RNIB Research Day 2014 presentations
Vision Rehabilitation Services: Increasing the
Evidence Base
Parvaneh Rabiee, Kate Baxter, Gillian Parker and Sylvia Bernard
Structure of presentation





Background and the rationale for the project
Aims and methods
The key findings
Conclusions
Implications for policy and practice
Background
 A rise in the number of people living longer with long-term
conditions
 Sight loss is most prevalent among older people
 Increasing pressure on health and social care services
 Preventive and rehabilitation services are a high policy priority
for all care settings
 Reduce the number of people entering the care system
 Reduce needs for on-going support
 Growing interest in rehabilitation not a new idea:
 1997: The Audit Commission
 2000 onwards: Significant investment in intermediate care
and reablement services
 2010: DH guidance on eligibility criteria for adult social
care - endorsed by:
 UK Vision Strategy Advisory Group 2013
 Vision 2020 UK 2013
 ADASS guidance 2013
 2013: RNIB - ‘Facing Blindness Alone’ campaign
 2014: Recent DH Care Act guidance
The rationale for the project
 Much of the existing research has focused on low vision
services – not clear
 What community-based rehab services are currently doing
to support people with VI
 What impact they have on people with VI
 What a model of ‘good practice’ might look like
 The study funded by Thomas Pocklington Trust is the first step
towards a future full evaluation study of vision rehabilitation
services
Aims and methods
 To provide an overview of the evidence base for communitybased vision rehab interventions:
 People aged 18 and over
 Rehab interventions funded by LAs in England
 The study involved 4 main research elements:
 A review of literature
 Scoping workshops with people with VI and key
professionals
 A national survey
 Case studies
The literature review
No secure evidence around effectiveness, costs and different
models of community-based vision rehab services – however
some strong messages for:
 The potential for vision rehab to have a positive impact on daily
activities and depression
 High prevalence of depression in people with VI and increased
need for emotional support
 Vision rehab interventions mostly target physical/functional
rather than social and emotional issues
 The cost effectiveness of group-based self-management
programmes
Who provides vision rehab services?
[Slide contains a bar chart showing two bars: All LAs (152) and
Survey respondents (87). Bars show breakdown of:
 In-house
 Contracted out
 Combination
 Joint health/social care
 Social enterprise
 Other
 None
 Not known
Most providers are In-house (62 percent on Survey respondents’
bar), followed by Contracted out with 33 per cent.]
How do teams describe themselves?
[Slide contains bar chart showing how teams describe themselves:
 Specialist sensory impairment
 Specialist vision impairment
 Multi-disciplinary/other
 Generic adult social care
 Specialist physical and sensory
A breakdown of whether they are In-house or Contracted out is
also given for each category. Amongst the Contracted out teams,
most describe themselves as Specialist vision impairment.
Amongst the In-house teams, most describe themselves as
Specialist sensory impairment.]
Background of team managers
[Slide contains a bar chart showing the background of team
managers:
 Generic social worker
 Specialist in vision impairment
 Specialist in sensory impairment
 Occupational therapist
 Other (not vision specialist)
Each background type is further broken down into In-house or
Contracted out. Out of the Contracted out teams, most have
managers that are Specialists in vision impairment. Out of the Inhouse teams, the spread of manager backgrounds is broadly even
across the five categories.]
Accessing vision rehabilitation services
 60 per cent screened by professional with specialist vision
rehab skills
 95 per cent assessed by professional with specialist vision
rehab skills
 25 per cent required FACS assessments
 66 per cent reported a waiting list
 Average waiting time 8-10 weeks
Measuring Impact
[Slide contains a bar chart showing if In-house and Contracted out
teams:
 Measure impact
 Use standard tools
Contracted out teams both measure impact and use standard tools
more than In-house teams.]
