ATTACHMENT A
Background paper on Wellness and Reablement approaches
to delivering Home and Community Care Services in WA and
Victoria
4 June 2010
WA Department of Health
Victorian Department of Health
Introduction
This paper provides and overview on progress made in translating wellness and
reablement approaches into practice in delivering Home and Community Care
Services in WA and in Victoria.
What are wellness and reablement?
Wellness is a term that describes an approach to community care delivery that
focuses on whole of system support for clients’ independence, by changing the
way that all people involved in service delivery work with people receiving
services.
Reablement refers to short term targeted interventions pitched at tertiary
prevention for people who already have a well established level of frailty or
disability as a result of age, chronic disease or both. General, these interventions
are low intensity and low in cost. In the UK, reablement has been defined as:
‘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.’
Both terms are used to distinguish the approaches they describe from a medical
model of rehabilitation.
Reablement programs tend to be led by allied health professionals, particularly
physiotherapists and occupational therapists but can be delivered by vocationally
qualified workers. They are highly goal focused and time limited. The goals,
however, are not so much clinical goals but goals meaningful to the person/client
that then motivate them to engage. The interventions tend to be functionally
specific programs of exercise, adjusted tasks and physical activity, geared around
the activities of daily living that, over a defined period, will increase the person’s
strength, balance and physical condition, with consequential and collateral
benefits for their ability to continue to perform the activities of daily living without
assistance.
A wellness approach involves redesigning the model of service delivery in
community care, starting from the premise that people who are frail or disabled
as a result of chronic disease or injury, have the capacity to make gains in their
physical, social and emotional well-being and can continue to live autonomously
and independently in the community if positively supported to do so. It involves
reorienting the practice of people involved in service delivery and the
management of services, so that those services can be tailored to respond to
individual needs and goals. More flexible and responsive approaches to service
delivery present challenges to the way service delivery is organised through
service providers.
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It focuses on achieving a more integrated response across different care
settings that delivers a consistent message and expectation of support for
people to continue to be self reliant and autonomous taking account the
realities of their circumstances and disability.
Both reablement and wellness offer potential benefits. If successful, they will
maintain people in a stable and reasonably autonomous state in the
community, containing their need to seek higher cost services through
hospitals and/or residential aged care.
In Australia, they leverage work already underway in other areas of the health
and community care system including primary care, sub acute and acute
services
The purpose is to maximise older people’s capacity to self manage as well as
their physical and psychosocial function with the expectation that this will
reduce their need to use acute services and reduce their call on ongoing
services.
The evidence base
There are two key drivers to this approach: our understanding of the evidence
base of what it is to grow old well and increasing demand.
Evidence for a ‘wellness’ or ‘active approach’ to service delivery
‘Wellness’ refers to a state of optimal physical and mental health, especially when
maintained by proper diet, exercise, and social engagement It is not only
dependent on the actions of a particular individual, but also on the dynamic
relationship between people and the quality of their physical and social
environment (McMurray, 2007). The concept of ‘wellness’ reflects a significant
shift from ‘treatment’ to ‘prevention’ that has gradually occurred in health
provision over the last 50 years.
Even when people are elderly and frail, there is increasing evidence that adopting
strategies for ‘wellness’ can make a positive difference to them (Stuck et al.,
1999; Peel et al., 2005; Seeman & Crimmins, 2001). These strategies can
include exercise (including low level activities such as shopping, cooking and
gardening), using aids and equipment, improving nutrition, developing new ways
of coping to deal with depressed mood or stress. These strategies often result in
an improvement in well-being and morale for the older person and, at least in
some cases, may reduce the number of hospital admissions and subsequently
delay any need for permanent institutionalisation (McWilliam, Diehl-Jones, Jutai,
& Tadrissi, 2000).
In Western Australia, the term ‘wellness’ has been used to describe a different
approach to people using home and community care services. While the emphasis
is mainly on older people the approach is applicable to anyone receiving support.
‘Wellness’ emphasises encouraging independence (in which positive expectations,
opportunities for development and positive experiences motivate improvement).
It moves away from emphasising illness or dependence (in which there is a focus
on difficulties, negative expectations and limited opportunities for development)
(O’Connell, 2006).
