Community Aging In Place, Advancing Better Living For Elders Research Articles

GOAL ATTAINMENT SCALING IN CAPABLE: A COMPARISON OF CARE PARTNER AND OLDER ADULT PARTICIPATION

Abstract Aging in place is an optimal outcome for our maturing population as health systems become increasingly overburdened. One program that facilitates aging in place is the Community Aging in Place, Advancing Better Living for Elders (CAPABLE) program. CAPABLE improves older adult performance in everyday activities and reduces inpatient and long-term service use. Although CAPABLE is designed as a person-centered program aiming to help older adults set and achieve goals, research demonstrates that care partners (i.e. family or friends providing unpaid support) are frequently involved in healthcare decisions and can reinforce intervention goals. This presentation will report findings from the trial stage of a Hybrid Type 1 Study of CAPABLE involving care partners for which recruitment is ongoing (N=100). We aim to describe how older adults and their care partners engage in goal setting using Goal Attainment Scaling, share the frequency of their goal attainment, and present the types of goals that they set. For example, older adult participant goals for our current sample focus on reduced fear when showering, improved mobility, and more efficient dressing. For our care partner participants, goals include finding respite and preventing older adult injury. All participants who have completed CAPABLE were able to achieve their goals by the end of the program. Findings from this study support care partner involvement in interventions to promote aging in place, aligning with the RAISE Act’s goal to engage family caregivers as key partners in the delivery of services and support.

CAPABLE: APPLYING AN EVIDENCE-BASED MODEL OF CARE FOR OLDER ADULTS WITH HIV

Abstract In the United States, more than half of people living with HIV (OWH) are at least 50 years. Older PWH experience increased comorbidities, earlier onset of geriatric syndromes, and functional decline. These health consequences intersect with complex social and environmental factors, further complicating aging with HIV. Yet initiatives focused on successful aging do not consider the unique needs of older PHWs. Models of care tailored to the individual that addresses both intrinsic (e.g., chronic infections, stress, and nutrition) and extrinsic (socioeconomic status, housing instability, food insecurity, and threats to safety) factors unique to older PWH are needed to improve health and functional outcomes. Community Aging in Place, Advancing Better Living for Elders (CAPABLE), an internationally recognized model of care, is a person-directed program that has been successful in supporting aging in place by reducing functional decline and disability among older adults. Over several months, the participant, occupational therapist, registered nurse, and handy worker collaborate on solutions to improve the participant’s bio-psych-functional capacity to function at home. In multiple trials, CAPABLE has demonstrated improvements in independence, safety, self-efficacy, and depression. CAPABLE is associated with healthcare cost reductions, including over $30,000 in Medicare and Medicaid savings. CAPABLE has not been adapted to older PWH, despite being well-positioned to address intrinsic and extrinsic factors affecting adherence, viral suppression, and other health outcomes. This presentation will discuss the first-ever translation of CAPABLE to a cohort of older PWH using human-centered design strategies and discuss initial feasibility trial of older PWH at Johns Hopkins.

Study protocol: Type III hybrid effectiveness-implementation study implementing Age-Friendly evidence-based practices in the VA to improve outcomes in older adults

BackgroundUnmet care needs among older adults accelerate cognitive and functional decline and increase medical harms, leading to poorer quality of life, more frequent hospitalizations, and premature nursing home admission. The Department of Veterans Affairs (VA) is invested in becoming an “Age-Friendly Health System” to better address four tenets associated with reduced harm and improved outcomes among the 4 million Veterans aged 65 and over receiving VA care. These four tenets focus on “4Ms” that are fundamental to the care of older adults, including (1) what Matters (ensuring that care is consistent with each person’s goals and preferences); (2) Medications (only using necessary medications and ensuring that they do not interfere with what matters, mobility, or mentation); (3) Mentation (preventing, identifying, treating, and managing dementia, depression, and delirium); and (4) Mobility (promoting safe movement to maintain function and independence). The Safer Aging through Geriatrics-Informed Evidence-Based Practices (SAGE) Quality Enhancement Research Initiative (QUERI) seeks to implement four evidence-based practices (EBPs) that have shown efficacy in addressing these core tenets of an “Age-Friendly Health System,” leading to reduced harm and improved outcomes in older adults.MethodsWe will implement four EBPs in 9 VA medical centers and associated outpatient clinics using a type III hybrid effectiveness-implementation stepped-wedge trial design. We selected four EBPs that align with Age-Friendly Health System principles: Surgical Pause, EMPOWER (Eliminating Medications Through Patient Ownership of End Results), TAP (Tailored Activities Program), and CAPABLE (Community Aging in Place – Advancing Better Living for Elders). Guided by the Pragmatic Robust Implementation and Sustainability Model (PRISM), we are comparing implementation as usual vs. active facilitation. Reach is our primary implementation outcome, while “facility-free days” is our primary effectiveness outcome across evidence-based practice interventions.DiscussionTo our knowledge, this is the first large-scale randomized effort to implement “Age-Friendly” aligned evidence-based practices. Understanding the barriers and facilitators to implementing these evidence-based practices is essential to successfully help shift current healthcare systems to become Age-Friendly. Effective implementation of this project will improve the care and outcomes of older Veterans and help them age safely within their communities.Trial registrationRegistered 05 May 2021, at ISRCTN #60,657,985.Reporting guidelinesStandards for Reporting Implementation Studies (see attached).

