What is community rehabilitation?

Community rehabilitation is rehabilitation delivered to a patient outside a hospital setting by a multi-professional team managed as a unit with a single budget, whose members have shared resources and meet regularly in their base to discuss cases, policies, and quality improvement.

Community rehabilitation sounds good to politicians (it saves money on buildings), patients (they will come to my home), professionals (much more relevant seeing someone at home), and the public. Rehabilitation also sounds good, as it implies getting better, probably back to ‘normal’. Are these expectations met? No. NHS England wrote, “Community rehabilitation services are uncoordinated and inconsistent, supporting data to help improve services is lacking and the workforce is often insufficient to meet current need.” Some people recall the move of people with long-term mental health problems from institutional care back into the community, considered better for the people and cost the health budget less. Community care for people with severe mental illness has not succeeded. One challenge is to understand what someone means when talking about community rehabilitation.

Introduction

On 15 August 2022, I published a post, ‘Community Rehabilitation,’ reviewing the topic. I concluded it is a crucial area of expertise that needs formal public recognition of its status through academic credentialing recognition. It must be integrated both within the community and with hospital services.

On 15 September 2023, NHS England published guidance for Integrated Care Boards on ‘A community rehabilitation and reablement model’. For anyone unfamiliar with the Byzantine bureaucracy associated with the UK National Health Service and Department of Health, it changes with monotonous regularity. It always obscures the reality that resources are woefully inadequate. Integrated Care Boards were introduced on 1 July 2022 to commission and manage health and social care. The Nuffield Trust explain.

The guidance needed to be more straightforward. For example, it introduced a term, reablement, which Lynn Legg and colleagues concluded “is an ill-defined intervention targeted towards an ill-defined and potentially highly heterogeneous population/patient group. There is no evidence to suggest it is effective at either of its goals; increasing personal independence or reducing use of personal care services.”

It was incoherent in its description of community rehabilitation: “Where the term ‘community rehabilitation’ is used, it includes therapy-led reablement interventions to support people to recover and retain function.” What else is included? Why only therapy-led, and how is that specific to community rehabilitation?

In April 2024, the Community Rehabilitation Alliance produced excellent guidance for the UK National Health Services, one for each UK country. In this post, I will use the guidance for England; I have not compared them, but I assume the differences relate only to the names given to organisations locally.

Considering the emphasis on community rehabilitation and the continued lack of understanding and confusion, I am updating and expanding my earlier post.

Community rehabilitation; names.

Community rehabilitation has many names. The World Health Organisation refers to community-based rehabilitation (CBR), and its guidelines state, “Promote CBR as a strategy for community-based development involving people with disabilities.” It highlights where rehabilitation is delivered but is a strategy, not a service. Home-based rehabilitation is a second commonly used phrase that highlights where the service is offered.

In contrast, other definitions concentrate on where rehabilitation is not delivered, specifically in hospitals; all rehabilitation delivered outside hospitals is community rehabilitation.

The UK Community Rehabilitation Alliance defined community rehabilitation as “all rehabilitation delivered to a patient in any setting outside a hospital. This description includes all rehabilitation delivered by Social Services and any rehabilitation provided in community hospitals or care homes. It is provided by a multidisciplinary team, to optimise function, social participation and improve health.”

In Canada, Kathryn Sibley and colleagues defined community rehabilitation as “rehabilitation services for people living in their homes or continuing place of residence, developed in partnership with clients and families, designed to optimize function and reduce disability, and delivered by an interdisciplinary team.”

The Canadian definition extended to include the goal and the approach, and Pim Kuipers and colleagues were more explicit, referring to community rehabilitation as “an approach that draws from primary health care and typically includes the provision of rehabilitation assistance in the community through the adaptation and “upskilling” of local, often informal resources; family members; and intermediate-level workers.”

I will exclude a discussion of strategies in this post and rely on the meaning of rehabilitation, which has been discussed widely on this site, starting here. I will accept that community means “not within hospital building” (i.e. not in-patient or out-patient hospital services) and refers to where the person is when being seen by the service. The term does not specify who pays for or manages the service, nor does it exclude services delivered by teams who also work in hospitals.

This leads to the description given at the start of this post:

This definition emphasises that rehabilitation must be delivered by a multi-professional team with the characteristics that define a team.

Empirical investigations.

In 2019, Hilda Mulligan and colleagues investigated the components of community rehabilitation programmes for adults with chronic conditions. Their systematic review included randomised trials and extracted features of the described programme. They “identified that the usual components of community rehabilitation programmes are education on symptoms, symptom management, and strategies to develop self-management skills.” The delivered programmes usually lasted 4-6 weeks. Unfortunately, most studies focused on disease management, not rehabilitation; this illustrates the need to use words correctly.

