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

Abstract

Background 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. Methods 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. Outcomes 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.

Factors associated with patient activation in an older adult population with functional difficulties

“…37 The participants in this study are part of a well-defined cohort that is taking part in a policy-relevant study, which will evaluate healthcare utilization. 25 Our current study may help clinicians approach patient activation conversations with older adults with functional difficulties.…”

Functional Goals and Predictors of Their Attainment in Low-Income Community-Dwelling Older Adults

“…Individuals who were hospitalized three or more times in the prior year, actively receiving cancer treatment or who had expected survival of less than one year, were cognitively impaired, 26 or had plans to relocate within one year were excluded. 10, 23 The Johns Hopkins University Institutional Review Board approved all trial activities, and study participants provided informed consent.…”

“…10, 23 In CAPABLE, each older adult and OT collaboratively select up to three goals to address during six program visits of 60–90 minutes, adding additional goals if time allows. Based on these goals, the OT and the older adult prioritize a work order for the handyman.…”

“…9, 11, 22 CAPABLE is delivered in older adults’ homes by an occupational therapist (OT), a registered nurse (RN), and a handyman who work with participants to identify strategies that address functional goals prioritized by the older adult. 10, 13, 23 …”

Evaluating Distinctions in the Assessment of Late-Life Disability

“…In prior work (3), we found that participant responses to questions about difficulty and dependence (ie, personal assistance) provide complementary information that together depicts the continuum of disability more fully than does the response to either question alone. These results informed the development of functional scales that have served as disability outcomes in longitudinal studies and clinical trials, with each activity in the scale scored as 0 (no difficulty or need for help), 1 (difficulty but no need for help), and 2 (need for help) (17)(18)(19)(20). In the Women Health and Aging Study II, an additional category of modification, which was intermediate to difficulty and no help, was found to predict the subsequent need for personal assistance (21).…”