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

每年出院的700万老年人中有三分之二面临着新的困难 日常生活(ADL)在12个月后仍未解决。到目前为止，还缺乏对综合治理的研究。 健康和住房干预，以改善身体机能。我们提议的试验解决了这一科学鸿沟。 它建立在我们的医疗保险和医疗补助创新挑战赠款中心的结果基础上。老年人 在前一年住院的(N=78)接受有效干预的患者，该干预结合了证据- 基于护理、职业治疗和杂工组件，报告的困难在5岁时减少了41%的ADL 较基线随访1个月。如此大幅度的改善可能会使老化在 独立回家，需要机构照顾。拟议的研究将针对这一弱势群体 提供有关改善身体功能的新的、可重复的知识 务实的试验设计。我们建议在康复的老年人中测试CABLE的有效性 时间和典型治疗不足以恢复其功能。这些人至少会是 出院后60天，已经完成了医疗保险允许的熟练家庭保健，并且仍然 对ADL有困难。我们将招募年龄较大的(65岁的≥)，主要是拉丁裔和非洲裔美国成年人 ≥1 ADL困难来自纽约市医疗保险优势人群的访问护士服务。我们会 在家里采访参与者，并将他们随机分为治疗组(有能力的干预)或对照组 (照常护理)。治疗组的参与者将接受最多10次家庭会议-≤6访问与 职业治疗师和≤4护士的访问-≤从1,500美元的安全和修改服务 持证杂工。每个治疗参与者将接受每个干预部分(教育， 评估、确定职能目标、为目标量身定做和基于协议的具体战略)。 通常护理小组的参与者将不会得到与补助金相关的照顾。所有参与者都将被重新评估 在20周和52周时，由一名研究助理戴着面具接受治疗。研究的主要目的是 要：1)在20周内测试在困难的情况下减少ADL数量的能力的有效性 随机化后；以及2)估计Capable对后续卫生保健利用的经济影响 与有能力的计划成本相比，随机化后一年多的成本。我们的次要目标包括：1) 在52周时测试ADL功能的能力有效性；2)测试关键亚组的效果(性别， 种族)；以及3)研究治疗机制的理论驱动的调解途径。建议数 研究将创造新的知识，以改善住院后的功能。我们的方法响应了 NIA的战略目标是了解残疾和改善不同老年人口的健康。我们的 在促进老龄化人口就地老龄化方面，这种方法也具有及时的政策相关性。

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.