Costs and caseloads
 Survey data on budgets poorly reported
 Annual budgets £13,000 to £800,000
 Average budget £221,000
 Annual caseloads 16 to 2000
 Additional data from three case studies
 Annual budgets £238,000 to £336,000
 Annual caseloads 282 to 3322
Case studies
 Who provides the service
 A and B: LA in-house
 C: Contracted out service
 Team delivering vision rehab
 A: Sensory Needs
 B and C: Visual Impairment
 Manager specialism
 A: Social Work
 B and C: Visual Impairment
 Current waiting time:
 A: up to 6 months
 B: up to 2 months
 C: up to 1 month
Key features of vision rehabilitation services
 35-40 per cent of time spent on admin duties – travelling time
varied
 Differences in the way services operated
 Sites A & B restricted activities to one-to-one intervention - Site
C offered a range of group-based activities
 Only one site (C) measured outcome using an evaluation tool
 Limited staff training & networking opportunities - more
opportunities in site C
Staff views on factors impacting on the benefits of
vision rehab support
 Access to specialist knowledge and skills
 Concerns about the loss of specialist input within the team
 Early access to vision rehab interventions
 Late referrals risk care needs intensifying and clients losing
motivation
 A tendency among health professionals to see vision rehab
as the last resort
 The characteristics of people who use vision rehab services
Experiences of people who use vision rehab services
 A long gap between diagnosis and referral - in particular those
with degenerative conditions
 Rehab goals tailored around individual needs
 Support could continue as long as needed - But...
 Waiting list to get additional training - Site B
 Time constraints - Site C
 Progress monitored informally & no follow-up contacts
 Boosted confidence, improved independence. Increased
motivation
 People felt safer
 Greatest benefits related to mobility training, independent living
skills and supply of aids, adaptation and equipment.
 Group-based activities offer great opportunities to socialise and
learn from peers’ experiences
 Positive impacts on families
Perceived limitation of vision rehab support for people
who use services
 Information not always forthcoming and timely
 Concerns about future needs
 Help often offered when it is too late/when people ‘have to have
it’
 Emotional needs not met effectively
 Social activities most often geared towards
older people
Key features of good practice









Staff with specialist knowledge and skills
High quality assessment
Personalised support
Offering a wide range of support
Flexibility to adapt to users’ abilities
Timely intervention
Shared vision among all relevant health and social care staff
Regular follow-up visits
Easy access to information
Conclusion - key messages
 Potential for vision rehab to have a positive impact on the
quality of life for people with VI
 A wide variation of vision rehab provision – measuring
outcomes not a common practice
 Restricting access on the basis of FACS assessment
 Negative impacts of financial cuts
 Lack of recognition of specialist vision rehab skills
 Group-based activities effective but limited
 Main focus is on the physical aspects of life
Implications for policy and practice
 All LAs should follow the recommended practice on FACS
eligibility criteria – timely intervention
 Raising the profile of specialist vision rehabilitation skills
 Safeguarding specialist assessments
 Taking account of individual priorities
 Improved staff training and networking opportunities
 Greater focus on group-based activities
The Care Act 2014 – Implications for Statutory
Visual Impairment Services
Simon Labbett, Rehabilitation Workers’ Professional Network
Main issues
 Visual Impairment Rehabilitation mentioned in law for the first
time
 Opportunities to emphasise role of CVI
 Strong safeguards for Deafblind people
 Eligibility will remain contentious
 Understanding how the sightloss pathway is implemented
locally will be crucial to developing services
Children and Families Act 2014
 The core offer – consider implications for local authority sensory
provision in widest sense (Habilitation and Rehabilitation)
 Transition arrangements will overlap with Care Act
Sight Loss Pathway
[Slide shows routes for accessing services within Sight loss
pathway. ‘Referral’ leads to ‘Screening assessment’, then to one of
three paths:
A: ‘Special assessment’ to ‘Rehabilitation’, then to either ‘No
service’ (terminating there) or ‘Social Care Assessment’. From
there if you are eligible you will go on to receive a ‘Care package’
or get ‘No service’ if you are not eligible.
