Embracing the reablement approach as a model of restorative care for the elderly

The world population is aging rapidly, and this phenomenon continues to pose a signifi cant challenge to the socio-economic feasibility of increased life expectancy [1,2]. The Ageing situation in Organization for Economic Co-operation and Development (OECD) countries has given rise to a position where healthcare spending already surpasses gross domestic product (GDP). Without urgent and necessary action, it will increase from 6 percent in 2010 to 14 percent of GDP in 2060 [3]. Couple with a population that is aging fast is the challenge in the reduction in healthcare personnel that is both shrinking and aging amidst the increasing demand for healthcare services [4,5]. In the USA, majority of older adults population continue to reside at home despite deteriorating health, and the situation is also similar in Europe [6]. Customarily, in the management of the elderly over the years, health and social care have always focused on critical and recurrent conditions while little emphasis is placed on strategies for early detection or prevention of old age-related health challenges [5]. Thus, it becomes imperative for a new approach encompassing both health and social care to be developed in the management of the frail and older adults. Adopting a model where the innate abilities and the immediate surroundings the older people reside allow for healthcare delivery to be directed toward goals and targets that are most important for older people to live a meaningful life becomes essential [7]. Therefore, it is sacrosanct for healthcare personnel to embrace an approach that focuses on older people’s intrinsic capacities to control, adjust, and sustain independence [8]. To this end, some highincome countries worldwide have developed their homecare programs by instituting reablment to benefi t communitydwelling older adults, an approach that emphasizes maximizing independence [9].


Introduction
The world population is aging rapidly, and this phenomenon continues to pose a signifi cant challenge to the socio-economic feasibility of increased life expectancy [1,2]. The Ageing situation in Organization for Economic Co-operation and Development (OECD) countries has given rise to a position where healthcare spending already surpasses gross domestic product (GDP). Without urgent and necessary action, it will increase from 6 percent in 2010 to 14 percent of GDP in 2060 [3]. Couple with a population that is aging fast is the challenge in the reduction in healthcare personnel that is both shrinking and aging amidst the increasing demand for healthcare services [4,5]. In the USA, majority of older adults population continue to reside at home despite deteriorating health, and the situation is also similar in Europe [6]. Customarily, in the management of the elderly over the years, health and social care have always focused on critical and recurrent conditions while little emphasis is placed on strategies for early detection or prevention of old age-related health challenges [5]. Thus, it becomes imperative for a new approach encompassing both health and social care to be developed in the management of the frail and older adults. Adopting a model where the innate abilities and the immediate surroundings the older people reside allow for healthcare delivery to be directed toward goals and targets that are most important for older people to live a meaningful life becomes essential [7]. Therefore, it is sacrosanct for healthcare personnel to embrace an approach that focuses on older people's intrinsic capacities to control, adjust, and sustain independence [8]. To this end, some highincome countries worldwide have developed their homecare programs by instituting reablment to benefi t communitydwelling older adults, an approach that emphasizes maximizing independence [9]. Ageing (IFA) Global Think Tank and Copenhagen Summit 2015/2016, one of the major highlights of this event was its defi nition given to reablement [11]. At this event, the term reablement was defi ned as "an active process of (re)gaining skills and confi dence in maintaining or improving function or adapting to the consequences of declining function. It also supports the individual to remain socially engaged within the community context in a safe, culturally sensitive and adaptable way" [11]. This meaning seems to be direct enough; it is still not universally accepted, as some experts claimed reablement conception is still very new and currently it is yet to be regulated (even though it has been in practice for over two decades in many OECD countries); to this end, this defi nition is being considered to be imperfect as the knowledge of the outcome is inadequate when it has been achieved [2,5].
Moreover, signifi cant differences exist in the reablement approach across jurisdictions and contexts [8]. Consequently, a Delphi study by Metzelthin, et al. [5] was carried out to establish a universally acceptable defi nition for reablement, which at the same time address other issues like its features, constituents, goals, and potential users [5]. They defi ne reablement as an individual-focused, comprehensive approach that expects to improve a person's physical level and/or other functional activities to promote and enhance independence in executing daily living activities, thereby reducing their dependence on long term care and other support services. The study further stated that reablement comprises numerous visits carried out by a prepared and well-coordinated interdisciplinary group. It incorporates a thorough evaluation and re-evaluation with a primary objective of achieving a positive outcome through an organized plan or approach. Reablement approach helps individuals acquire their desires, which are made relevant through participation in daily living activities, and use of assistive devices, and involvement in social interaction in the community [5].
With the world facing the challenge of an aging population with an associated prevalence increase in age-related disabilities, the conception of 'reablment' that promotes independence in older adults by optimizing their intrinsic functional abilities is becoming more popular [12]. The central goal in reablement is to functionally improve older adults' abilities regarding the challenges they face in their activities of daily living in the community by implementing rehabilitative care, which has before now being missing in residential care services [13]. The increasing expenditure on long-term care for senior citizens, couple with the intent to promote successful aging, had made policymakers (government inclusive) embrace the concept of reablement [7,8].
It is a time-bound approach that helps older people return to the capacity to independently perform activities of daily living such as grooming, eating, and ambulating on their own, rather than having a caregiver performing it for them [14]. It is quite different from traditional home care services, which sought to promote dependency when there is a loss of function and is equally not time-bound [15,16]. According to Christopher, et al. [12], a well-structured reablement approach should have four primary attributes: It should be individually tailored and goal-focused, taking into cognizance factors like social-psychological and surrounding attributes, and collaborating with the affected individual and sometimes with caregivers as the case may be.
Goal settings should encompass functional, cognitive, somatic, behavioral, and communicative abilities.
Targets are to be set following a detailed analysis of individual potentials to ensure an outcome that is viable, positive, benefi cial, and relevant.
Approaches that are driven by empirical evidence that guarantees that affected persons actively engaged in the pursuit of set-out goals are adopted.
Two main reasons have been attributed to referrals for reablemet: to facilitate the transition of a client from an acute care facility such as a hospital back to home; and to improve independence for community-dwelling adults to reduce dependence on support services from caregivers (UK department of health, 2015). Its bedrock is how to maximize disease management [12] and not how to resolve health conditions [17].
As many empirical studies have found out, the concept of reablement is essential for partakers. It reassures them and boosts their innate capacity in their approach towards daily living activities and engagement in the community. However, few recent studies have confl icted with this claim that the effi cacy of reablement on human well-being is still unclear [13].

