Abstract
Abstract Background A Reablement Team (RT) was established in a level two hospital for patients who are medically fit for discharge from either Medical Assessment Unit (MAU) or in-patient care, to prevent hospital admission and to support early discharge, through the provision of home rehabilitation. The team consists of senior grade medical social worker, occupational therapist, speech and language therapist, physiotherapist and a rehabilitation assistant. Intensive rehabilitation is provided in the home for up to 6 weeks. This study sought to evaluate service impact and performance in 2022. Methods A mixed method design was employed. Quantitative data was used by analysing number and nature of patients seen, discharge outcomes and pre and post outcome measures to determine goals achieved, quality of life and independence levels. Qualitative data included patient satisfaction questionnaires. Results In 2022, 78 patients were seen, 41 female and 37 male. Mean age of 79 years. Of the total number of patients, 59 (76%) were discharged early from hospital and 19 (24%) avoided hospital admission after attending the MAU. Underlying diagnosis of patients comprised Stroke (n = 29), progressive neurological disorders (n = 11), respiratory disorders (n = 2) orthopaedic/musculoskeletal (n = 13), falls (n = 20), patients medically unwell (n = 3). Of the patients discharged, 86% remained at home (n = 67), while 14% were readmitted. Using pre/post outcome measures, 89% reported an improvement in quality of life as measured by the ICECAP assessment and the mean increase of all patients in independence was 5.4% measured on the modified Barthel index. 91% of patients achieved one or more primary rehabilitation goals. All patients rated service satisfaction as high. Conclusion Findings indicate that a RT service can reduce LOS and prevent unnecessary admissions when intensive rehabilitation is provided by a dedicated team of HSCPs in the home. Additional benefits include reduction of primary care waiting list and integrated home care.
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