Implementation of the CAPABLE Program With Older Adults During the COVID-19 Pandemic.

This study explores the implementation and impact of an evidence-based client-driven program, CAPABLE (Community Aging in Place Advancing Better Living for Elders), during the COVID-19 pandemic. The study reviews outcomes related to client engagement and retainment, client-directed goals, therapeutic intervention, home modifications, and functional outcomes of older adult participants. The CAPABLE program addresses basic and instrumental activities of daily living, medication use, pain, mobility, fall prevention, and environmental modifications within the home. The services were provided by an interprofessional team which included an occupational therapist, a registered nurse, and home contractor professional. The study team utilized descriptive, paired t test, and correlational analyses to evaluate the CAPABLE programs' influence on the functional outcomes of older adults living within the city of St. Louis, during the COVID-19 pandemic. This study identified significant improvement in instrumental activities of daily living (IADLs) independence, readiness to change, self-reported health status, and depressive symptoms, and 11 significant correlations were found between age, implementation expenses, and functional outcomes.

Promoting sleep in low-income older adults with disabilities: Comparing CAPABLE with a social engagement control

Sleep plays a vital role in older adults’ health. The Community Aging in Place—Advancing Better Living for Elders (CAPABLE) trial, conducted in Maryland between 2012 and 2016, is a 5-month biobehavioral environmental intervention study to reduce functional disabilities in 300 low-income older adults. Individual and environmental factors impacting sleep were addressed in CAPABLE. This secondary data analysis was to test the preliminary effect of CAPABLE on actigraph-measured sleep, compared with a social engagement control in 73 CAPABLE participants with pretest-posttest actigraph data. Participants in this analysis were aged 75.8±7.5 years; 86.3% of them were females and 84.9% were Black/African Americans. Both CAPABLE intervention and social engagement control improved sleep efficiency and reduced sleep onset latency. The effect of CAPABLE on sleep was comparable to social engagement. These findings underline the importance of promoting physical function and maintaining social activity for sleep in low-income older adults with disabilities.

Program Implementation of CAPABLE With Community-Dwelling Older Adults During the COVID-19 Pandemic

Abstract Date Presented 04/01/2022 This presentation explores the implementation and impact of an evidence-based, client-driven program, CAPABLE (Community Aging in Place, Advancing Better Living for Elders), during the height of the COVID-19 pandemic. We review outcomes related to client engagement and retainment, client-directed goals, therapeutic intervention, home modifications, and functional outcomes of older adult participants residing in a major midwestern urban area. Primary Author and Speaker: Selena Washington Additional Authors and Speakers: Emma Bottin, Emily Cler Contributing Authors: Selena Washington, Emma Bottin, Emily Cler, Stacy West-Bruce

Community Aging in Place, Advancing Better Living for Elders (CAPABLE) program: Understanding the potential involvement of care partners.

Older adults frequently turn to care partners for support to remain in their homes for as long as possible. Yet, many evidence-based home and community programs to support ageing in place do not formally involve care partners. This study sought to understand how to involve care partners in the Community Aging in Place, Advancing Better Living for Elders (CAPABLE) program. A qualitative descriptive study was conducted. Framework analysis of multiple sources of data, including descriptions from stakeholders (N=24) and available CAPABLE resources, provided the basis for understanding how to involve care partners in the program. Considerations for involving care partners when initiating, delivering and following the program were generated; namely, providing older adults' choices while screening for the program, defining roles and sharing information in a collaborative manner and reinforcing knowledge and skills training. Embracing these considerations in geriatric practice and research efforts is likely to help care partners' ability to provide assistance, thus enabling older adults to remain in their homes for as long as possible. Providers can use findings to better involve and support care partners in their delivery of programs to older adults. Researchers should further develop and test a care partner-supported CAPABLE program.