Developments in understanding ‘wellness’ are paralleled with more recent shifts
in thinking that emphasise ‘successful ageing’: this focuses on promoting physical
activity and active participation in society to maximise the physical and mental
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well being of people as they age. It contrasts with a view that older adults
disengage and withdraw from activities or society as they age (Buys & Miller,
2006).
The World Health Organisation ‘Active Ageing’ framework (WHO, 2002) has been
developed to overcome key criticisms of previous models. The term ‘active
ageing’ was chosen in order to emphasise the valuable contribution older people
make to their families, communities and society. It is defined as “the process of
optimising opportunities for physical, social and mental well being throughout the
life course, in order to extend healthy life expectancy, productivity and quality of
life in older age (WHO, 2002, p. 12.) It emphasises the value of continued
involvement across six life domains: social, economic, civic, cultural, spiritual and
physical. The WHO definition of active ageing comprises three key pillars:
•
Participation: lifelong learning, paid and unpaid work;
•
Health: achieving and maintaining good physical and mental health in later
life; and,
•
Safety: ensuring the “protection, safety and dignity of older people by
addressing the social, financial and physical security rights and needs of
people as they age”.
There are some similarities between an Active Service Model and the WHO ‘Active
Ageing Framework’; they both aim to keep older adults “engaged in life” for as
long as possible. They both emphasise a focus on the quality of older people’s
lives and their engagement in the community (Wistow, Waddington, & Godfrey,
2003). They are consistent with an ecological approach to wellness, which
suggests that well being comes from family, community and social engagement,
stepping outside ourselves and becoming enmeshed in a web of reciprocal
relationships and interests (McMurray, 2007).
From this perspective,
improvements in a person’s health and functional capacity are necessary but not
sufficient. Measures to (re)connect people into community involvement and
social relationships are essential.
Evidence for the efficacy of reablement programs
Reablement has been the approach used in both the Silver Chain Home
Independence Program and in the United Kingdom Homecare Reablement
Program.
In WA, the Silver Chain experience with its Home Independence Program
demonstrated that it is possible in many cases, to reverse, slow down or prevent
inability to continue to undertake the activities of daily living and that a person’s
capabilities can be maintained, with modest interventions. The Home
Independence Program aimed to develop and test a cost effective model of home
care by designing services that would improve participants’ functional
independence and thus reduce or limit their need for formal services.
Over a six-year period, Silver Chain has trialled two new home care reablementfocussed programs (Home Independence Project (HIP) and Personal Enablement
Program (PEP) aimed at persons aged 65years and over.
The Home Independence Project (HIP) had a specific objective of developing and
testing a more cost-effective model for home care by designing services that
would maintain or improve individuals’ functional independence and thus reduce,
or limit, their need for formal services. It was targeted at clients with low to
medium needs at two points: either when they were first referred to home care or
when they were being re-referred for increased home care services.
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The Personal Enablement Program (PEP) was established on the success of the
HIP project targeting clients being discharged from hospital.
The programs were designed as a short-term intervention (up to 3 months)
directed at “optimising functioning, preventing or delaying further functional
decline, promoting healthy ageing and encouraging self-management of chronic
diseases” (Lewin et al, 2008:15).
The HIP model’s aim of promoting independence was designed both as a means
of reducing an individual’s immediate need for services, and therefore reducing
the demand for services, and as part of a longer term prevention strategy to
assist the individual to maximise their health status and quality of life. It is about
optimising function and promoting successful ageing.
Some
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key features of the programs were:
interdisciplinary team;
comprehensive multi-dimensional assessment;
goal-orientated care planning in partnership with client;
targeted evidenced-based interventions (see below);
minimised face-to-face contact, including telephone support and follow-up;
use of participatory language with clients and families;
recognition of importance of social support aspect of home care services
and supporting clients to develop other avenues to gain this support; and
 use of local resources (Silver Chain, 2007)
Areas of functioning and types of targeted, evidence-based interventions
included:
 promotion of active engagement in activities of daily living (ADLs) and
instrumental activities of daily living (IADLs).
 chronic disease self-management;
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falls prevention strategies;
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improvements or maintenance of skin integrity; and
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medications, continence and nutrition management.