B: ‘No service’
C: ‘Social Care Assessment’. If you are not eligible you will get ‘No
service’. If you are eligible you will get a ‘Care package’, leading to
‘Rehabilitation’. This leads to another eligibility assessment which
could lead to ‘No service’ or ‘Reduced care package’.]
General Areas of Challenge
 Failure to screening at assessment level (including offering
registration)
 Failure to undertake adequate assessment (including comms.
needs)
 Failure to offer or to provide adequate rehabilitation
 Failure to plan or anticipate future service needs
 Failure to provide information and in accessible formats
Issue: people not getting through screening barrier
Legal: failure to screen (in a way that anticipates
obligations; failure to skill-up staff to recognise need)
 6.23 LAs must ensure that every adult with an appearance of
care and support needs…receives a proportionate
assessment…
 22.18 Upon receipt of the CVI, the LA should make
contact…within two weeks to arrange inclusion on the LA’s
register…Where there is appearance of need for care and
support, LAs must arrange an assessment of their needs…
 (CVI guidance Dept. Health: “purpose of form…if the person is
not known to social services as someone with needs arising
from their VI, registration also acts as a referral for a social care
assessment)
 6.20 LAs should not remove people from the process [of
screening] too early…LAs must ensure that their staff are
sufficiently trained and equipped to make the appropriate
judgements needed to steer individuals towards either
preventative services or a more detailed care and support
assessment.
Implications for entering the system
 Will Local Authorities need to process CVIs differently?
 How will Local Authority “call-centre” staff be trained and what
will be sufficient? – i.e. skilled to identify
a) the “risks of visual impairment” and
b) what rehabilitation is and if it is an option
Issue: not getting specialist assessment/assessed by
specialist
Legal: Deafblind people not receiving specialist
assessment of needs from an expert
 6.77 LAs must ensure that an expert is involved in the
assessment of adults who are deafblind.
 6.78 During an assessment the appearance of both sensory
impairments…must trigger a specialist assessment. This
assessment must be carried out by an assessor or team that
has specific training and expertise relating to individuals who
are deafblind.
 6.36 …LAs must provide information about the assessment
process in an accessible format [i.e. to vi as well as dual
sensory]
Implications for workforce






Implies requirement for good screening
Requires LA to employ expert assessors
Requires LA to devise specialist assessment tool
Should encourage LA to keep deafblind register??
Requires LA to skill-up assessors
Adopt current SENSE guidelines (or will SENSE strengthen
them)?
 Just not enough Deafblind Studies Diploma holders – makes
sense to strengthen Rehab. Worker skills to meet this need.
Current SENSE guidelines on skill level
 Has demonstrable understanding of deafblindness and its
implications …..
 Is currently required to carry out assessments in a specialist
role, either working with dual sensory impairment or with people
who have a single sensory impairment [ie ROVI]
 Has thorough knowledge of all legislation and guidance of
relevance to deafblind people…. [i.e. social care law not just
“section 7”]
 Can communicate with the deafblind person themselves or with
support from an interpreter
Issue: not being offered rehabilitation or early support
Legal: failure to consider and offer any or timely
assistance
 2.38/6.85 LA must consider whether a person would benefit
from… preventative services, facilities or resources.
 6.85 …when doing so the LA may decide to pause the
assessment to provide reablement…This will mean the
determination of eligibility will be similarly paused until after the
anticipated outcome of [rehabilitation]
 2.19 In developing a local approach to prevention, the LA must
take steps to identify and understand both the current and
future demand for preventative support and the supply in terms
of services, facilities and other resources available
Issue: rehabilitation provision is
insufficient/inappropriate
Legal: failure to provide a service that meets need
 2.8 LAs Must provide or arrange services, resources or facilities
that maximise independence for those already with such needs,
for example, interventions such as rehabilitation…
 2.29 LAs should put in place arrangements to identify and
target those individuals who may benefit from particular types of
preventative support [particular types = vi rehab.]