Approaches across countries
The approach of reablement is related to strategies that emphasize 'functional' and 'restorative' management [5]. As stated by Aspinal et al. [8], it is an empowering approach that focuses on helping the senior citizens to optimize their ability in coping with activities of daily living and other challenges without depending on others [8]. Critically examining reablement among practicing countries will aid in deepening the principle behind the approach while further adding weight to its integrity and effi cacy. However, there are little data comparing it among countries. In Europe and the continent of Australia where it is been practiced, reablement takes place majorly as a homecare service. In contrast, its conception in the USA has its root in facilities that render long-term care [5].
Reablement is increasingly gaining recognition and popularity as policymakers in some countries have already integrated it into their national healthcare policy. This assertion is right in the UK [18,19], New Zealand [20,21], Australia [22,23]. The increasing acceptability of reablement has been linked to the rising needs of the rapidly aging population in demand for standard home care services and individually tailored healthcare [24].

Evidence of its effectiveness
Despite being a new approach that is just gaining popularity and acceptability in many countries, reasonable studies support DOI: http://dx.doi.org/10.17352/aggr.000027 reablement effi cacy, particularly in Health-Related Quality of Life (HRQoL) and service implementation [8,9]. The fi rst study to explore the effi cacy of reablement was conducted by Tinetti et al. when they compare restorative care with traditional home care practices, and the fi ndings revealed that at discharge, participants in restorative care show more improvement in Activities of Daily Living (ADL) and mobility than the other group [25]. A retrospective study conducted by Newbronner et al. in the UK to examine the long term impacts of reablement found out that before two years or after, more than one-third of participants in reablemet did not need other home care assistance (Newbronner et al. 2013). In another retrospective study conducted in Australia over fi ve years by Lewin, et al.
they found out that individuals participating in reablement are less likely to use any other home care intervention for the next three years and health carer for the next fi ve years when compare to those receiving services in traditional home care model. They further stated that a participant in reablement is averagely able to have a savings of AU $12,500 in a period of fi ve years of participation compared to those receiving services in the traditional homecare [10]. In New Zealand, a cluster-randomized trial found out that more participants in the reablment group have lesser healthcare services needs than the controlled group [20].
Although some studies have questioned the effi cacy of reablement, stating that there is little evidence to suggest improvement in the domain of ADL [26]. Aspinal, et al. [8], however, indicated that obtainable proof on the effi cacy of reablement is limited to four results; result for participants, results for those rendering the service, result for the service usage, and how economical the approach is [8]. Furthermore, like some other studies [15,27] they also corroborated the existing unresolved arguments as regards how it can infl uence participant performance aside ADL, reduction in long term care support, and reduction in fi nancial implication when compare to traditional home care, mode of operation and practice, duration of approach and the class of individuals that will benefi t more from this approach.

