Reducing disability following hospital discharge in vulnerable older adults: the CAPABLE intervention

点击翻译按钮获取中文摘要

Two thirds of the 7 million older adults discharged from the hospital annually face new difficulty with activities of daily living (ADLs) that do not resolve by 12 months. To date there has been scant investigation of integrated health and housing interventions to improve physical function. Our proposed trial addresses this scientific gap. It builds upon results from our Center for Medicare and Medicaid Innovation Challenge grant. The older adults hospitalized in the previous year (N=78) who received the CAPABLE intervention, which combines evidence- based nursing, occupational therapy, and handyman components, reported difficulty with 41% fewer ADLs at 5 month follow-up than baseline. An improvement of this magnitude could make the difference between aging at home independently and needing institutional care. The proposed study will target this vulnerable group to provide new reproducible knowledge about improving physical function after skilled care using a rigorous pragmatic trial design. We propose to test the effectiveness of CAPABLE in older adults for whom recovery time and typical treatment were not sufficient to regain their functional ability. These individuals will be at least 60 days post-hospital discharge, have completed the skilled home health care allowed by Medicare, and still have difficulties with ADLs. We will recruit older (≥age 65), principally Latino and African American adults with ≥ 1 ADL difficulties from the Visiting Nurse Service of New York City Medicare Advantage population. We will interview participants at home and randomize them to either treatment (CAPABLE intervention) or control (usual care). Participants in the treatment group will receive up to 10 in-home sessions - ≤6 visits with an occupational therapist and ≤4 visits from a nurse – and ≤$1500 in safety and modification services from a licensed handyman. Each treatment participant will receive each intervention component (education, assessment, identification of functional goals, specific strategies tailored to goals and based on protocols). Participants in the usual care group will not receive grant related attention. All participants will be reassessed at 20 and 52 weeks by a research assistant masked to treatment condition. The primary aims of the study are to: 1) test the effectiveness of CAPABLE in reducing the number of ADLs performed with difficulty at 20 weeks post-randomization; and 2) estimate CAPABLE’s economic impact on subsequent health care utilization and costs over 1 year post-randomization compared to CAPABLE program cost. Our secondary aims include: 1) testing CAPABLE effectiveness on ADL function at 52 weeks; 2) testing effects for key subgroups (gender, ethnicity); and 3) examining theoretically-driven mediation pathways for treatment mechanisms. The proposed study would create new knowledge to improve function following hospitalization. Our approach responds to NIA’s strategic goals to understand disability and to improve the health of diverse older populations. Our approach also has timely policy relevance in promoting aging in place in an aging population.