The ageing population is placing significant challenges on health and social aged care services in Australia [1
]. In 2011, the proportion of Australia's population aged 65 years and over was 14.6% and is predicted to rise to 19.4% by 2031. Current predictions estimate an increase in government expenditure on aged care from 0.8% of gross domestic product (GDP) in 2009–10 to 1.8% of GDP by the year 2050 [3
]. Accordingly, such a major shift in the composition of Australia's population will have implications on demand for aged care services due to increased incidence and prevalence of a wide range of chronic illnesses and subsequent decreased ability to perform functional activities of daily living [5
]. Additionally, the impact of population ageing will reduce the availability of service provision due to the declining health and aged care workforce [4
]. Given this demographic shift, it is clear that aged care service providers and health professionals will need to adapt and foster innovative models of care to overcome the challenges of rising demand and decreased service capacity [8
]. In 2012 the Australian Commonwealth introduced the Living Longer Living Better
reforms, which focussed on increasing the proportion of aged care delivered in the community to reduce dependency on long-term supportive services and delaying an older person's transition to residential aged care [1
]. Central to these reforms, the reablement model of care has been mandated by the Australian Government through guidelines for delivery of all community based aged care [9
Over the last two decades, reablement has emerged as a practice model in community-based home aged age [10
]. The reablement model challenges the traditional model of aged care of maintenance and support, shifting to a focus which aimed at preventing further functional decline and a restoration of lost function [11
]. A recent Delphi study defined reablement as a "person-centered and holistic approach that aims to increase or maintain a clients' independence and participation in daily and meaningful activities (at home or in the community) and to reduce their need for long-term services and related costs" [10
]. Despite its increasing adoption into practice, there remains variation between, and even within, some countries regarding its conceptual understanding and implementation [15
]. In Australia, the Commonwealth Government describes reablement as a model of practice aimed at supporting older people to maintain independent in activities of daily living, to improve autonomy, physical and emotional health, while reducing the need for longer term service delivery [9
In Australia, an individual's reablement period is typically time-limited for up to 12 weeks and consists of interventions including physical training and adaptive equipment to strengthen and improve activities which the older person has defined as important [9
]. Interventions are based off reablement goals which are developed collaboratively with the older person to focus on activities of daily living which will allow them to age in their usual place of residence and to participate socially. The outcomes of an older persons reablement is generally defined by the goals which they have developed in collaboration with the reablement team. As a person-centred, holistic, and strengths-based approach to care, reablement relies on an inter-disciplinary team of nursing and allied health professionals that can meet the increased complexity of older people in need of aged care services [16
Central to the implementation of the reablement model is ensuring that community-based health professionals working with older people can effectively collaborate to ensure the best outcomes for older people [17
]. Given that reablement is a shift in the delivery of aged care through doing with
, rather than doing for,
a lack of specific skills from health professionals in the reablement approach is not uncommon [12
]. Therefore, determining and evaluating readiness for the reablement approach across the health professional workforce is important to ensure care delivered is congruent with reablement and older people's expectations. To date research into reablement practice has focussed on the physiotherapy and occupational therapy disciplines [17
Whilst literature on podiatry practice in reablement is limited, evidence suggests that older people represent the largest proportion of care provided by podiatrists in Australia and their attendance at podiatrists tends to be recurrent [20
]. The link between foot problems in older age which reduce mobility and decrease quality of life has been well established [22
]. Therefore, it is reasonable to assume that podiatrists are well placed to be integrated into reablement teams. For instance, fear of falling and previous falls are important predictors which can lead to older adults to avoid activities that they are still able to do [32
]. Podiatrist delivered interventions including prescriptive exercises aimed at increased strength and balance, provision of foot orthoses, and falls prevention and footwear education have been shown to decrease the incidence of falls among older people [35
Accordingly, the aim of this study was to explore Australian podiatrists understanding and current practice of implementing a reablement approach to older clients.
The aim of this study was to explore Australian podiatrists understanding and current practice of implementing a reablement approach when working with older people. The findings presented here suggest that there are complex multi-level influences which have impact podiatrists practice and attitudes towards their clinical practice when working with older people and their ability to apply the reablement model. Three themes characterised podiatrists' views and attitudes towards reablement: Thinking and practicing differently, Reconciling reablement practice with competing pressures, Funding influences on podiatry practice and reablement.
