Sarah L. Szanton, PhD CRNP Assistant Professor Johns Hopkins University School of Nursing

1. CAPABLE: A person-environment intervention to improve function and health-related quality of life in disabled, older adults Sarah L. Szanton, PhD CRNP Assistant ProfessorJohns Hopkins University School of Nursing Center for Innovative Care in Aging Core Faculty Hopkins Center for Health Disparities Solutions Johns Hopkins Center on Aging and Health Hopkins Population Center Associate Adjunct Faculty for Johns Hopkins Center for Injury Research and Policy Robert Wood Johnson Nurse Faculty Scholar 2011-2014sszanto1@jhu.edu

2. Home

3. Home as the ultimate translational context • Lab research • Translation from lab to clinical • Clinical hospital research • Translation to clinics • Outpatient research • Home

4. Benefits of function in home • Individual • Family • Societal • Tax-payer or social policy

5. The problem • 42% of current older adults report a functional limitation or disability • Absolute number will increase as the population ages • These disabilities are the primary modifiable predictor of nursing home admission • Nursing homes cost $150 billion/year

6. Disability as a gap • The gap between a person’s abilities and their environment (Verbrugge and Jette, 1994)

7. Mrs. B

8. Clinic visit for Mrs. B • Focus on her medical problems • But what keeps her out of a nursing home?

11. If disability is the gap, how to approach?

12. Focus on individual: RN or PT • Many studies that focus on underlying impairments in individuals • Nursing visits decreased mortality but did not increase independence at home( Elkan et al, 2001) • Functional decline reduced in programs with clinical evaluation, but inconsistent effects on nursing home admission (Stuck, 2008)

13. Focus on individual: OT • Occupational therapists focus on function • Steultjens (2004) meta-analysis some evidence on enhancing functional ability and quality of life • ABLE (2006) OT intervention modifies behavior with small focus on environment

14. Focus on environment only • Administrations on Aging provide as common sense • Interventions that use person-environment fit are most successful (Wahl, 2009) • Benefits of environmental change most likely in combination with functional strategies

15. Disability gap for low-income older adults • Significant disparities in housing quality • More likely to have chronic conditions and more likely to be disabled • Fewer resources to address both

17. CAPABLE • 3 pronged intervention • Each catalyst for function separately and synergistically

18. Conceptual Framework Intervention Biobehavioral-Environmental Intervention addressing risk factors for functional decline and relocation consisting of: home repair and assistive devices training in use of compensatory strategies strength and balance training depression education and problem solving treatment medication review and adherence support Proximal Outcomes Disability - ADLs and IADLs Mobility Quality of Life Environmental Safety Contributors to Further Disability Extrinsic Environmental Intrinsic Whole Individual Physiologic Distal Outcomes Emergency Room visits Hospitalization NH Admission Study Population Low income disabled older urban adults P/E fit P/E fit

19. Pilot Study design • Randomized control pilot study (N=41) • Baseline and 6 month follow-up • Low-income functionally vulnerable older adults (≥ 1 ADL or ≥ 2 IADL limitations) • Cognitively intact • Intervention group received all three interventions • Control group received equivalent amount of “attention.” Szanton et al, 2011 JAGS

20. Pilot Sample • Recruited through Commission on Aging, Baltimore Housing Department and CHAI • Living on own, with no services • Approx 80% lived alone • 80% African-American • Average age 79 (range 66-92) • Average ADL limitations were 2.3 • Average EuroQOL of 0-100 = 60

21. Intervention • Participant-centered, tailored • Goal –centered • First visit for each discipline is assessment and helping participant decide goals. • Next visits, a combination of following up, modifying, training etc based on the participants’ goals • OT: 6 visits, RN:4 visits, Handyman: til done

22. Treatment strategies

23. Treatment strategies

24. Treatment strategies

25. Treatment strategies

26. Treatment strategies

27. Treatment strategies

28. Treatment strategies

29. Attention control • Mirror the amount of social attention, empathy and engagement provided to experimental group

30. Attention control • Participants reminisce with RAs about lives • Sedentary activities of choice (e.g. scrapbooks, pictures, cookbooks) • Also receive printed material on exercise, fall prevention, home modification

31. CAPABLE pilot participants’ evaluation

32. CAPABLE pilot results (average change by group) from 0-24 weeks Szanton et al, JAGS, 2011

33. Participant re CAPABLE study • “I can go up and down the steps better. I do. I do everything better. Like I said, I’m not 40! But, I’m a whole lot better than I was. And, I believe that if I continue to do this that I won’t lose. Do you understand? I can only get better. I’m not trying to get to 40 again. But, I want to have a quality seniorhood. And, I think this is helping.”

34. Community Support • Baltimore City Commission on Aging • Baltimore City Housing Authority • Baltimore Deputy Health Commission for Healthy Homes • Civic Works, Americorps • CHAI • Rebuilding Together • GEDCO • Meals on Wheels

35. Larger CAPABLE RCT currently • R01 from NIH • Planned N= 300 • Same design but also measuring 52 week outcomes and health care costs for both arms

36. CMS innovation grant • Planned N = 500 • No control group, only comparison group • Working with CMS to pick comparison group • If deemed successful, can become national policy

37. Further Policy Implications • Community involvement in maintaining older adults houses – civic works, Americorps

38. Mrs. J.

39. Acknowledgements • Study participants • 1KL2RR025006-01 • Johns Hopkins Population Center Early Career Award • The John A. Hartford Building Academic Geriatric Nursing Capacity Program • 1R01AG040100: National Institute on Aging

40. Study staff and students • Alice Delaney, Jill Roth, Laura Fisher, Allyson Evelyn-Gustave, Allysin Bridges, Wanda Clark-Smith, Karen Harrison, Jerry Shorb, Elizabeth Spradley • CivicWorks

41. Co-investigators • Laura Gitlin Jack Guralnik • Emily Agree Ibby Tanner • Carlos Weiss Cynthia Boyd • Bruce Leff Roland Thorpe • David Bishai Jeri Allen

42. Discussion and Questions