 22.23 LAs should consider securing specialist qualified
rehabilitation and assessment provision...to ensure that the
needs of people with sight impairment are correctly identified
and their independence maximised………..
more on the nature of rehabilitation services
 2.46 The regulations require that intermediate care and
reablement provided up to six weeks, and minor aids and
adaptations provided up to the value of £1,000 must always be
provided free of charge.
 2.48…In some cases, for instance a period of reablement for a
person who has recently become sight-impaired, the support
may be expected to last longer than six weeks…LAs should
consider continuing to provide it free of charge beyond six
weeks…in view of the clear preventative benefits…
 22.23…As aspects of rehabilitation for people with sightimpairment are distinct from other forms of reablement, it
should not be time prescribed. LAs should also refer to the
ADASS position statement of December 2013.
 6.78 [deafblindness] …Training and expertise should in
particular include: communication, one-to-one human contact,
social interaction and wellbeing, support with mobility, assistive
technology and rehabilitation.
Implications for rehab. provision
 It has to be shown to have been considered at assessment
 The LA has to provide a service (by whatever arrangement)
 VI rehab. is mentioned in law for the first time and the guidance
references the adult sightloss pathway and ADASS’ statement
on vi rehabilitation
 Charging: slightly ambiguous, but strong indicators not to
charge for it
 No charging for equipment up to £1,000?
 Duration: time limited but not time prescribed
 Deafblind people: quite specific rehabilitative support identified
in the act
 Workforce planning: LAs need to be demonstrating they
recognise future need and how they will meet Unmet need
(6.24)
 (16.52) Children and Families Act – habilitation service within
core offer = combined services??
Eligibility
 However the criteria are defined, it will be contentious and
demand on budgets will be huge
 Meeting eligibility much more likely with deafblind and people
with LD
 Significant influencing factor will be the technical way the
assessment is undertaken: what questions are asked; how the
questions are asked; how the answers are scored and equate
to a budget. Type of questions are not conducive to getting
sensory needs support
 Focus on outcomes is welcome and makes the role of
rehabilitation within the eligibility process (6.85) all the more
crucial to local authorities and to individuals.
 The inter-disciplinary implications of the above will be easier for
in-house rather and outsourced rehab. Services to achieve?
Conclusions
 The Care Act offers major opportunities to address early
intervention needs of blind, partially sighted and deafblind
people
 The dust is nowhere near settling on the Act, so get in there!
 Shrewd, knowledgeable campaigning will be required to
achieve results
Simon.labbett8@btinternet.com www.rwpn.org.uk
Outcome Measurements in Rehabilitation
Janet Soper – Rehabilitation Officer and Debbie Ross- Business
Development Manager
Aims
 Background information
 Overview of service
 Self directed support planning & outcome
measurements/scoring definitions
 Examples applied to rehabilitation
 Pros & cons of service provision
 Statistics
Re-ablement Project/Service




Commissioned by Hampshire County Council in 2011
Project ran from February 2012 – March 2014
Service commenced April 2014
Current service provision in partnership with deafPlus (South),
Open Sight and Sense for 3 years
Overview of re-ablement service
 Hampshire County Council adult sensory services staff assess
individuals with sensory impairments and prepare a re-ablement
plan for those who meet the current eligibility criteria.
 The support plan outlines the outcomes to be achieved.
 Partnership provides re-ablement services to achieve these
outcomes.
 The service now receives referrals through support plans
completed by sensory and Deaf services staff across
Hampshire.
