Nursing Strategies for Promoting and Maintaining Function among Community-Living Older Adults: The CAPABLE Intervention

doi:10.1016/j.gerinurse.2012.04.002

Geriatric Nursing

Volume 33, Issue 6, November–December 2012, Pages 439-445

https://doi.org/10.1016/j.gerinurse.2012.04.002 Get rights and content

Although many programs aim to help older adults age in place, few target both the home environment and individual physical function. We present an interprofessional intervention called CAPABLE—Community Aging in Place: Advancing Better Living for Elders. CAPABLE's innovative approach incorporates a nurse, occupational therapist (OT), and handyman to address both individual and environmental factors that contribute to disability. The nurse component of CAPABLE addresses key barriers to functional independence such as pain, depression, strength and balance, medication management, and poor communication with the primary care provider. This article focuses primarily on the nursing aspect of the intervention and how it interrelates with the content and processes of the OT and handyman.

Section snippets

Need for CAPABLE

The number of older adults is expected to double to 71 million by 2030.³ Among current older adults, 42% report a functional limitation, or disability.⁴ Despite a small decline in disability rates in recent years, the absolute number of older adults with disabilities is predicted to increase, particularly among low-income, minority, and low-education older adults.⁴ Many hope to age at home or “age in place”⁵; however, disability can prevent older adults from staying at home. One goal of Healthy

How CAPABLE Differs from Current Practice

Although based on current evidence, the CAPABLE intervention differs from traditional home care practice in 4 ways: 1) although nurses and other clinicians care about patient function, they often do not use specific strategies to improve their function. CAPABLE training provides RNs and OTs with knowledge and skills to identify and remove barriers to daily functioning; 2) CAPABLE training provides the assessment skills and evidence-based tools to enable clinicians to engage in a client-centered

Summary

The CAPABLE intervention described here offers an interprofessional evidence-based approach to common problems confronting older adults who have conditions that affect mobility and independence. Combining nursing strategies with handyman repairs and skills-based occupational therapy decreased older adults ADL limitations by more than 1 full ADL limitation in a pilot study of the CAPABLE intervention.² Health care policy that removes payment barriers to nursing care in the home and promotes

Acknowledgments

This publication was made possible by Grant Number 1KL2RR025006-01 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH) and the John A. Hartford Foundation's Building Academic Geriatric Nursing Capacity Award Program.

ANTHONY T. PHO, MSN, MPH, CRNP, RN, Staff Associate in Medicine, Weill Cornell Medical College, New York, New York.

