please note: the video associated with this project has not been published at the request of the Home Care Re-ablement Team

Demographic projections show an increasing demand for adult social care and there is a need to make the best use of existing resources in order to provide support for an increasing number of older people. Responding to this need, the City of Edinburgh Council has redesigned a fifth of its in house home care service to provide a Home Care Re-ablement Service; the first in Scotland to do so. This pioneering service seeks to maximise service user independence, and by reducing the ongoing level of support required, to minimise the whole life cost of care. Implementation was incremental across the city from October 2008 to March 2009. Partnership working is key to Edinburgh’s Re-ablement service and extensive involvement with service users, carers, staff and stakeholders was built in to the redesign process. Health and Social Care teams ensure that a full spectrum of needs can be considered holistically. Each team is made up of a Home Care Re-ablement team co-ordinator, trained care workers, an occupational therapist, a housing support worker and an administration support worker. The specialised teams were recruited from existing staff and trained to work with service users and their unpaid carers around specific personalised goals for up to 6 weeks, in order to learn or re-learn daily living skills, build confidence and maximise independence. Home carers record the service user’s progress on a daily basis. This is then reviewed against the individual’s personalised goals in weekly multi-disciplinary meetings. This approach allows for flexible and timely responses to changes in need and packages of care can be adjusted on a daily or weekly basis. Positive outcomes for service users have been achieved as a result. Since teams use a ‘doing with’ rather than a ‘doing for’ approach, service users’ long-term independence and quality of life are maximised. Self-worth is also enhanced as small successful improvements are closely recorded. For the Council, the impact of Re-ablement has been significant. By actively helping older people to re-gain life skills and maintain as independent a life as possible, the need for ongoing support has been minimised. As a result, there has been an overall reduction in care hours provided and a reduced whole life-cost of care. This ensures that resources can be directed to others in need of support. Furthermore, the integrated approach of Edinburgh’s Re-ablement Service has ensured a high standard for the transition to long-term provision of care at home. This innovative model has already been replicated in other Councils due to its proven benefits and robust implementation procedures.