foundational aims of ‘restorative care’ services for older people seem to have transitioned to being called ‘reablement’ more broadly in the late-2000s, and our search identified 24 relevant articles from this time period. In the United Kingdom, this transition was reinforced by a retrospective longitudinal study of ‘homecare re-ablement’, “Research into the longer-term effects of reablement services”25, which was undertaken for the Care Services Efficiency Delivery (CSED) Programme at the Department of Health. In the Journal of Integrated Care, it was stated that homecare reablement had been widely accepted in the UK, and referred to “services for people with poor physical or mental health to help them accommodate their illness by learning or re-learning the skills necessary for daily living” 26.
Other British researchers emphasised progress in developing “outcomes-focused services for older people and the factors that help and hinder this” 27. The authors also described two small-scale, exploratory studies that examined the impact of home-care reablement on subsequent service use 28. These articles distinguish ‘reablement’ as its own unique approach, describing it as a service that “aims to help people ‘do things for themselves’, rather than ‘having things done for them’. Home care reablement services therefore provide personal care, help with mobility and other practical tasks for a time-limited period” 28. The authors further stated that user-identified outcomes are central to the reablement process, particularly with regards to personal care, daily living tasks, or social activities. They also pointed out that reablement services can be offered to adults of all ages in the UK, although they suggested that “even very elderly…users may regain skills and attitudes to help sustain them for a relatively long period” 28. The same authors published a prospective longitudinal study and working paper that investigated the longer-term impacts of “home care re-ablement services” 29.
During this time period, a greater focus on professional practice was beginning to develop 30, and a professional column in British Journal of Community Nursing stated that reablement is “generally provided by local authorities as part of adult social care provision with a focus upon promoting self-care skills and rebuilding confidence” 31. Reablement services targeted specifically at older people was also beginning to emerge in northern Europe – particularly, Finland. However, such programmes were termed “geriatric rehabilitation’ 32 and did not take place within the home setting. But, other than this difference, the Finnish intervention had aims similar to other reablement programmes; e.g., the goal was “to achieve and maintain functional independence, and to enable older people to remain community-dwelling” 32.
By 2011, British experts reiterated the burgeoning ‘reablement philosophy’, which states that “the focus is on restoring independent functioning rather than resolving health care issues, and on helping people to do things for themselves rather than the traditional home care approach of doing things for people that they cannot do for themselves” 33. Other researchers claimed that “home-care re-ablement or ‘restorative’ services” should enable older people to live independently in the community, writing that “the assumption underlying re-ablement is that enhancing independence and practical skills reduces needs for ongoing service support” 34. However, there remained a lack of consensus about the definition, organisation, and practices related to the overall concept of reablement. For example, a 2011 Taiwanese article discussed community hospital-based post-acute care (PAC) to improve functional ability amongst frail older patients 35, which appears to be the first time East Asian researchers mention the term.
A 2012 British article – which claimed to be the first in-depth study of the experiences of home-care reablement service users and carers – described reablement as “a short-term, intensive service that helps people to (re-)establish their capacity and confidence in performing basic personal care and domestic tasks at home, thereby reducing needs for longer term help” 36. The authors noted that similar programmes were also being implemented in Australia and New Zealand. In Australia, the term ‘restorative care’ was being used to describe interventions with aims similar to many current reablement programmes. For example, the provision and nature of home-care services had developed a “new focus on activity, independence and successful ageing” and concluded that “a restorative approach to home care has significant advantages over the traditional approach aimed at maintenance and support only” 37. However, the National Development Manager–Care and Communities for Age UK argued that reablement is “nowhere near as effective as it could be” because it lacks personalisation and “fails to appreciate what motivates people to make the substantial effort involved in regaining lost skills and abilities” 38.
By 2013, Australian researchers began to describe restorative home care services as “short-term and aimed at maximizing a person’s ability to live independently. They are multidimensional and often include an exercise program to improve strength, mobility, and balance” and “the intervention should ultimately “create independence, improve self-image and self-esteem, and reduce the level of care required through the delivery of an individualized program” 39. The linguistic transition from ‘restorative care’ to ‘reablement’ in Australia is clearly seen in a study that aimed “to determine whether older individuals who participated in a reablement (restorative) program rather than immediately receiving conventional home care services had a reduced need for ongoing support and lower home care costs” 40. These authors also provided a straightforward definition of reablement in Australia; i.e., “an emphasis on capacity building (…) to maintain or promote a client’s capacity to live as independently as possible, with an aim of improving functional independence, quality of life, and social participation, (…and) an emphasis on a holistic, person-centered approach to care, which promotes clients’ wellness and active participation in decisions about care” 40.