Benefits for people participating in these programs included:
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Improving their ability to self care and to perform everyday activities of
daily living
Minimising their need for ongoing home care services
Reducing the likelihood that they will fall and injure themselves
Increasing their "healthy ageing" behaviours
Increased feelings of independence, autonomy and self efficacy
Increasing involvement in the management of their health and abilities
Avoiding hospital admission for reasons directly addressed by this
program,
for
example,
falls,
medication
or
chronic
disease
mismanagement
As part of its research, in 2002-04 Silver Chain conducted a randomised
controlled trial of HIP. Some of the key findings were that:
 the HIP group demonstrated better ADLs, better mobility, reduced falls
and higher morale;
 clients receiving HIP made it 15 times more likely that a client at three
months would no longer be receiving assistance, and at 12 months, seven
times more likely not to be needing ongoing services.(Lewin and
Vandermeulen, 2006b).
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In 2008, Lewin et al produced a peer-reviewed paper in Geriaction outlining the
findings from a pilot and an operational trial of HIP (these were in addition to the
controlled trial above).
The purpose of the pilot was to test the program’s effectiveness in increasing
participants ’independence (i.e. increased functionality and reduced need for
services) and identifying any refinements required to the program. The program
was found to be effective in both areas, with demonstrated gains in functioning of
41 clients who completed the program: 71% had less difficulty performing IADLs,
33% no longer needed ongoing services and 39% needed a lower level of service.
In the UK, Homecare Reablement is now offered by 148 of 152 Councils, which
have responsibility for community or social care. The program, similar to the HIP
run by Silver Chain, targets people at the point of entry to social care and
provides time limited (up to 2 months) programs of rehabilitation in the person’s
home. Evaluations have shown that the reablement programs resulted in a
reduction in the need for ongoing care packages compared with care as usual. A
recently published retrospective longitudinal study found that 53-68% of people
left reablement requiring no immediate home care package. Of that group, 3648% continued to require no formal assistance 2 years later. 34-54% had
maintained or reduced their levels of assistance 2 years after reablement.
In New Zealand, the Restorative Home Support program is based on care
management, comprehensive assessment, and functional and repetitive ADL
training. A key concept of the service is to base a support program on the goals
and aspirations of the older person. The model relies on a multidisciplinary team
(primarily registered nurse, physiotherapist and occupational therapist) providing
an in depth support plan delivered by trained support workers or therapy aides
under the supervision of the team.
Analysis revealed a reduction in mortality, in comparison to usual care; an
apparent reduction in risk of entry to residential care in comparison with usual
care; no rise in carer stress in the intervention groups, despite people with
complex needs continuing to live at home and an improvement in functional
capacity of older adults.
What has been done in WA?
Following the success of the Home Independence Program pilot study, the WA
Department of Health, via the Home and Community Care (HACC) Program
funded Silver Chain to undertake a two year operational trial. The trial involved
418 participants14 and was again implemented by the same multidisciplinary
team of allied health professionals that implemented the pilot.
The key outcome measure for the trial was whether clients required ongoing
home care services immediately after completing the program, and when
assessed again after one year. At service end, 70% of clients no longer needed
ongoing home care services and 7% of clients needed a lower level of service
than at referral. One year later, 62% of those clients who had ceased services
were still not using any home support services (Lewin et al, 2008).
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The Wellness Approach to Community Home Care
In March 2006, the WA HACC Program adopted a wellness approach as its policy
position for the future delivery of HACC services across the state.
From 2008/09 all growth applications from HACC-funded agencies needed to
reflect a wellness approach in their service delivery models.
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Wellness is a new organisational approach to HACC service delivery and requires
organisational and attitudinal change (O’Connell, 2008, podcast).
Wellness can be seen as the foundation stone of implementing a reablement
program and whilst it is possible to take a wellness approach and not implement
a reablement program it would be very difficult to implement a reablement
program without also undertaking the accompanying organisational change
towards a ‘wellness’ approach.
Essentially a Wellness Approach is a shift away from a dependency model of care
and support predominate in the HACC sector to one that enables an individual
receiving a HACC service to build on their capacity by working with their abilities
as opposed to their disabilities. Thereby supporting them to continue to do as
much as appropriate for themselves.