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If independently validated in other studies, these risk profiles could be used by primary care and other community-based clinicians to identify older adults living in the community who may be at risk for poor outcomes and trigger clinicians to initiate individualized, targeted interventions. Targeted interventions may include the initiation, continuation or increased frequency of several community-based services such as nurse-led care coordination,34 home health care,39,40 hospice, phone calls between visits,41 telehealth,42 physician follow up43 and handyman services44 to mitigate risk. Additionally, the risk profiles, if further refined, could be integrated into clinical decision support systems to assist clinicians identify specific community-based referrals needed by older adults according to their level of risk.45
Preventing adverse events among chronically ill older adults living in the community is a national health priority. The purpose of this study was to generate distinct risk profiles and compare these profiles in time to: hospitalization, emergency department (ED) visit or death in 371 community-dwelling older adults enrolled in a Medicare demonstration project. Guided by the Behavioral Model of Health Service Use, a secondary analysis was conducted using Latent Class Analysis to generate the risk profiles with Kaplan Meier methodology and log rank statistics to compare risk profiles. The Vuong-Lo-Mendell-Rubin Likelihood Ratio Test demonstrated optimal fit for three risk profiles (High, Medium, and Low Risk). The High Risk profile had significantly shorter time to hospitalization, ED visit, and death (p < 0.001 for each). These findings provide a road map for generating risk profiles that could enable more effective targeting of interventions and be instrumental in reducing health care costs for subgroups of chronically ill community-dwelling older adults.
Home fire safety beliefs and practices in homes of urban older adults
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Nurses are in an opportune position to facilitate the development and implementation of HFS programs targeted toward older adults by promoting links with existing community services and resources (e.g., local fire departments, Meals on Wheels programs) thereby improving the sustainability of such programs. HFS could also be incorporated into more extensive in–home senior-based interventions such as CAPABLE.24 A cognitive screen such as the CDT should be included in the intake assessment performed by social services to be evaluated concurrently with the existence of support within and outside the older adult's home.
The purpose of this study is to examine factors influencing urban older adults and develop a thematic analysis of how these factors affect seniors' home fire safety (HFS) beliefs and practices. This was a focused ethnography using participant observation and semi-structured interviews. Additionally, public housing records, cognitive functioning, and general health status were assessed. Individual interviews were transcribed verbatim using a constant comparative analysis. Eight seniors participated in the study. Two main themes described older adults' HFS while aging in place: the risk associated with the living environment and the journey associated with maintaining independence. All participants experienced HFS challenges such as limited mobility and financial constraints. Participants' general health and cognitive status additionally influenced their ability to maintain HFS. The findings suggest that urban seniors may have diverse HFS environment risks compared with the general population, highlighting the need for older adult focused HFS interventions.
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The CAPABLE intervention involves universal assessment of every client by a registered nurse (RN)/occupational therapist (OT) team that then allows an interdisciplinary team including the client, the nurse, the OT, a home repair specialist (handyman), and a pharmacist to tailor an individualized plan of care that addresses potential threats to aging independence in the home environment while working toward functional goals set by the client. Table 1 provides a description of the visits and their sequencing and the protocol and description of what the nurse does in CAPABLE is given by Pho and colleagues.21 Between 2009 and 2010, a randomized controlled pilot trial of CAPABLE was conducted with a sample of 40 low-income older adults, randomly assigned to receive the CAPABLE intervention.
The 2013 National Nursing Research Roundtable: Advancing the science of chronic illness self-management
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CAPABLE trial: A randomized controlled trial of nurse, occupational therapist and handyman to reduce disability among older adults: Rationale and design
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The first RN session follows the first OT session within one month. In this session, the RN assesses the participant using the C–CAP RN developed specifically for CAPABLE [50] in which the RN focuses on how and whether pain, depression, strength and balance, medication management and ability to communicate with the PCP impact daily function. In this assessment, the RN and the participant identify and prioritize goals, and make plans to achieve those goals.
As 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.
The 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 4 months.
The 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.
Pilot Intervention Addressing Social Support and Functioning of Low Socioeconomic Status Older Adults With ESRD: The Seniors Optimizing Community Integration to Advance Better Living with ESRD (SOCIABLE)Study
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For example, if the participant’s goal was to improve mood, the nurse and participant might decide to try having the participant do simple Otago exercises,24 cook together with their spouse, and address the cramping after dialysis that affected the participant’s mood. In the final visit, the nurse reviewed strategies that participants found effective and helped them consider ways to use what they learned to address future challenges.23 Finally, the nurse wrote a letter to the primary care provider and nephrologist summarizing the participant’s goal achievements.
Older adults with end-stage kidney disease have increased morbidity, fatigue, and decreased physical function, which can inhibit self-care and social engagement. We pilot tested a home-based program to improve physical and social functioning of low socioeconomic status older adults treated with hemodialysis (HD).
Qualitative study and randomized waitlist control intervention.
Older adult HD patients in Baltimore, MD.
We identified functional needs and home environmental barriers to social engagement through focus groups; mapped findings onto aspects of an established program, which includes home visits with an occupational therapist, nurse, and handyman to provide ≤$1,300 worth of repairs, modifications, and devices; and piloted the program (Seniors Optimizing Community Integration to Advance Better Living with ESRD [SOCIABLE]) among 12 older adult HD patients. We delivered the services over 5 months in a staggered fashion.
Feasibility and acceptability of the intervention and change in disability scores.
Focus group themes included fatigue, lack of social support, and desire to live independently. SOCIABLE pilot participants were recruited from 2 dialysis units and all were African American (50% men); mean age was 69 years. At baseline, the mean disability score for activities of daily living (ADLs) was 4.4 and for instrumental ADLs (IADLs) was 6.3 (both out of a possible 16). Among the 9 participants alive at follow-up, there was 100% intervention completion and outcomes assessment. All treated participants improved a mean score of 2.3 for ADL and 2.6 for IADL disability, and social support and social network scores improved by 4.8 and 4.6, respectively.
Small sample size; all participants were African American.
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View all citing articles on Scopus

ANTHONY T. PHO, MSN, MPH, CRNP, RN, Staff Associate in Medicine, Weill Cornell Medical College, New York, New York.

ELIZABETH K. TANNER, PhD, RN, FNGNA, Associate Professor, Johns Hopkins University School of Nursing, Baltimore, Maryland.

JILL ROTH, BSN, RN, Research Nurse, Johns Hopkins University School of Nursing, Baltimore, Maryland.

MEGHAN E. GREELEY, MSN, MPH, CRNP, RN, Nurse Practitioner, Baltimore Medical Systems, Inc., Baltimore, Maryland.

CARMALYN D. DORSEY, MSN, RN, Instructor, Johns Hopkins University School of Nursing, Baltimore, Maryland.

SARAH L. SZANTON, PhD, CRNP, RN, Assistant Professor, Johns Hopkins University School of Nursing, Baltimore, Maryland.

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Feature ArticleNursing Strategies for Promoting and Maintaining Function among Community-Living Older Adults: The CAPABLE Intervention

Section snippets

Need for CAPABLE

How CAPABLE Differs from Current Practice

Summary

Acknowledgments

Soc Sci Med

Lancet

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

J Am Geriatr Soc

Environment and other determinants on well-being of older people

Gerontologist

Heathy People 2020

Interventions for enhancing medication adherence

Cochrane Database of Systematic Reviews

Assessment of older people: Self-maintaining and instrumental activities of daily living

Gerontologist

Predicting nursing home admission in the U.S.: a meta-analysis

BMC Geriatrics

A randomized trial of a multicomponent home intervention to reduce functional difficulties in older adults

J Am Geriatr Soc

Feature Article
Nursing Strategies for Promoting and Maintaining Function among Community-Living Older Adults: The CAPABLE Intervention