However, it appears that a semantic debate was still occurring in Ireland and the UK. An Irish intervention protocol described ‘reablement’ (in scare-quotes) as “an innovative approach to improving home-care services for older adults in need of care and support or at risk of functional decline” 41, and the authors identified five essential defining criteria for an intervention to be called ‘reablement’: 1. participants must have an identified need for formal care and support, or are at risk of functional decline; 2. the intervention must be time-limited (typically 6–12 weeks) and intensive (e.g., multiple home visits); 3. the intervention must be delivered in the older person’s own home; 4. the intervention must focus on maximising independence; and 5. the intervention must be person-centred and goal-directed 41. A 2013 British article described such programmes as “re-ablement or restorative homecare services that provide time-limited input aimed at reducing dependency in personal activities of daily living, and preventing or delaying the need for further homecare support” 42 while a 2014 Australian paper made the distinction between terminology in the different countries: “Restorative home-care services, or re-ablement home-care services as they are now known in the UK, aim to assist older individuals who are experiencing difficulties in everyday living to optimise their functioning and reduce their need for ongoing home care” 43.
Nearly all of the articles during this time period also cite a growing political interest in cost-savings. For example, although the emphasis in the UK remained on providing services to adults of all ages (not specifically older adults), the white paper, Caring for Our Future: Reforming Care and Support, provided a definition of reablement in which “users receive home-care but are supported to increase their ability to manage tasks independently, in order to reduce the amount of homecare they will require in the longer term” 44, and further distinguished reablement from rehabilitation, stating that reablement services “adopt a social model of recovery rather than a medical model” 44. During this time, there is also increased emphasis on developing professional practice; e.g., a critical literature review analysed evidence on the effectiveness and cost-effectiveness of occupational therapy interventions for older people in social-care services, including rehabilitation and reablement 45.
In Scandinavia, reablement programmes started to be offered in the 2000s; the first was established in Östersund Municipality, Sweden, in 1999 and – inspired by the Swedes’ positive experiences – soon began to develop in neighbouring Denmark (2008) and Norway (2012) under different names. The study protocol for a randomised controlled trial (RCT) of reablement in community-dwelling adults described it as “an approach to improve home-care services for older people needing care or experiencing functional decline. It is a goal-directed and intensive intervention, which takes place in the person’s home and local surroundings with a focus on enhancing performance of everyday activities defined as important by the person” 46. A subsequent Danish article referred to the Nordic concept of ‘help to self-help’, which is based on “ways of providing help that involves the activation of older people, the aim being to enable them to manage as much as possible themselves” 47.
3.1.4 The boom of reablement services (2015–2019)
Our search identified 56 articles from this time period; the majority were published by researchers from Norway (n=19) and the United Kingdom (n=12), and they include both quantitative and qualitative studies conducted in these countries as well as a few collaborative studies conducted by researchers from different countries. There are no articles from Asia, South/Central America, or Russia and only one from continental Europe. If reablement-like programmes have been or are currently being offered in these regions, they are most likely called another name. We have summarised the regional studies and organised these results alphabetically by region in Table 1.
Table 1. Concept of Reablement in Various Geographic Regions between 2015–2019
Region (Country)
|
Concept of reablement between 2015–2019
|
Australasia
(Australia /
New Zealand)
|
- Australian research mentions that ‘reablement’, developed and formalised since the 1990s, has focused on goal-oriented cognitive rehabilitation to improve everyday functioning for people with dementia. Such interventions have been described as a form of reablement (e.g., Cations et al., 2018; Clare et al., 2019a, 2019b; Jeon et al., 2018; Jeon, 2015; Poulos et al., 2017, 2018).