In contrast, Kathryn Sibley and colleagues investigated the concepts involved in community rehabilitation services. The extracted data from many sources: “194 papers, 30 Canadian programs, 29 community rehabilitation service and system providers, and six older person and family caregiver dyads.” The data were analysed and synthesised by a group, with broad consultation and revision to arrive at a draft definition, given above, and conceptual framework. The conceptual framework has two components: the principles and the organisation.

The principles are that community rehabilitation should be:

Culturally safe
Equity-focussed
Evidence-informed
Person- and family-centred
Restorative

The organisational features are that community rehabilitation should be:

Appropriate
Coordinated
Continuous through an episode
Evaluated
Stepped (adjusted in intensity according to need)
Team-based

You can see immediately that these principles and organisational features apply to all rehabilitation and health care. They do not specify anything unique to community rehabilitation. The need to develop and publish them is a robust implied criticism of how community rehabilitation is often delivered.

Katherine Jackson and colleagues reviewed 39 qualitative studies investigating the patient experience of community rehabilitation. As with the last research, many synthesised findings apply to all rehabilitation. For example, “process quality is determined by interactions, and that it is a prerequisite for activities of patient centered care, such as personalized care and shared decision making.” and “… goals have the potential to provide structure, motivation and satisfaction …”

One finding relates specifically to community rehabilitation, but primarily its relationship to other services: coordination to ensure continuity during the transition from hospital to community services is essential (and often poor). Both parties are responsible for the transition.

Pam Enderby and I surveyed all UK community rehabilitation services in 2001. Details are in the paper. We found four types of teams:

Community rehabilitation teams
Young disabled community teams
Community rehabilitation teams for older adults
Client-group specific teams (e,g. for people with multiple sclerosis)

Of greater interest, we had used a register of community rehabilitation teams, but respondents included three classes of service that could not be construed as community rehabilitation services:

Community therapy teams, which were all one profession in one management unit unrelated to any other profession or team
Rehabilitation coordinators coordinating a variety of other services
Outreach teams based in hospitals for a specific patient group.

Only 25 of the 98 bona fide teams had a dedicated manager; the remainder had management split between clinical and organisational managers, individual professional managers, or distant management.

Pam Enderby used the data to focus on teamwork in community rehabilitation. She concluded, “The biggest threat to community rehabilitation teams being effective in this study seemed to be lack of attention to the principles of teamworking.”

From this overview of existing studies, I conclude that the only feature distinguishing community rehabilitation from other rehabilitation is the location used when seeing a patient. Others might add a second feature – a failure to provide adequate resources so that basic rehabilitation principles cannot be followed.

Effectiveness of community rehabilitation.

When considering the evidence on effectiveness, one must establish that it is as effective as rehabilitation delivered in hospital settings and that it is not associated with additional harms, such as falls or stress on carers. Thus, various outcomes must be measured to capture unexpected benefits or harms. At the same time, one should consider cost-efficiency from a societal perspective, not simply a healthcare perspective.

When looking for evidence, one must realise that different names are used, and to capture all relevant studies, a broad search is needed to include, for example:

Early supported discharge, transitional rehabilitation, etc, to evaluate the rehabilitation delivered in the community
Home-based and hospital-at-home rehabilitation
Community-based rehabilitation

Community rehabilitation is often referred to by alternative names such as reablement, restorative care, outreach care, and intermediate care, all of which are rehabilitation. Furthermore, some community rehabilitation is delivered virtually, using video technology, and may not include any term that means community, yet they are community-based studies.

There is reasonable evidence to support community rehabilitation for patients:

After knee arthroplasty
considered for day hospital rehabilitation,
After a stroke, especially in coordination with the hospital services
Needing cardiac rehabilitation
have musculoskeletal conditions
Chronic respiratory conditions, using telerehabilitation

The list above is not comprehensive. There are many other reviews covering specific conditions or more general groups. It illustrates the principle that community rehabilitation seems equally effective. However, more research is needed to delineate when it is cost-efficient and how to avoid stress on carers or risk to the patient.

Significant issues to resolve.

There is little doubt that rehabilitation delivered to patients in the community is possible, is probably as effective as rehabilitation delivered in the hospital, and maybe cost-efficient. At the same time, community rehabilitation is undoubtedly considerably under-resourced, often lacks expertise and sustainability, is isolated and poorly managed, and has low status and attention.

Teamwork.

Multi-professional teamwork is a crucial feature of rehabilitation, and its absence is a significant feature of community rehabilitation services. This includes having all necessary professions and working as a team under a single management, with its budget and a team base. It also requires a large enough group to ensure sustainability and ongoing team development and learning without depending on one or two individuals.