Engaging Stakeholders to Implement the Community Aging in Place, Advancing Better Living for Elders (CAPABLE) Program in a Local Area Agency on Aging

Abstract Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations. The Community Aging in Place, Advancing Better Living for Elders (CAPABLE) Program is a successful evidence-based intervention involving an OT, a nurse, and a handyman to promote aging in place for older adults. This presentation reflects important adaptations identified by stakeholders for implementation of CAPABLE through an Area Agency on Aging for a non-Medicaid population and reinforces the importance of early stakeholder engagement in knowledge translation. Primary Author and Speaker: Pamela Toto Additional Authors and Speakers: Beth Fields Contributing Authors: Caylee Yanes

Adapting the Community Aging in Place, Advancing Better Living for Elders Program to Include Care Partners

Abstract Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations. Many evidence-based home and community programs designed to support aging in place do not include care partners, including the well-known Community Aging in Place, Advancing Better Living for Elders (CAPABLE) program. How OT practitioners can include care partners in CAPABLE and which strategies may work best for care partners are currently being explored. This presentation will discuss recent evidence on how to adapt CAPABLE to include care partners. Primary Author and Speaker: Beth Fields Additional Authors and Speakers: Pamela Toto Contributing Authors: Molly Ennis, Caylee Yanes

Including Caregivers in the Community Aging in Place, Advancing Better Living for Elders Program

Older adults frequently turn to informal caregivers for support to age independently in their home as long as possible. Yet, many evidence-based programs designed to support aging in place do not include caregivers, including the well-known Community Aging in Place, Advancing Better Living for Elders (CAPABLE) program. The purpose of this qualitative study was to adapt CAPABLE to include caregivers using a grounded theory approach. Data collection occurred with stakeholders from an Area Agency on Aging (AAA) in Pennsylvania. Two, 60-minute focus groups were conducted with frontline providers (n=7) and administrators (n=7). Eight, 30-minute individual interviews were conducted with AAA consumers including older adults and their caregivers. Constant comparative analysis of the data were completed using NVivo 12 Pro. Stakeholders described three considerations for adapting CAPABLE to include caregivers: older adult preference and caregiver willingness, clear guidelines and expectations, and hands-on training. Older adults and caregivers recognized the need to “allow them to decide when and why family should be involved in the program.” Frontline providers and administrators explained the importance of “determining whether older adults and caregivers should have shared or separate goals for the program.” All stakeholders expressed that including caregivers would “reaffirm the hands-on training like fall prevention.” These perspectives shed light on how and why to include caregivers in CAPABLE. Information gleaned from this study may help researchers think about ways in which to adapt other evidence-based programs to include caregivers, and help healthcare providers target and support caregivers in the delivery of their services.

Improvements of Disability Outcomes in CAPABLE Older Adults Differ by Financial Strain Status.

The Community Aging in Place-Advancing Better Living for Elders (CAPABLE) program reduces disability in low-income older adults. In this study, we used CAPABLE baseline and 5-month data to examine whether its effects in reducing activities of daily living (ADLs) and instrumental ADLs (IADLs) difficulties differed by participants' financial strain status. At baseline, participants with financial strain were more likely to report higher scores on depression (p < .001), have low energy (p < .001), and usually feel tired (p = .004) compared with participants without financial strain, but did not differ in ADL/IADL scores. Participants with financial strain benefited from the program in reducing ADL (relative risk [RR]: 0.61, 95% confidence interval [CI]: 0.43, 0.86) and IADL disabilities (RR: 0.69, 95% CI: 0.54, 0.87), compared with those with financial strain receiving attention control. Individuals with financial strain benefited more from a home-based intervention on measures of disability than those without financial strain. Interventions that improve disability may be beneficial for financially strained older adults.