- The book Ageing in Australia included a chapter “Care and Support for Older People” with a section on the more ‘typical’ reablement, defined as “(short-term) services for people with poor physical or mental health to help them accommodate their illness by learning or relearning the skills necessary for daily living”(Jeon and Kendig, 2017: 250). It was discussed as a person-centred service and emphasised the necessity to develop an aged-care workforce of professionals capable to do things with older persons and find optimal ways to engage family carers.
- While restorative home care / reablement services for older adults have been “shown to be effective in reducing functional dependency and increasing functional mobility, confidence in everyday activities, and quality of life” (Lewin et al., 2016: 807), the literature often focuses on support workers and non-health professionals; e.g. to receive better training and improve collaboration (Lewin et al., 2016), to promote health-behaviour change (Lawn et al., 2017a), and to develop the skills to work with complexity in community aged care (Lawn et al., 2017b).
- A trend towards developing better collaboration is evident in a paper about the feasibility of LifeFul, a relationship and reablement-focused “culture change program” in residential aged care (Low et al., 2018). However, the authors stated that one of the main challenges to successfully implementing reablement has been compliance by staff.
- A critical review described reablement as “an emerging global practice model in community- and home-based care for older people” (Doh et al., 2019: 1) and, although it is gaining acceptance worldwide, researchers and policy makers still have questions about what reablement means and how it is used in practice. They found nine essential features, the most predominant being the wish to improve the functionality of clients so they can continue to live in their own homes; the authors concluded that the under-representation of social connectivity for clients was regrettable (Doh et al., 2019: 13).
- A New Zealand paper discussed benchmarking to assist the improvement of service quality in home support services for older people and stated that the country “has developed restorative home support services, very close to what in the United Kingdom are called reablement services, involving elements of goal facilitation, functional and repetitive ADL exercises, support worker training and enhanced supervision, health professional training, care management and comprehensive geriatric assessment” (Jacobs et al., 2018: 113).
|
Continental Europe (Netherlands)
|
- A Dutch study protocol for a randomised controlled trial (RCT) on the effects, costs, and feasibility of the ‘Stay Active at Home’ reablement training programme for homecare professionals described reablement as home-care services that are “goal-oriented, holistic and person-centred taking into account the capabilities and opportunities of older adults” (Metzelthin et al., 2018: 1).
|
North America
(Canada / United States)
|
- · Despite the early implementation of reablement in the United States, our search did not result in any articles from this country during this time period.
- · A Canadian systematic review explored the effectiveness of reablement and factors that contribute to successful implementation (Tessier et al., 2016).
- · Another Canadian systematic review described “the 4R interventions” (reablement, reactivation, rehabilitation, and restorative) with older adults receiving home care to improve “functional abilities, strength, gait speed, social support, loneliness, and the execution of activities of daily living (ADL) and instrumental ADL (IADL)” (Sims-Gould et al., 2017: 653).
|
Scandinavia
(Denmark / Norway / Sweden)
|
- · Although Denmark and Sweden were the earliest adopters of reablement programmes this region, it was typically referred to as “everyday rehabilitation” or “home rehabilitation”. The first Scandinavian paper to use the term ‘reablement’ discussed a Danish pilot study on whether a home-based reablement programme influenced the ADL ability of older adults (Winkel et al., 2015).
- · A Swedish systematic review stated that “re-ablement services are in a period of strong development, but the terms and definitions used remain unclear, and the scientific evidence is still weak” (Pettersson and Iwarsson, 2017: 273).
- · A Swedish study was conducted to illuminate older adults’ perceptions of a multi-professional team’s caring skills as success factors for health support in short‐term goal‐directed reablement (Gustafsson et al., 2019), and concluded that health professionals’ caring skills need to be addressed as an evidence base in the area of homecare for older people.
- A Norwegian RCT on the effectiveness of reablement in home-dwelling older adults (Tuntland et al., 2015) and a study protocol for further investigation of the effects described reablement as “an intensive, multidisciplinary, multicomponent, person-centered, home-based type of rehabilitation, where ordinary activities of daily living are used for rehabilitative purposes” (Langeland et al., 2015: 2).
- A Norwegian study on the validity, interpretability, and feasibility of the Canadian Occupational Performance Measure described reablement as a “time limited, person-centered, and goal directed, delivered by a multidisciplinary team” (Tuntland et al., 2016: 411–12). The authors followed up with a cost-effectiveness analysis alongside an RCT (Kjerstad and Tuntland, 2015).