Interdisciplinary approach in reablement
An integral part of reablement is the interdisciplinary work that is embedded in it [28]. An interdisciplinary team has been defi ned as an assembly of professional workers functioning together in the same order to actualize common targets [13].
In the healthcare sector, it is increasingly being popularized as an approach to tackle some of the system's challenges to reduce expenditure, advance the standard of care, strengthen the workforce, and to ensure job fulfi llment [29]. This system enables team members to share ideas and views in reaching an approach to adopt in addressing health issues to actualize favorable results (Castro, et al. 1986). Customarily, the practice of interprofessional collaboration has been fl awed with superiority and assertiveness rather than cooperation and accountability [13]. Three essentials components are essential for effective interprofessional teamwork: freedom, communication, and equal opportunities [30]. Communication has been described as the connection among group members that allow for an interprofessional approach [31]. In interprofessional collaboration, members need to trust each other with respect for each other professional inputs and contributions.
In a broader perspective of teamwork, terms such as interdisciplinary, transdisciplinary, and multidisciplinary have synonymously been used, with the latter most frequently used in place of interprofessional collaboration. Birkland et al. defi ne multidisciplinary as a system where the various professionals carry out their roles autonomously but sharing details [13].
An essential part of the daily rehabilitation program is interprofessional cooperation [32]. Moe and Brataas argued that for rehabilitation services that focus on the elderly population residing at home to be effective, the model should be interdisciplinary that encourage community-dwelling and promote independence [33]. Although evidence-based studies into interprofessional collaboration in reablement are limited, it is known that reablement is a highly collaborative rehabilitative care, and it is a new interdisciplinary approach for people residing at home. Hjelle et al.'s study emphasizes the benefi t of sharing information and ideas among professional team members participating in reablement [29]. Another trend of teamwork in reablement is matters that deal with professional boundaries of the various health caregivers involved in the process and the relationship amidst them. It is vital for the reablement team to promote fairness and acknowledge efforts to have an effective multidisciplinary team [33]. There should be respect among the health professionals and health personnel involves in the reablement process. As stated by Hjelle et al., it's essential for all members of the group to have a say in the team [34].
Various studies have highlighted the roles of the different professional groups that function in reablement.
The multidisciplinary team members are often made up of physiotherapists, occupational therapists, nurses, and home trainers. Each profession performs particular tasks by virtue of their practice [31]. In one specifi c study conducted by Hjelle et al., one of their fi ndings revealed that the team's unifi cation and bond in the reablement process are driven by the client's goals [28].
It is critical to know that both physiotherapists and occupational therapists who played a supervising role in the reablement process often have overlapping areas in practice and sometimes differences in their interventions [35]. However, physiotherapists are involved over a more extended period in the reablement process when compared to occupational therapists.

Physiotherapy in reablement
Physiotherapists play critical roles in reablement. Their responsibility has been summarized to include but not limited to; assessing participants' functional level and goals, planning the reablement approach and overseeing home trainers' activities [33,36]. The reablement approach which is aimed towards enabling users to be independent in their activities of daily living as it focus on participants own goals. Intervention by physiotherapists in the reablement process center around physical exercises and guidance in daily activities. Physiotherapy practices in reablement are guided by an evidence-based approach, although no entrenched protocols are guiding the services rendered [37]. Debate on the guideline of strategy to use, advocate for the theory of motor control and motor learning [38]. However, a qualitative study suggested that there are three approaches to reablement by physiotherapists, and they are; exercise-based approach, activity-based approach, and in between these two is an approach that encompasses both activities and exercises [37].