Support planning










I would like to manage the day to day running of my home
I would like my personal care done in a way that suits me
I would like to find new, or maintain the relationships I have
I would like to take part in activities in my local area
I would like to learn new things or get a job
I would like to feel safe at home and have the right
support/equipment to stay safe
I would like support so that I do not hurt myself or others
I would like to have enough to eat and drink
I would like help to make decisions when I need it
I would like support when I need it
Outcome measurements
Scoring definitions 1-5
 1 = Dependent-needs task completed by someone else
 2 = Needs physical assistance to complete the task (eg food
prep, using LVAs, hearing aids)
 3 = Needs supervision (inc prompting) to complete task (eg food
prep, using LVAs hearing aids)
 4 = Needs only equipment to complete task (eg liquid level
indicator, Bellman’s pager)
 5 = Independent – No support needed
Examples of support plans
Mobility
 Outcome: That I am able to take part in activities in my local
area: Difficulty being able to access the local community safely To advise and offer mobility skills and long cane technique: 10
sessions
Living skills
 Outcome: That I feel safe at home and have the right
support/equipment to stay safe: Difficulty using the cooker hob
and oven – To demonstrate and train in safe techniques using
the cooker, mark cooker controls, train in safe techniques for
making hot drinks: 4 sessions
Further examples
Hearing loss
 Outcome: That I am able to get or maintain the relationships I
already have: Demonstrate amplified phones and loop with
loop pad and follow up to check client is able to use equipment:
2 sessions
Information technology
 Outcome: That I am able to manage the day to day running of
my home life: Would like to learn how to use his computer and
access information and communicate with others: 2 sessions
Procedure for re-ablement service
 SSO refers client to deafPlus for re-ablement with copy of
assessment, referral letter and support plan – plan to include
starting measurement score. Referral forwarded to Open Sight.
 Estimated waiting time sent to referrer and client is contacted by
letter or phone call depending on priority and waiting times
 ROVI contacts clients and starts re-ablement
 After 3rd session ROVI feeds back to SSO regarding client’s
progress
 Upon completion, ROVI sends summary to referrer, detailing
service and equipment provided and outcome score
 Open Sight sends copy of summary and closure letter to client
Pros and cons – Pros




Provides early intervention following sight loss
Assessment is offered much sooner
Service provided is specifically tailored to clients needs
Client has access to non statutory services that they may not
have been previously aware of
 Provider is able to focus on the client’s re-ablement plan,
without the need to complete a detailed assessment
 Re-ablement worker may identify other needs not picked up
during the sensory services assessment (clinic based).
Pros and Cons – Cons
 Service providers find it difficult to determine how many
sessions to request.
 Client may need to wait longer for re-ablement to be started
 Assessment may not have been carried out in the client’s home
and some needs may have been overlooked.
 Delays in getting appropriate equipment supplied
 Variations in procedure according to which area made the
referral
 Referrals not always appropriate
Statistics
Number of referrals received - pilot project
 2012 (Based on closed cases)
1st qtr = 6
2nd qtr = 8
3rd qtr = 10
4th qtr = 15
TOTAL: 39
 2013 (Based on referrals)
1st qtr = 25
2nd qtr = 29
3rd qtr = 37
4th qtr = 39
TOTAL: 130
Number of referrals - re-ablement service
 No of referrals for 1st qtr this year (Apr –Jun 2014)
TOTAL : 24
 No of referrals for 2nd qtr this year (Jul-Sept 2014)
TOTAL : 29
Hours requested




Pilot 1st year – 491
Pilot 2nd year- 658
Service – 1st qtr – 147
Service 2nd qtr - 192
Outcome scores
Based on 16 closed cases
Starting scores
1 -10
2-0
3-5
4-1
5-0
Outcome scores
1–3
2–0
3–0
4–0
5 – 13
Habilitation (Mobility & Independent Living
Skills) research project
What is Habilitation training?
Habilitation training includes: the teaching of early movement
skills; sensory, spatial and body concepts; cane training, route
learning and independent living skills; and can significantly help a
child or young person with a vision impairment to develop the
necessary skills to get around and care for themselves safely and
independently.