- The same authors also investigated potential factors that predict an older person’s “occupational performance and satisfaction with that performance at 10 weeks follow-up” (Tuntland et al., 2017), and later conducted a clinical controlled trial in 47 Norwegian municipalities on the health effects of reablement in home-dwelling adults, writing that “reablement is an emerging approach in rehabilitation services, but evidence for its efficacy is rather weak and inconsistent” (Langeland et al., 2019: 1); emphasis added).
- A Norwegian qualitative study explored how an integrated multidisciplinary team experiences participation in reablement (Hjelle et al., 2016), followed by another study on how older adults experienced participation in reablement (Hjelle et al., 2017b).
- Another Norwegian study examined interdisciplinary collaboration (Birkeland et al., 2017), and the same authors also described how relatives in a community setting experienced participation in the reablement process (Hjelle et al., 2017a). They then conducted a qualitative study on interdisciplinary reablement teams’ roles and experiences and described reablement as “a service for home-dwelling older people experiencing a decline in health and function” (Hjelle et al., 2018).
- Other qualitative research described reablement as an intervention “to provide necessary assistance to the client’s own efforts to achieve the best possible functioning coping ability and participation in social life” (Moe et al., 2017: 2), as “an approach that aims to assist older adults, irrespective of diagnosis, to continue with their desired activities – as well as the activities of daily living – and to increase their independence” (Jakobsen and Vik, 2018: 1), and as “an interprofessional, home-based rehabilitation service that aims to enable senior residents to cope with everyday life and to prevent functional impairments” (Moe and Brinchmann, 2018: 113).
- Another study wrote “many welfare states offer reablement, also known as restorative care, as an intervention to promote healthy ageing and support older adults in regaining or maintaining their independence in daily life” (Jokstad et al., 2018: 1).
- The development of professional practice was the focus of a study that presented a cross-sectional descriptive survey of community-working occupational therapists’ involvement in research and development projects (Bonsaksen et al., 2018), which included occupational therapy services and reablement. The authors wrote that “reablement is synonymous to the term ‘restorative care’, which is more commonly used in the USA, and describes home-based, goal-oriented intervention provided by a coordinated multidisciplinary team to home-dwelling elderly with functional decline” (Bonsaksen et al., 2018: 2).
- Another study explored the content of physiotherapists’ supervision of ‘home trainers’ in reablement teams (Eliassen et al., 2018a); the lead author also published a paper that discussed variations in physiotherapy practices across reablement settings (Eliassen et al., 2018b).
- In an article that examined the practice of support personnel supervised by physiotherapists (PTs) in Norwegian reablement services, the authors focused on PTs’ work, writing that “the key characteristics of the [reablement] service are the short‐term and goal‐oriented interventions provided by an interprofessional team” (Eliassen et al., 2019: 2).
|
United Kingdom
(England / Scotland / Wales)
and Ireland
|
- · In discussing a Patient Reported Experience Measure for use by older people in community services, the authors distinguished between social care re-ablement and healthcare hospital-at-home services (Teale and Young, 2015).
- · One British article examined ‘re-ablement’ or ‘restorative homecare’ interventions developed as an alternative to reduce dependency in ADLs in homecare to provide “time-limited, intensive input with the specific and explicit aim of enabling people to become independent in personal care activities wherever possible” (Whitehead et al., 2015: 1065).
- · Another article described reablement as a “new paradigm to increase independence in the home amongst the ageing population” (Bond et al., 2015: 30).
- · A systematic review of the evidence on home-care reablement services “found no studies fulfilling our inclusion criteria that assessed the effectiveness of reablement interventions. We did note the lack of an agreed understanding of the nature of reablement” (Legg et al., 2016: 741).
- · In the UK’s first RCT of occupational therapy in homecare reablement, the authors state that The Care Act 2014 statutory guidance considers reablement to be “an example of prevention and has been identified as one of the ‘top-ten’ prevention services for older adults” (Whitehead et al., 2016: 1), outlining that these services “aim to assist the person to maximise their ability to carry out activities independently with the aim of reducing the amount of paid care worker input required in the long term” (Whitehead et al., 2016: 1).