Innovative care models across settings: Providing nursing care to older adults

The aging demographic shift occurring world-wide is creating an opportunity for innovative care models to address the burgeoning care needs of the expanding population of older adults. Nursing and advanced practice nursing as well as interprofessional models past and present hold insights into how to meet the needs of older adults across the continuum of care. A review of past and present models of care is provided. These models across settings emphasize maximizing the role of nurses and advanced practice nurses. The models reviewed include: On LOK and Programs of All-inclusive Care for the Elderly (PACE); Community Aging in Place, Advancing Better Living for Elders (CAPABLE); Teaching Nursing Homes; Interventions to Reduce Acute Care Transfers (INTERACT); Missouri Quality Initiative (MOQI); Evercare/Optum; Nurses Improving Care for Health System Elders (NICHE); Acute Care for the Elderly Unit (ACE Unit); Hospital Elder Life Program (HELP); Age-Friendly Health Systems; and the Transitional Care Model. Each model emphasizes education on the special needs of older adults, providing easy access to evidence-based tools and interventions, as well as strong interprofessional collaboration. Sustainable evidence-based nursing and interprofessional innovations are present across health care settings from the community, long-term care and the acute care setting to address the complex needs of older adults.

Recruiting Older Adults With Functional Difficulties Into a Community-Based Research Study: Approaches and Costs.

The CAPABLE (Community Aging in Place, Advancing Better Living for Elders) trial in Baltimore City tested whether an interdisciplinary team of occupational therapists, nurses, and handymen reduces disability and health expenditures in community-dwelling older adults with functional difficulties. This study describes methods and associated costs of recruiting 300 low-income, cognitively intact, older adults with functional difficulties into this study. Sources of participant enrollment included direct mailings (35%), government program referrals (19%), community-based organizations (16%), ambassador referrals (15%), and media (4%). Fifty six (30%) of 187 older adults referred through government organizations were enrolled, while 49 (7.6%) of 648 referred from community-based organizations were enrolled. Total recruitment costs were US$81,453.12. Costs per participant for mailings, media, ambassadors, and community-based organizations were respectively US$745.10, US$256.82, US$22.28, and US$1.00. Direct mailings yielded the most participants but was the most costly method per participant. Ambassadors were least expensive and may offer a low-cost addition to community outreach for recruitment of older adults into research.

Home-Based Care Program Reduces Disability And Promotes Aging In Place

The Community Aging in Place, Advancing Better Living for Elders (CAPABLE) program, funded by the Center for Medicare and Medicaid Innovation, aims to reduce the impact of disability among low-income older adults by addressing individual capacities and the home environment. The program, described in this innovation profile, uses an interprofessional team (an occupational therapist, a registered nurse, and a handyman) to help participants achieve goals they set. For example, it provides assistive devices and makes home repairs and modifications that enable participants to navigate their homes more easily and safely. In the period 2012-15, a demonstration project enrolled 281 adults ages sixty-five and older who were dually eligible for Medicare and Medicaid and who had difficulty performing activities of daily living (ADLs). After completing the five-month program, 75percent of participants had improved their performance of ADLs. Participants had difficulty with an average of 3.9 out of 8.0 ADLs at baseline, compared to 2.0 after five months. Symptoms of depression and the ability to perform instrumental ADLs such as shopping and managing medications also improved. Health systems are testing CAPABLE on a larger scale. The program has the potential to improve older adults' ability to age in place.

Communication between office‐based primary care providers and nurses working within patients' homes: an analysis of process data from CAPABLE

Aims and ObjectivesTo examine themes of communication between office‐based primary care providers and nurses working in private residences; to assess which methods of communication elicit fruitful responses to nurses’ concerns.BackgroundLack of effective communication between home health care nurses and primary care providers contributes to clinical errors, inefficient care delivery and decreased patient safety. Few studies have described best practices related to frequency, methods and reasons for communication between community‐based nurses and primary care providers.DesignSecondary analysis of process data from ‘Community Aging in Place: Advancing Better Living for Elders (CAPABLE)’.MethodsIndependent reviewers analysed nurse documentation of communication (phone calls, letters and client coaching) initiated for 70 patients and analysed 45 letters to primary care providers to identify common concerns and recommendations raised by CAPABLE nurses.ResultsPrimary care providers responded to 86% of phone calls, 56% of letters and 50% of client coaching efforts. Primary care providers addressed 86% of concerns communicated by phone, 34% of concerns communicated by letter and 41% of client‐raised concerns. Nurses’ letters addressed five key concerns: medication safety, pain, change in activities of daily living, fall safety and mental health. In letters, CAPABLE nurses recommended 58 interventions: medication change; referral to a specialist; patient education; and further diagnostic evaluation.ConclusionsEffective communication between home‐based nurses and primary care providers enhances care coordination and improves outcomes for home‐dwelling elders. Various methods of contact show promise for addressing specific communication needs.Relevance to clinical practiceNurses practicing within patients’ homes can improve care coordination by using phone calls to address minor matters and written letters for detailed communication. Future research should explore implementation of Situation, Background, Assessment and Recommendation in home care to promote safe and efficient communication. Nurses should empower patients to address concerns directly with providers through use of devices including health passports.