Currently the majority of services provided by HACC can be described as utilising
a dependency model, in other words they provide services mainly to support or
maintain an individual at an appropriate level.
Services, including prepared meals, domestic care, personal care and social
support are often provided in a standardised way to all eligible clients, and
typically act as a substitute for client’s participation in caring for themselves.
Emerging research over the last 10 years suggests that this way of delivering
support, which is largely passive, with too much emphasis on task completion and
doing as much as possible for a client may work against improving functional
status and promoting independence.
Refocussing of the current community care service model towards
wellness/capacity building approach is one of many initiatives for WA Health.
a
The Wellness Approach also fits within the broader policy direction of The Model
of Care for the Older Person developed by the WA Aged Care Network in response
to initiatives undertaken by WA Health Networks.
2 (a) Key principles and components driving the approach
The Wellness Approach is an initiative which explicitly focuses on building client
capacity. HACC ‘clients’ in this context include both service recipients and their
carers.
The core components of the Approach are:
 Capacity building and social connectedness to maintain or promote a client’s
capacity to live as independently as possible with or without HACC support
 A strength based holistic assessment and approach to support that promotes
clients’ wellness and active participation in goal setting and decisions about
their support needs
 Support and planning that can respond to people’s goals and are capable of
maximising the client’s independence.
 Support focussed on functional and social goals with a focus on community
connections
 Collaborative partnerships between individuals and providers; and, between
providers for the benefit of clients
 Time limited support as appropriate
 Planned review process and changes to support plans to accommodate
progress, including ongoing appropriateness of service
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To support this process of change, WA HACC and CommunityWest Inc., a not forprofit organisation, began a partnership initiative in 2006 to develop the model
and resources to support the philosophical and cultural change across the
Program.
As a result of this partnership, CommunityWest has:
 developed an Information Booklet – Wellness Approach to Community
Home Care;
 developed Equipment & Resource Guide
 developed Client Case study examples
 developed a DVD – The Wellness Approach in WA
 developed change management and other materials to support
organisations to commence a change process developed documentation
for assessment and care planning;
 conducted training workshops for HACC agencies to assist them to adopt
this new approach and
 made various presentations on the wellness approach; including The HACC
National Forum, held in Melbourne in February 2008, which brought
together over 400 key stakeholders to explore the evidence base and
implications for more thoroughly adopting a wellness, capacity building
and restorative care approach to HACC service provision
A small team of experienced community care professionals work directly with
organisations using the materials developed to support organisations through the
change process.
The teams work with providers cross a broad spectrum of resource development,
consultations and partnerships, marketing, change management facilitation and
quality improvement.
Key Features
Through this work CommunityWest identified some key features/strategies that
have assisted agencies to implement a wellness approach. They can be
categorised into two broad areas, organisational and service delivery, which have
the following features:
Organisational
 changing the mind set of all stakeholders, i.e. management, staff, volunteers
clients and their families, about the views they hold in relation to the capacity
of older people and people with disabilities to improve in their functioning;
 building staff awareness, skills and confidence to promote the wellness
approach;
 undertaking staff training in the principles of the wellness approach and how
to undertake assessments and develop client support plans using the
approach. “Time spent at beginning, working with staff to gain confidence in
new skills is well spent” (CommunityWest, 2008).
Service Delivery
 looking at the reason behind the request for assistance or change in
support instead of just providing services or increasing services;
 undertaking ability-based assessments and support plans;
 undertaking goal planning in partnership with client;
 undertaking time-limited interventions and services;
 client and carer education in principles of optimising function and wellbeing;
 regular reviews and changes to support plans to accommodate progress,
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including looking at the appropriateness of continuing service;
an emphasis on social networks and community connections to link clients
back to their communities; and
at the end of service, looking at the appropriateness of connecting clients
with mainstream community programs /services.
2 (b) Evaluation
In 2008 a small evaluation (25 Providers) of the Wellness Approach was
conducted by independent researchers from Edith Cowan University. The purpose
of the evaluation was to ascertain the process of change to date with regard to
knowledge, attitudes and beliefs about Wellness, organisations commitment to
the approach, and organisational impacts of the implementation of the approach.