- · A formal examination of reablement stated that “there is limited evidence regarding the organisation and delivery of reablement services in England” (Mann et al., 2016: 1).
- · One study examined family-inclusive approaches to reablement in mental health, and defined reablement in terms of empowerment and social participation, particularly with regards to maximising users’ independence, choice, and quality of life (Tew et al., 2017).
- · Evaluating three reablement services, researchers found a need for greater investment in research on user engagement (Mayhew et al., 2019).
- · Another article studied goal-orientated cognitive rehabilitation in early-stage Alzheimer’s disease (Clare et al., 2019a); in a subsequent article, the authors stated that “rehabilitation (or reablement) is grounded in a philosophy of enablement reflecting a positive approach to finding solutions and encouraging optimal functioning. This philosophy emphasises a collaborative approach in service delivery, (…and) translates into specific individualised interventions aimed at optimising functioning” (Clare et al., 2019b: 40).
- · In a cost analysis of home care reablement for older people, reablement “actively engages the person in activities of daily living, thus improving their ability to perform those activities, which they might have lost after an episode of illness or other adverse life event” (Bauer et al., 2019: 2).
|
Cross-national studies
|
- A British–Irish systematic review assessed the effects of time‐limited home‐care reablement services for maintaining and improving the functional independence of older adults, and stated that “the reablement approach emphasises the active participation of an older person in working towards agreed goals that are designed to maximise independence and confidence” (Cochrane et al., 2016: 6).
- British, Danish, Norwegian, and Dutch researchers comprehensively reviewed the reablement approach, describing it as “an intensive, time-limited intervention provided in people’s homes or in community settings, often multi- disciplinary in nature, focusing on supporting people to regain skills around daily activities. It is goal-orientated, holistic and person-centred irrespective of diagnosis, age and individual capacities” (Aspinal et al., 2016: 574).
|
3.2 Quantitative Analysis
We created a term map based on text mining the abstracts of the final eligible articles; see Figure 2. Our term map shows the most relevant terms from the abstracts of all 86 final eligible articles. Out of 2,238 terms, 220 met the threshold of five occurrences. Here, we visualised 60% of the most relevant terms, which amounted to 132 terms with 3,315 links between the terms. Each circle represents a term from the various abstracts, and the lines connecting the circles represent the interrelatedness of different terms. The size of the circle represents the number of occurrences of the term. The closer the circles are to each other indicates a high co-occurrence of terms representing a topic. The term map is coloured according to publication year, with dark blue/purple circles indicating terms from the earliest publication in 1947 until 2012 transitioning to teal in year 2013–2014, then turquoise/green in 2015–2017, and thereafter yellow indicating terms from the most recent publications in year 2018–2019.
Based on the number of occurrences of terms emerging in Figure 2, we can see the central concepts that have been emphasised in the literature throughout the years as listed in Table 2. In the earlier papers from 1947 until 2012, the core principles of reablement had already been conceptualised as a form of rehabilitation for hospitalised patients with disabilities and/or a need for homecare and social care services. In 2013–2014, there appears to be a shift of the target group from ‘patients’ to ‘users’. There was also an emphasis on developing specialised staff training that could create an impact by improving cost-effectiveness, and these programmes were offered as an alternative treatment to usual care. In 2015–2017, there appears to be another shift from ‘users’ to ‘participants’, with special attention to their goals and satisfaction with the programmes. This period also underlined the importance of assessing the performance of reablement services, particularly regarding the health professionals’ and carers’ roles, skills, knowledge, and experience (specifically, nurses and occupational therapists). In the most recent publications from 2018–2019, the focus shifted towards how to organise reablement teams and the programme’s overall approach, particularly on improving user involvement and collaboration between healthcare professionals, homecare personnel, and family members. The literature also highlighted an increased interest in making reablement programmes more inclusive to accommodate participants with dementia.