What is Habilitation training? cont.
However, habilitation training is not currently available for all
children and young people in the UK.
Guide Dogs and Blind Children UK fervently believe that all
children and young people with sight loss in the UK should have
access to habilitation training that adheres to the Habilitation
Quality Standards as and when they need it – be it, in school, the
home or the community.
Habilitation research
In 2013, we scoped two projects to explore the accessibility and
quality of current habilitation provision for CYPVI in the UK:
 Case studies work: of habilitation provision in local authorities
for each of the four UK countries, and to benchmark the
provision against the Habilitation Quality Standards.
 Survey work: to ask CYPVI and young adults, and parents of
CYPVI what they require[ed] from habilitation training, and to
consult them on their past and present experiences of
habilitation training.
Habilitation research: Case studies
Firstly, we commissioned Dr Clare Thetford and team from the
University of Liverpool to carry out a qualitative exploratory study
in relation to Habilitation services for CYPVI in the UK.
12 detailed case studies were carried out as examples of current
practice across the UK in the provision of habilitation services to
CYPVI aged 0 to 18 years, and benchmarked against the Quality
Standards in the Delivery of Habilitation Training (Quality
Standards) (Miller et al., 2011).
This project was completed in September, 2014.
Habilitation research: Survey work
Secondly, we are currently undertaking an in-house research
project involving CYPVI aged 12 to 25 years, and parents of CPVI
aged 1 year to 18 years.
We wish to obtain CYPVI’ first-hand experiences of habilitation
training; along with the experiences and perspectives of
parents/guardians of CYPVI.
Our project involves CYPVI taking part in a 30 minute telephone
interview or completing an online survey, as well as
parents/guardians completing a separate online survey.
Our project sample is made up of the service users of Blind
Children UK, which amounts to almost 4,000 CYPVI and their
families.
Habilitation research: Case studies
The objectives of this study were to identify and explore:
 (i) notions of quality and what can be achieved when
recommended standards are met;
 (ii) whether and how providers have achieved all or some of the
learning outcomes in the Quality Standards;
 (iii) the problems that CYPVI and their parents continue to face
in accessing habiltation services;
 (iv) issues faced by professionals working in this field in
delivering habilitation services to CYPVI.
Habilitation research: Case studies
Notions of quality and key factors in effective habilitation
services:
 An underlying ethos of holistic service provision, tailored to the
individual and their family.
 Flexible services, provided in a wide range of environments and
during school holidays and outside school hours which
facilitated accessibility.
 Effective communication and a collaborative approach between
the range of professionals involved in the delivery of habilitation,
providing integrated services.
Habilitation research: Case studies
Notions of quality and key factors in effective habilitation
services, cont:
 Positive communication and engagement with parents.
 Staff delivering habilitation were suitablly qualified and
experienced.
In addition to specific features of the services, a range of
contextual factors common to services where service users
reported high levels of satisfaction and service providers reported
comprehensive provision.
Habilitation research: Case studies
The main implications of the findings
There is a lack of clarity surrounding exactly what habilitation is;
whether it is a form of education, or a social service. The lack of
clarity of exactly what it is and who is responsible for delivering its
various components it is at the heart of the problems of
responsibilities for funding and delivery.
The provision of habilitation services within the UK is highly
variable; this variation appears to be due to local level decision
making and models of service delivery.
Habilitation research: Case studies
The main implications of the findings. cont:
Whilst there are examples of excellent practice, CYPVI and their
families continue to experience considerable difficulties accessing
the habilitiation services they believe they need within the UK.
Habilitation research
Research outcomes
 To inform Guide Dogs’ CYPVI service provision.
 To inform the UK Vision Strategy Children’s group.
 To provide some of the evidence for a good practice guidance
document about effective local habilitation provision for CYPVI
and their families. (The National Sensory Impaired Partnership
(NatSIP) and Guide Dogs).