In-reach re-ablement service in care homes

How does the care home re-ablement service work?                          

• Patients are discharged from hospital to a care home. 
• In the care home a HomeLink Healthcare physiotherapist completes an initial assessment. If suitable for re-ablement, an individualised care plan is completed for each patient including planned visits each week. 
• Based on individual patients’ needs, a HomeLink re-ablement support worker visits the patient and supports the care home staff with continuing the re-ablement programme in between visits.
• The patient completes the rehabilitation programme in preparation for returning home. 
• The patient returns to their home when they are ready, and any ongoing support is informed.

Benefits for patients

Whilst in hospitals or care home environments, patients may become deconditioned, leading to them to lose confidence, muscle strength and endurance. These factors combined can lead to an increased risk of falls, poor mobility and increased care needs. By receiving timely regular support that is tailored to individual needs, patients are able to recover and return home more quickly.

Tracking clinical outcomes (EQ-5D-5L) and mBarthel scores enable us to evidence the progression of our patients.

As with all HomeLink Healthcare services the in-reach re-ablement service has seen improved outcomes for patients.

The below percentages indicate self-reported improvements that patients have made on the service:

Wider system benefits

By enabling patients to leave hospital when they no longer meet the criteria to reside, the in-reach re-ablement service helps hospitals to reduce delayed discharges, increase hospital capacity and improve patient flow. Read our in-reach re-ablement case study here.