Table 2. Number of Occurrences of Terms Emerging from Figure 2 over Publication Year
1947 - 2012
Dark Blue - Purple
|
2013 - 2014
Teal
|
2015 - 2017
Turquoise - Green
|
2018 - 2019
Yellow
|
Term
|
N
|
Term
|
N
|
Term
|
N
|
Term
|
N
|
home care
|
38
|
cost
|
42
|
participant
|
50
|
dementia
|
25
|
patient
|
38
|
group
|
39
|
goal
|
37
|
health professional
|
14
|
rehabilitation
|
37
|
user
|
32
|
role
|
30
|
reablement team
|
10
|
re ablement
|
23
|
team
|
27
|
performance
|
28
|
home care personnel
|
9
|
re ablement service
|
22
|
impact
|
24
|
skill
|
25
|
kin
|
9
|
social care service
|
22
|
staff
|
18
|
interview
|
24
|
theory
|
9
|
hospital
|
17
|
training
|
18
|
experience
|
21
|
health care professional
|
8
|
part
|
17
|
cost effectiveness
|
17
|
professional
|
18
|
primary outcome
|
8
|
disability
|
15
|
treatment
|
15
|
carer
|
18
|
reablement process
|
8
|
support worker
|
14
|
usual care
|
15
|
occupational therapist
|
17
|
Hts
|
7
|
process
|
13
|
development
|
12
|
satisfaction
|
17
|
reablement approach
|
7
|
social care
|
13
|
function
|
12
|
knowledge
|
15
|
user involvement
|
7
|
ablement
|
10
|
supervision
|
12
|
nurse
|
15
|
family member
|
6
|
Implication
|
9
|
confidence
|
9
|
point
|
15
|
resident
|
6
|
Probability
|
9
|
efficacy
|
9
|
control group
|
14
|
secondary outcome
|
6
|
social care cost
|
9
|
organisation
|
9
|
municipality
|
14
|
stroke
|
6
|
Cent
|
7
|
account
|
7
|
context
|
12
|
everyday functioning
|
5
|
help
|
7
|
article
|
6
|
task
|
12
|
mca
|
5
|
interaction
|
7
|
bed
|
6
|
caregiver
|
11
|
mcas
|
5
|
local authority
|
7
|
inclusion
|
6
|
participation
|
11
|
medication
|
5
|
discharge
|
6
|
question
|
6
|
daily activity
|
10
|
|
|
home care episode
|
6
|
significant difference
|
6
|
intervention group
|
10
|
|
|
homecare re ablement service
|
6
|
total
|
6
|
Norway
|
10
|
|
|
intermediate care
|
6
|
semi
|
5
|
addition
|
9
|
|
|
ablement service
|
5
|
|
|
cognitive rehabilitation
|
9
|
|
|
conventional home care service
|
5
|
|
|
physiotherapist
|
9
|
|
|
end
|
5
|
|
|
risk
|
9
|
|
|
functional status
|
5
|
|
|
COPM
|
8
|
|
|
relative
|
5
|
|
|
everyday activity
|
8
|
|
|
site
|
5
|
|
|
goal attainment
|
8
|
|
|
|
|
|
|
information
|
8
|
|
|
|
|
|
|
interdisciplinary collaboration
|
8
|
|
|
|
|
|
|
theme
|
8
|
|
|
|
|
|
|
way
|
8
|
|
|
|
|
|
|
Canadian occupational performance measure
|
7
|
|
|
|
|
|
|
communication
|
7
|
|
|
|
|
|
|
early stage dementia
|
7
|
|
|
|
|
|
|
government
|
7
|
|
|
|
|
|
|
self
|
7
|
|
|
|
|
|
|
societal cost
|
7
|
|
|
|
|
|
|
conversation
|
6
|
|
|
|
|
|
|
evidence base
|
6
|
|
|
|
|
|
|
focus
|
6
|
|
|
|
|
|
|
functional ability
|
6
|
|
|
|
|
|
|
medicines reablement
|
6
|
|
|
|
|
|
|
pharmacy technician
|
6
|
|
|
|
|
|
|
researcher
|
6
|
|
|
|
|
|
|
sample
|
6
|
|
|
|
|
|
|
bias
|
5
|
|
|
|
|
|
|
consumer
|
5
|
|
|
|
|
|
|
everyday life
|
5
|
|
|
|
|
|
|
focus group discussion
|
5
|
|
|
|
|
|
|
Intention
|
5
|
|
|
|
|
|
|
main theme
|
5
|
|
|
|
|
|
|
Medline
|
5
|
|
|
|
|
|
|
own home
|
5
|
|
|
|
|
|
|
stakeholder
|
5
|
|
|