Home Visit Intervention Reduces Disability in Older Adults

Tara Haelle

January 08, 2019

A 5-month program involving 10 home visits from healthcare professionals significantly decreased disability in low-income older adults who already had a self-reported disability, according to a randomized clinical trial published online yesterday in JAMA Internal Medicine.

Professionals such as occupational therapists and registered nurses helped participants "identify and achieve their own functional goals through a combination of strategies, including targeting the individual and the home environment," Sarah L. Szanton, PhD, Johns Hopkins University School of Nursing in Baltimore, Maryland, and colleagues write.

The authors tested a person-directed, tailored intervention called Community Aging in Place—Advancing Better Living for Elders (CAPABLE) that aims to improve daily function and meet the needs of low-income older adults.

"This well-powered, randomized trial provides further support that the CAPABLE intervention reduces disability scores in a high-risk subset of the older adult population," the authors write. "As such, the program merits consideration of inclusion in payment innovations, such as those from [Centers for Medicare & Medicaid Services; CMS] that allow Medicare Advantage to pay for nonmedical costs with the medical budget or through a Special Needs Plan geared toward people with disabilities who are dually eligible for Medicaid and Medicare."

The researchers note that a previous single-arm study of CAPABLE, costing $2825 per participant, resulted in Medicare cost savings of $22,000 per participant (compared with a propensity score-matched group), according to the CMS Innovation Center. Healthcare organizations in 22 cities and rural areas in 11 states have since implemented the CAPABLE program, the authors write.

The current randomized study involved 300 low-income adults, aged 65 years or older, who lived in Baltimore between March 18, 2012 and April 29, 2016. All participants had a disability — "self-reported difficulty with 1 or more activities of daily living (ADLs) or 2 or more instrumental ADLs [IADLs]" — but no evidence of cognitive decline.

Occupational therapists, registered nurses, and home modifiers made 10 home visits during 5 months to the 152 people randomly assigned to receive the intervention. A registered nurse assessed pain, depression, medication understanding, strength, balance, and communication with a primary care provider.

Occupational therapists assessed the participants' disability and home safety before helping them identify functional goals they could achieve with personal changes and changes in the home environment, incorporating strategies brainstormed from the participants themselves.

Environmental modifications may have included home repair or acquiring home medical equipment. Examples included "filling in holes in floors, stabilizing shaky banisters, lowering microwaves to reachable heights, installing tailored bathroom safety equipment, and raising toilet seats," Marlon J. R. Aliberti, MD, and Kenneth E. Covinsky, MD, both from Veterans Affairs Medical Center in San Francisco, California, explain in an invited commentary.

Meanwhile, a research assistant made 10 visits to the 148 people in the control group. Data came from interviews at baseline, immediately after the intervention (5 months) and 12 months after baseline. The 10 questions addressed participants' perceptions of the program's benefits, including effect on safety, ease of living, effort required for the intervention, changes in confidence or distress, and similar issues.

Women comprised 87.5% of the intervention group and 87.2% of the control group. Participants who self-identified as black made up 82.9% of the intervention group and 89.9% of the control group. 

Substantial Reduction in Disability

At the intervention's conclusion, those participating in the intervention showed a 30% drop in ADL disability scores compared with controls (relative risk [RR], 0.70; P = .01). The raw score change, on a scale of 0 to 16, went from 4 at baseline to 2.22 at 5 months in the intervention group, compared with 3.99 decreasing to 2.83 in the control group.

These scores rated performance of eight ADLs: walking across the room, bathing, dressing, eating, using the toilet, getting in and out of bed, and grooming. Each activity was rated from 0 to 2, and a 1-point change was deemed clinically meaningful.

"Participants in the control group who received individualized attention also improved, reporting smaller magnitude reductions in ADL and IADL disability scores," the authors write.

Though intervention participants also had 17% lower IADL disability scores than control group participants, the difference was not statistically significant (RR, 0.83; P = .13).

More than twice as many intervention participants (79.8%) as control group participants (35.5%) said the program helped them take care of themselves (P < .001) and helped improve their confidence in handling daily challenges (79.9% vs 37.7%; P < .001). Similarly, 82.3% of the intervention participants and 43.1% of control group participants said the program made life easier (P < .001). 

The researchers point out that daily function can be improved despite it rarely being prioritized in either primary or specialty care — possibly because it is thought to be non-modifiable, they suggest. They add that a booster visit during the year following the intervention might help address the diminished effect seen between 5 and 12 months after baseline.

"In addition, a screening for possible benefits like the Supplemental Nutrition Assistance Program or involvement by a social worker, community health worker, or physical therapist could augment the effect," the authors write, noting that some of the sites that adopted CAPABLE are testing such added features.

The study's biggest disadvantage is potentially having limited generalizability, given its predominantly black, female, urban participants. The researchers also point out that adults regarded as "high-cost utilizers are often harder to engage and may not have the same uptake or same results."

Legislation Opened Funding Opportunities for Under-recognized and Unmet Needs

"Most interventions for disability in older people have focused on physical ability (either restoring capacity or preventing decline), but the CAPABLE intervention has added a substantial innovation: making home modifications to restore physical function," Aliberti and Covinsky write in their commentary.

"This innovative strategy is necessary because declines in physical capacity are often not reversible," they write. But since disability "represents a mismatch between the environment and physical capacity," it is possible to improve functional abilities by reducing obstacles in the environment, such as installing grab bars in the bathroom.

"Such home improvements can meet the real needs of individuals with a disability and support them in living at home safely for an extended period despite a reduced physical capacity," the editorialists write.

They note that the disparate, uncoordinated US healthcare system often neglects not only older adults' complex needs but also their values and goals, such as living independently at home.

"The typical disease-focused model of care leads clinicians to pay insufficient attention to that goal and sometimes even to make therapeutic decisions that directly hinder that goal," Aliberti and Covinsky explain. Obstacles that often go unaddressed can include "falls, polypharmacy, cognitive challenges, limited health literacy, and urinary incontinence," especially in those with multiple chronic conditions.

Funding for programs like CAPABLE has traditionally been challenging since Medicare does not typically pay for nonmedical services, they acknowledge, but the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017 offers opportunities for changing that. The new law provides more flexibility to Medicare Advantage plans and accountable care organizations for coverage of nonmedical services, such as bathroom grab bars and wheelchair ramps in patients identified as high-need and/or high-risk.

The research was funded by the National Institutes of Health. Dr Szanton and coauthor Dr Laura Gitlin invented the CAPABLE program, whose implementation involves fees to Johns Hopkins University. Aliberti and Covinsky have disclosed no relevant financial relationships.

JAMA Intern Med. Published online January 7, 2019. Full text, Editorial

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