Community rehabilitation is often perceived as cheap: getting two or three professionals to work together without any support, career development, ongoing education, etc. It also focuses on small groups of patients, for example, with teams for stroke, multiple sclerosis, chronic fatigue, musculoskeletal problems, motor neurone disease, and cardiac rehabilitation, all working independently in the same locality.

A locality should have a single community rehabilitation service to see people with rehabilitation needs. Naturally, individuals will have expertise in specific conditions within the team, but only a large team can be sustained and support quality control and educational processes.

Integration.

Rehabilitation services tend to be set up in response to a perceived need or specific incident. They rarely are developments of existing services. Moreover, hospitals are seldom entrusted with services delivered in the community, and separate organisations exist to provide community health services.

This fragmentation exacerbates the existing state where social services are separate from health; mental health is separate from acute services; learning disability is separate from almost everything; and so on.

Everyone recognises this, yet no one does anything; worse still, politicians suggest setting up even more isolated services, such as post-COVID rehabilitation services.

Community rehabilitation services must be integrated in many ways:

With all other rehabilitation services, especially other community rehabilitation services
With all other healthcare systems
Into educational and professional support organisations
With social services, housing, employment, and educational services

Status/specialisation.

I have written about ‘specialist rehabilitation’, concluding that it distorts perception and is inaccurate; rehabilitation is a specialist area of practice, like cardiology or surgery. Specialisation within rehabilitation exists, but it is not specialist rehabilitation so much as a rehabilitation service that is specialised in …. For example, we commonly refer to spinal cord injury rehabilitation, prosthetic rehabilitation, specialist wheelchair services, or trauma rehabilitation.

Thus, the logical step is to refer to a service specialised in providing rehabilitation in the community (or out of the hospital). In practice, this will include several areas of expertise that other services may lack:

Tailoring rehabilitation therapies to the physical and social circumstances
Knowledge of the locality – who is good at what, where local resources are, etc.
Liaison with social services, education, etc.
Long-term support and the natural history of conditions; how people adapt successfully.

We should stop acting as if specialist rehabilitation was the only specialist rehabilitation class, with all others being non-specialist. Rehabilitation services delivered in care homes, social service day centres, peoples’ homes, places of employment, etc., are as effective, valuable, and complex as all other types.

Solutions.

There is no single solution. Healthcare is too complex to expect any part to alter itself radically. Only two steps are essential:

Acknowledging that the present situation is imperfect and change is vital.
Starting to work toward a better arrangement.

Two principles must always be remembered:

No single solution will work,
- some will improve matters, but others will fail
this is a long-term project
- expecting a dramatic change in the short term (1-3 years) is unrealistic.

I will put forward two ideas to start with.

Care homes as bases

On 23 November 2023, NHS England published the ‘Enhanced health in care homes framework’. Though it is not framed as rehabilitation, the framework contains many rehabilitation features:

Enhanced primary care support
Multi-disciplinary team (MDT) support, including coordinated health and social care
Falls prevention, Reablement, and rehabilitation, including strength and balance
High quality palliative and end-of-life care, Mental health, and dementia care
Joined-up commissioning and collaboration between health and social care
Workforce development
Data, IT and technology

I have written a detailed post about the framework, suggesting that selected care homes could be a base for community rehabilitation services. For example, a community rehabilitation service covering 500,000 people might use ten care homes scattered across the geographic patch as bases.

Rehabilitation network.

The Community Rehabilitation Alliance advocates for rehabilitation networks and a director of rehabilitation within each Integrated Care Board. I have written two blog posts on Rehabilitation Networks. The first sets the scene, starting with the Beveridge Report that led directly to the National Health Service within five years (1943-1948). The second discusses networks and how one might be developed for rehabilitation.

Developing a network should highlight most issues and facilitate a slow evolution and development of more coherent services.

Conclusion

Expert rehabilitation delivered by a multi-professional team to patients outside the hospital is effective. It may often be more cost-efficient than not providing any rehabilitation, only providing it in specialist centres (levels I and II in NHS jargon), using isolated therapists or only one profession, or expecting non-professional care staff to try without support. Current community rehabilitation services are patchy, usually small and isolated, often restricted to selected patients for short, time-limited episodes, and considered of low status and not very important. A radical overhaul and reorganisation of rehabilitation services, including all services that deliver parts of rehabilitation in the community, is needed. A less radical starting point is to initiate rehabilitation networks. But a start is required today.

Quick links

General theory of rehab

NHS Community Rehab toolkit

2022 first post on Comm Rehab

Rehabilitation syllabus

Star page

What is community rehabilitation?

Table of Contents

Introduction

Community rehabilitation; names.

Empirical investigations.

Effectiveness of community rehabilitation.