Preliminary Data from Community Aging in Place, Advancing Better Living for Elders, a Patient‐Directed, Team‐Based Intervention to Improve Physical Function and Decrease Nursing Home Utilization: The First 100 Individuals to Complete a Centers for Medicare and Medicaid Services Innovation Project

Current medical models frequently overlook functional limitations and the home environment even though they partially determine healthcare usage and quality of life. The Centers for Medicare and Medicaid Services (CMS) Innovation Center funds projects that have potential to affect the “triple aim,” a framework for decreasing costs while improving health and quality of life. This article presents preliminary data from Community Aging in Place, Advancing Better Living for Elders (CAPABLE), a model funded by the CMS Innovation Center and designed to overcome the functional and home environmental barriers of older adults. CAPABLE is a patient‐directed, team‐based intervention comprising an occupational therapist, a registered nurse, and a handyman to decrease hospitalization and nursing home usage of community‐dwelling older adults with functional limitations who are dually eligible for Medicare and Medicaid. Activity of daily living limitations improved in 79% of the first 100 people who completed the intervention. Preliminary findings of this novel intervention may have implications for other older adults with functional limitations.

CAPABLE trial: A randomized controlled trial of nurse, occupational therapist and handyman to reduce disability among older adults: Rationale and design

BackgroundAs the population ages, it is increasingly important to test new models of care that improve life quality and decrease health costs. This paper presents the rationale and design for a randomized clinical trial of a novel interdisciplinary program to reduce disability among low income older adults based on a previous pilot trial of the same design showing strong effect. MethodsThe CAPABLE (Community Aging in Place, Advancing Better Living for Elders) trial is a randomized controlled trial in which low income older adults with self-care disability are assigned to one of two groups: an interdisciplinary team of a nurse, occupational therapist, and handyman to address both personal and environmental risk factors for disability based on participants' functional goals, or an attention control of sedentary activities of choice. Both groups receive up to 10 home visits over 4months. OutcomesThe primary outcome is decreased disability in self-care (ADL). Secondary outcomes are sustained decrease in self care disability as well as improvement in instrumental ADLS, strength, balance, walking speed, and health care utilization. Careful cost tracking and analysis using intervention data and claims data will enable direct measurement of the cost impact of the CAPABLE approach. CAPABLE has the potential to leverage current health care spending in Medicaid waivers, Accountable Care Organizations and other capitated systems to save the health care system costs as well as improving low income older adults' ability to age at home with improved life quality.

Community Aging in Place, Advancing Better Living for Elders: A Bio‐Behavioral‐Environmental Intervention to Improve Function and Health‐Related Quality of Life in Disabled Older Adults

To determine effect size and acceptability of a multicomponent behavior and home repair intervention for low-income disabled older adults. Prospective randomized controlled pilot trial. Participants' homes. Forty low-income older adults with difficulties in one or more activities of daily living (ADLs) or two or more instrumental activities of daily living (IADLs). The Community Aging in Place, Advancing Better Living for Elders (CAPABLE), coordinated occupational therapy, nursing, and handyman visits, was compared with attention-control visits. The intervention consisted of up to six visits with an occupational therapist, up to four visits with a nurse, and an average of $1,300 in handyman repairs and modifications. Each intervention participant received all components of the intervention clinically individualized to risk profile and goals. Each attention-control participant received the same number of visits as the intervention participants, involving sedentary activities of their choice. difficulty in performing ADLs and IADLs. health-related quality of life and falls efficacy. Thirty-five of 40 adults (87%) completed the 6-month trial, and 93% and 100% of the control and intervention group, respectively, stated that the study benefited them. The intervention group improved on all outcomes. When comparing mean change in the intervention group with mean change in the control group from baseline to follow-up, the CAPABLE intervention had effect sizes of 0.63 for reducing difficulty in ADLs, 0.62 for reducing difficulty in IADLs, 0.89 for quality of life, and 0.55 for falls efficacy. The CAPABLE intervention was acceptable to participants and feasible to provide and showed promising results, suggesting that this multicomponent intervention to reduce disability should be evaluated in a larger trial.