Can an occupational therapy intervention increase independence in activities of daily living (ADL) in people who use homecare re-ablement services?

Abstract

Homecare re-ablement services have been widely implemented by local authorities in England, although there are widespread variations in relation to occupational therapy input within them. These services aim to improve users’ ability to manage independently at home and reduce the need for other health and social care services. It is not known whether outcomes are better for people who receive occupational therapy as part of their homecare re-ablement compared with those who do not. This thesis reports a programme of work investigating this, encompassing: a systematic review, a qualitative interview study, and a feasibility randomised controlled trial (RCT) of an occupational therapy intervention targeted at activities of daily living (ADL). For the systematic review, 11 databases were searched and 13 studies were identified comparing interventions to improve performance in ADL with routine homecare. The review found variability in the content of interventions delivered and the measures used for ADL ability. However, there was moderate evidence that the interventions led to improvements in ADL ability, although most effects were not statistically significant. Those interventions involving occupational therapists led to improvements in ADL, but the content of the occupational therapy input varied. Semi-structured qualitative interviews were completed with 12 occupational therapists working in re-ablement services and ten people who had received re-ablement services. Interviews covered experiences and opinions of the service, and were analysed using thematic analysis. Findings were categorised in three themes: (1) Re-ablement: Tasks and Activities (2) Re-ablement: Modalities and Strategies for Delivery, and (3) Facilitators and Barriers. The occupational therapists’ primary focus was delivering graded programmes to improve users’ ability to manage ADL, which they believed they were uniquely placed to provide and tailor to each individual’s needs. People using services valued this graded approach believing that it improved their confidence to manage activities. A feasibility randomised controlled trial (RCT) was conducted in which 30 re-ablement users were randomised to receive either: usual homecare re-ablement without routine OT input (control) (n=15), or usual homecare re-ablement plus a tailored OT programme targeted at ADL (intervention) (n=15). The OT programme was tailored for each participant and included: goal-setting; teaching or practising techniques; equipment and adaptations; and provision of advice or support. Outcomes were: personal and extended ADL; quality of life; falls; and health and social care service use. These were assessed at two-weeks, three and six months post re-ablement. Although there were methodological challenges due to service changes which affected usual care and trial recruitment, it was feasible to enrol and retain participants, deliver the intervention, and collect outcome data which were responsive to change. Participants in both groups showed improvements from baseline, although overall the OT group showed greater improvement; they also used homecare services less frequently and had fewer falls. However, confidence intervals were wide, reflecting the small sample. The intervention was acceptable to participants who particularly valued the tailored advice and support. The principal conclusions were that there is some evidence that interventions targeted at personal activities of daily living can reduce homecare service users’ dependency. Although the content of interventions is variable, those involving occupational therapists appear to be beneficial. Occupational therapists believed that their specialist skills and knowledge in ADL performance were essential facilitators implementing an approach which was suited to each individual’s needs and therefore to successful re-ablement. The RCT was feasible and a further powered definitive study is warranted, subject to methodological alterations. The favourable trends in the OT group indicate the potential benefits in this population group. This is the first RCT of occupational therapy in homecare re-ablement and it is therefore important in the development of the evidence base for this area of practice. A definitive RCT is needed given the widespread national and local government investment, and policy and legislation that continues to underpin the development of homecare re-ablement services