The evaluation findings suggested that West Australian HACC agencies associate
Wellness with the concept of maximising client independence and believed it
provided a sound philosophical basis for service delivery.
HACC agencies that had made progress with the implementation of Wellness
generally cited multiple benefits of the change process, including increased staff
satisfaction, client and carer benefits, and greater equity in service delivery.
2 (c) WA Assessment Framework 2009
In 2009 The WA HACC Program developed an Assessment Framework document
that provides a broad outline of the redesign of HACC services to support the
streamlining of access, information, eligibility screening and face to face
assessment for people needing support to remain living independently in the
community.
The overall goal of the Assessment Framework is to develop, support and build on
best practice that builds formal linkages between all key community care service
providers to effectively manage client pathways, provide appropriately targeted
service responses and refocus service delivery towards an approach that supports
the implementation of the philosophy of Wellness to maintain and improve client
independence wherever possible.
The framework will be implemented in the metropolitan area from 1 January
2011.
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Where is WA now
To date over 80% of HACC providers in West Australia have commenced
organisational changes towards implementing a Wellness Approach. The
evaluation found that among the forces for progress with implementation was a
clearly expressed view by most organisations that Wellness was the best
philosophy for services and that sound progress was being made with
implementation,
The WA Assessment Framework amongst other reforms in WA will support the
bedding down of the approach as Access to community care is streamlined,
assessment practices become more consistent and support is delivered
consistently in a manner that focuses on building the client’s capacity and
enabling them to remain at their optimal level of independence.
What has been done in Victoria?
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The Victorian HACC Active Service Model (ASM) is characterised as a quality
improvement initiative that explicitly focuses on promoting capacity building and
restorative care in community care service delivery. It has taken as its point of
departure the work on wellness undertaken in WA with some elements of
reablement programs in the UK and NZ.
The Victorian HACC Active Service Model is based on the premise that all clients
have the potential to make gains in their wellbeing and that Home and
Community Care services can support improvement. Our approach is to
strengthen good practice and build capability through quality improvement.
The goal of the Active Service Model is for people in the HACC target group to live
in the community as independently and autonomously as possible. In this
context, independence refers to the capacity of people to manage the day to day
activities of their daily life. Autonomy refers to making decisions about one’s life.
Not all HACC clients will be able to live independently and autonomously, but the
goal of this initiative is to ensure that clients are able to gain the greatest level of
independence they can and want to achieve, and equally, that they can be as
actively involved in making decisions about their life as they can and want to be –
such as the type of services they receive and the goals they wish to achieve.
The principles underpinning the Active Service Model are that:
 people wish to remain autonomous
 people have the potential to improve their capacity
 people’s needs should be viewed in an holistic way
 HACC services should be organised around the person and his or her
carer, that is, the person should not be simply slotted into existing
services, and
 a person’s needs are best met where there are strong partnerships and
collaborative working relationships between the person; their carers and
family; support workers and between service providers.
From a service delivery perspective core components are:
 promoting a ‘wellness’ or ‘active ageing’ approach that emphasises optimal
physical and mental health of older people and younger people with
disabilities and
 acknowledging the importance of social connections to maintain wellness
 an holistic and family-centred approach to care that promotes wellness
 actively involving clients in setting goals and making decisions about their
care and
 providing timely and flexible services that support people to reach their
goals.
Projects to test approach in practice – results of evaluations
Victoria has undertaken a broad range of developmental work and pilot projects
over the past three years relevant to this approach.
A major focus has been strengthening assessment as good quality home based
assessment and care planning are key enablers for the ASM approach. The
Victorian Assessment Framework foreshadowed this and its implantation has now
been integrated with the ASM. Strategies have included:
 strengthening working relationships between HACC Assessment Services and
Allied Health through:
o Co-locating allied health staff with assessment staff
o Developing joint training opportunities
o Promoting opportunities for joint assessment, secondary consultation
and case conferencing
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Developing a range of partnership protocols and practices within local service
systems to enhance practice.
Strengthening the understanding of practice through the development of a
HACC Assessment Practice guide that helps to put approach into operation.