Overwhelmingly, participants viewed reablement as a major shift in how they delivered care to older people. Participants mostly described their practice in aged care as within the biomedical model, and that this was strongly influenced by current funding models whilst also acknowledging a general lack in knowledge and skills to deliver reablement. Participants with greater experience working within the reablement model explained how other disciplines such as physiotherapy and occupational therapy had been influential in their education. For others, a lack of understanding and ability to apply reablement was attributed to their training as a podiatrist. Most participants linked a clients need to see a podiatrist with a medical condition. The implications for this approach to care has been explored by Boden [49
], who interviewed older people in England receiving podiatry care and reported that through the podiatrist's medicalisation of footcare, older people acquiesce into the patient role,
becoming passive recipients of care leading to increased dependency on podiatrists.
A change in societal beliefs and service preferences has been identified as a strong external force on changing professional boundaries [50
]. Gill and Cameron [51
] explored Australian baby boomer expectations for aged care services and reported that specific changes to the industry which focus on truly empowering older people to self-determine and self-manage. Boden [49
] identified that by approaching care through the biomedical model, identifying medical conditions, and linking these to a client's foot health, podiatrists will not fully appreciate their clients' expectations and needs. In contrast, application of the reablement model by podiatrists could facilitate their assessment of how older people manage their foot health, with a focus on recourses that will support care that is focussed on enhancing independence.
Working with older people is a significant part of podiatry practice and previously identified as a major source of occupational stress amongst Australian podiatrists [21
]. Tinley [52
] reported that Australian podiatrists describe their work with older people as repetitive and insufficiently challenging with perceived limited clinical gains, akin to a palliative approach to care, and that this contributed to stress. Care delivered within a reablement focus can have a positive impact on health professionals, increasing their job satisfaction, and reducing attrition compared to working within more traditional models of care [53
Population ageing will mean that older people are increasingly in need of health and aged care services, supporting a strong rationale for a change in focus to more progressive care models that address functional decline and shift attitudes of aged care practice. However, the appeal for increased focus of aged care podiatry development have been documented for almost two decades [52
], yet the response from participants in our study suggests that aged care practice training continues to be limited and remains a low status area within the profession.
Participants in the current study also highlighted a lack of appropriate funding arrangements which would support the implementation of reablement in podiatry practice. Private sectors participants were particularly impacted and had concerns that the limitations of Medicare TCA had inadvertently increased older people's dependency on podiatry services. Previous research has identified issues in allied health practice where the TCA only funds the consultation fee and none of the associated supplies, aids and equipment required for more effective management of older people [55
]. Consequently, these associated costs must be financed by the client, whose socioeconomic status impacts their ability to pay and the subsequent uptake of recommendations by the podiatrist [56
]. Other concerns raised about the effects of Medicare TCA on practice related to the inadequacy of the rebate to maintain a viable business [55
]. This study also identified that low levels of rebate resulted in a tendency to "churn" clients through to ensure sufficient income to sustain a financially viable practice.
Strengths and limitations
A key strength of the current study was the use of in-depth interviews with practicing podiatrists. Whilst this limits the number of participants, the data attained is rich and provides insights not possible with quantitative methods. A benefit of individual interviews over focus groups was the confidentiality provided meaning participants may feel more comfortable discussing their personal experiences. Using purposeful sampling podiatrists were recruited from across clinical settings with experience from 4 years to almost 30 years. Telephone interviews offered the advantage of recruiting from diverse geographical locations.
As with all studies, limitations exist. The study population was biased in relation to gender and is not a true reflection of the current podiatry workforce in Australia. Telephone interviews, whilst also discussed as a strength, can potentially make developing a rapport with the participants more difficult and this could limit levels of engagement with the participant [58
]. Further, telephone interviews do not allow us to observe visual cues which could assist and influence with the interpretation of the data. Finally, as reablement is an emergent model of community aged care in Australia, experience of working with the model was varied. Whilst some participants were very familiar with reablement, others were less familiar. We addressed this issue by providing both written and verbal information on the topic (both prior and during the interview), however low levels of experience may have meant in some interviews in-depth discussion of the application of reablement was limited.
Reablement is an increasingly adopted model of aged care practice within Australia. This study has provided an understanding of some of the current perceived barriers which may impact on its implementation within podiatrists practice when working with older people. The findings suggest that some podiatrists lack knowledge and skills in the application of biopsychosocial informed models of care, that there is limited time in a podiatry consultation, and that current funding arrangements are inadequate. It is apparent from our study that systemic, and seemingly intractable challenges, appear to impact the uptake of the reablement model in Australian podiatrist's practice. Therefore, in addition to increased training and awareness of more holistic approaches to care, major structural changes, including reform to funding structures which would facilitate reablement practice are needed to facilitate Australian podiatrists adopting the reablement model into their clinical practice.
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