Exercise-based approach
This standardized approach adopts a model of using exercises as an intervention strategy by physiotherapists in the reablement process. It aims to improve muscle strength and balance thereby promoting functionalities and preventing falls among users [39][40][41].
One major limitation to this approach, as stated by Eliassen & Lahelle, is the constraint movement, which places emphasis on body function and structure under the international classifi cation of functioning, disability, and health (ICF) model leaving out the activity and participation parts of it [37].

Activity-based approach
This is a goal-driven approach. The participant goals form this approach's basis and are an integral part of the reablement process [42,43]. In relationship to the ICF, this model embraces the activities and participation of users. It promotes learning and relearning of essential activities in the lives of the users [36]. Participants need to be highly motivated, and attention must be paid to details in the performance of a task to achieve increased success [44]. This approach, however, leaves out the domains of body structure and function of ICF.

The combined approach
This approach combines the use of activities targeted towards participants' goals, which focus on the activity and participation domain of ICF and at the same time using exercises to address impairment that affect the body at both the structural and functional level [37].
An ideal approach should fuse both exercise-based and activity-based approaches. It is therefore important to know that all the components of ICF are to be addressed in functionality assessments and interventions.

Reablement and its variability
A qualitative study done by Eliassen & Lahelle fi ndings revealed that there is a lack of consistency in reablement intervention [37]. Studies on reablement have not been able to clearly state the target group, differentiating between the participants that will benefi t from reablement and those that would benefi t from the customary home care services [45]. The Reablement model is an all-inclusive approach as it features preventive, rehabilitative, and health promotion [46]. Studies have shown that home-based exercise therapy had proven to be very useful as a preventive mechanism of old age-related health diseases [40,47,48]. It is evident that an exercisebased approach of homecare is majorly practical for disease prevention and health promotion. Still, a process that needs to address particular functions required a more customized approach [36].

Reablement outcome predictor
As the reablement approach continues to spread out internationally, studies are limited on what are the predictors of its outcome. In a study conducted by Tuntland, et al. fi ndings identify that factors such as; a high COPM score at assessment, the female gender, having hip fracture as the major health challenge, and an excellent motivation for the approach are predictors of a good outcome for users of reablement [49]. As corroborated by other studies, the female gender has shown to have a longer life span and lower morbidity rates among older adults [50,51]. The relevance of the high level of motivation in reablement has also been further emphasized by Hjelle et al., they describe it as the 'driving force' for the approach [52].
On the other hand, anxiety, the presence of a neurological problem aside from stroke, balance issue, and pain have all been linked as predictors of more unsatisfactory outcomes of reablement [49]. Older adults with dizziness and balance issues have a phobia of falling, and this has an impact on their self-confi dence, affecting their activities of daily living, hence affecting their recovery progression [49,52].

Reablement: Implication for physiotherapy practice
Reablement is an emerging approach to older adult care, and as stated in a study, it is an untapped resource [53][54][55][56][57][58]. While affording physiotherapists opportunities, it equally shoulders on the profession the responsibility to positively contribute in developing a health care system that takes care of older adults and at the same time minimize expenditure.
With the theoretical and evidence-base of the profession, it is therefore easier for physiotherapists to meaningfully contribute to reablement by helping to identify older adult's challenges through a detailed assessment and addressing them using the knowledge about exercises and functional activities in collaboration with other team members.

Conclusion
This write-up has been able to explore the many angles of reablement as a new, progressive, and innovative approach which focus more on promoting independence among older adults.
As evidence, the reablement approach promotes HRQoL, reduces dependence on institutionalizing care support while enhancing independence in the community. It also allows users of the service and their family members to participate in making decisions as regards the care they received. Although the debate on having a universal consensus on the defi nition of reablement appears to have been laid to rest through the Delphi study conducted by Metzelthin, et al. many grey areas as regards the approach still need to be cleared.
There is a need to reduce the knowledge gap vis-à-vis the outcome for individual users through extensive studies [8].
More studies needs to be done to.