Other areas of pilot project focus have included:
Developing models of home care that better support clients to do things for
themselves
Exploring how low maintenance gardens can contribute to greater
independence for clients
Providing social support options from a perspective that enhances nutrition,
physical activity and emotional well being
Focussing district nursing on how clinical services can adapt to this approach,
with a particular focus on continence
Building partnerships and alliances between providers to support the approach
Implementation steps
Victoria is approaching the implementation of the ASM as a longer term quality
improvement strategy building on existing strengths of the system. It is a major
change management project.
Victoria released an ASM implementation plan in February 2010. This set out a
range of strategies and tasks to support implementation until the end of the
current HACC triennium in 30 June 2010. The first task for HACC funded
agencies is to assess their strengths and weaknesses in taking an ASM approach
and develop an initial implementation plan for change. The Victorian Department
of Health is developing a range of resources to assist them in this process
including the development of a practice review tool to use within their agencies.
Regional Industry Consultants have been established to provide capacity building
support to organisations and Regional staff in implementing the approach.
Planning and development is coordinated with a range of other related initiatives
being put into place such as implementation of the Victorian HACC Assessment
Framework, the Diversity Planning Framework and a major review of social
support and respite services. The direction is also consistent with other measures
taken in other related settings such as chronic disease management and disability
services.
Next steps
Victoria is now considering ways of mobilising resources in the HACC program to
enable a targeted reablement focus within the broader context of a wellness or
active service model approach to service provision.
We are also developing an evaluation framework, based on the HACC MDS and
incorporating other measures to track the impact of the change.
Lessons from this experience
Key learnings from HACC agencies in WA that have begun implementing a
wellness approach can be categorised under organisational, staff and clients:
Organisational
 wellness is a philosophical change and needs to be part of an agency’s
overall vision and approach to service delivery (ie organisational culture
needs to support this way of working and put structures in place to ensure
change takes place at all staffing levels;
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Staff
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the receptive context is important, it needs senior management to be key
drivers; there needs to be a ‘can do’ organisational culture; and a history
of successful change;
good communication is critical; there must be both early and ongoing
consistent messaging and dissemination of information to all stakeholders;
there should be a steering group, led by a Senior Manager and including a
cross-section of staff, which has decision-making powers and oversees
implementation;
policies and procedures need to support this new way of working (ie
referral processes, reviews and staff feedback mechanisms; and
a strategy for staff education and training in the approach and how to
implement it needs to be developed.
having the support of home care coordinators/supervisors is critical in
persuading support workers of the merits of the approach.
Service Delivery approach
 staged implementation is important to allow for development and testing;
 mapping the processes and having action items helps the implementation
process; and
 it is easier to implement a wellness approach with new HACC clients but it
is also possible to implement with existing HACC clients but the changes
need to be implemented more slowly. (CommunityWest, 2008).
Findings from work to date in Victoria have been:
 the majority of clients involved in pilots have embraced the concept and made
good progress through the approach.
 Identifying and harnessing the motivation of clients is crucial in moving to this
approach and goal setting that is meaningful to clients as part of the
assessment process generates client motivation.
 There are no clear indicators, based on the evidence available that this
approach is only good for a particular target group and evidence that this
approach can benefit all recipients of community care services. It is more
difficult to engage people who are already in receipt of community care
services so the approach taken is to work with new clients to a service to
enable more positive expectations to be set from the start of service
engagement.
 For many staff, this approach represents a major philosophical shift and
challenges traditional habits and assumptions about how they work and make
decisions. Although some staff find this challenging, Victoria’s work to date
and overseas experience find that most are enthused by the philosophy and
find increased job satisfaction through the approach.
 The nature of successful change requires a whole of organisation engagement,
with managers playing a crucial role. For implementation to be sustained,
each organisation needs to review its systems and supports, across the
clients experience of the service
Conclusions
The implementation of the Wellness Approach in WA and the Active Service Model
in Victoria is based on the premise that clients have the potential to make gains
in their wellbeing and that the range of HACC services can facilitate this.
The approach supports the core aims of the HACC Program but also offers a way
of building on the Program’s intent of enabling people to maintain or maximise
their independence.
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Targeted enablement programmes combined with a sector wide philosophical
change towards a Wellness Approach or Active Service Model, can deliver the
core aims of the HACC program by more effectively meeting the needs of future
clients and carers.
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