Environmental Skill-building Environmental Skill-building Program (Program (SkillsSkills22Care™) Care™)

A Proven Home-based A Proven Home-based Occupational Therapy Intervention Occupational Therapy Intervention

for Families of Individuals with for Families of Individuals with DementiaDementia

Laura N. Gitlin, Ph.D.Laura N. Gitlin, Ph.D.Director, Jefferson Center for Applied Director, Jefferson Center for Applied

Research on Aging and HealthResearch on Aging and HealthThomas Jefferson University, PhiladelphiaThomas Jefferson University, Philadelphia

Laura.gitlin@jefferson.eduPrepared for Rosalynn Carter Institute Prepared for Rosalynn Carter Institute

Webinar August 16, 2010Webinar August 16, 2010

OutlineOutline

The evidence – who benefits?The evidence – who benefits? What is SkillsWhat is Skills22Care™ ?Care™ ? Training Requirements Training Requirements Organizational requirements Organizational requirements How to sustain the program?How to sustain the program? QuestionsQuestions

A NEW NAMEA NEW NAME

Environmental Skill-building Program is now Environmental Skill-building Program is now calledcalled

SkillsSkills22Care™Care™

Funding SourcesFunding SourcesOriginal Randomized Trial ResearchOriginal Randomized Trial Research:: National Institute on AgingNational Institute on Aging National Institute on Nursing ResearchNational Institute on Nursing Research National Institute of Mental HealthNational Institute of Mental Health PA Dept. of Health, Tobacco Settlement FundsPA Dept. of Health, Tobacco Settlement FundsTranslational ResearchTranslational Research:: Carter/Johnson & JohnsonCarter/Johnson & Johnson Administration on AgingAdministration on Aging Farber Family FoundationFarber Family Foundation

Who Benefits?Who Benefits?

Benefits to Individuals with Benefits to Individuals with DementiaDementia

Decrease frequency of Decrease frequency of behavioral occurrences behavioral occurrences Reduced functional Reduced functional dependencedependence Enhanced engagement Enhanced engagement and quality of lifeand quality of life

Gitlin, et al., (2005). Gitlin, et al., (2005). Maintenance of effects of the home environmental skill- building program for Maintenance of effects of the home environmental skill- building program for family caregivers and individuals with Alzheimer’s disease and related disorders. family caregivers and individuals with Alzheimer’s disease and related disorders. Journal of Journal of Gerontology: Medical Sciences, 60A(3)Gerontology: Medical Sciences, 60A(3), 368-374; Gitlin, et al., (2001). A randomized, controlled trial of , 368-374; Gitlin, et al., (2001). A randomized, controlled trial of a home environmental intervention: Effect on efficacy and upset in caregivers and on daily function of a home environmental intervention: Effect on efficacy and upset in caregivers and on daily function of persons with dementia. persons with dementia. The Gerontologist, 41The Gerontologist, 41, 4-14., 4-14.

Benefits to Family Caregivers Benefits to Family Caregivers Enhances family caregiver:Enhances family caregiver:

• Skill to use effective communicationsSkill to use effective communications• Skill using simplification strategiesSkill using simplification strategies• Confidence managing day-to-dayConfidence managing day-to-day• Well-being (particularly for spouses and women)Well-being (particularly for spouses and women)

Reduces family caregiver:Reduces family caregiver:• Upset with behaviorsUpset with behaviors• Burden and depression Burden and depression • Time spent “on duty” for male caregivers in Time spent “on duty” for male caregivers in

particularparticular

Gitlin, et al. (2003). Gitlin, et al. (2003). Effects of the Home Environmental Skill-building Program on the Effects of the Home Environmental Skill-building Program on the Caregiver-Care Recipient Dyad: Six-month Outcomes from the Philadelphia REACH Caregiver-Care Recipient Dyad: Six-month Outcomes from the Philadelphia REACH Initiative. Initiative. The GerontologistThe Gerontologist, , 43(4),43(4), 532-546; 532-546; Gitlin, et al., (2001). A randomized, controlled trial of a home environmental Gitlin, et al., (2001). A randomized, controlled trial of a home environmental intervention: Effect on efficacy and upset in caregivers and on daily function of persons intervention: Effect on efficacy and upset in caregivers and on daily function of persons with dementia. with dementia. The Gerontologist, 41The Gerontologist, 41, 4-14., 4-14.

WHAT IS SkillsWHAT IS Skills22Care™ ?Care™ ?

A Program to enhance skills of A Program to enhance skills of family caregivers to provide care family caregivers to provide care for individuals with dementia for individuals with dementia and manage the everyday and manage the everyday challenges of caregivingchallenges of caregiving Theory-driven:Theory-driven:

Stress process theoriesStress process theories Competence-environmental press and Competence-environmental press and

environmental vulnerability environmental vulnerability frameworksframeworks

Tested using randomized trial Tested using randomized trial methodology:methodology: Community-based families in Community-based families in

Philadelphia regionPhiladelphia region Over 1000 families of individuals with Over 1000 families of individuals with

mild to moderate/severe dementiamild to moderate/severe dementia

Core Treatment Principles Core Treatment Principles Client-centeredClient-centered

Culturally relevant Culturally relevant

Tailored/customized Tailored/customized

Active learning techniques Active learning techniques

Problem-solving orientedProblem-solving oriented

Delivery Characteristics Delivery Characteristics Home-basedHome-based Flexible visit schedule Flexible visit schedule

depending upon service depending upon service contextcontext Recommended 6 session but can Recommended 6 session but can

range up to 10 sessions over 3 to range up to 10 sessions over 3 to 6 months6 months

Each session 60 to 90 minutesEach session 60 to 90 minutes Sessions scheduled flexibly Sessions scheduled flexibly

based on caregiver needs, OT based on caregiver needs, OT training considerations and training considerations and service setting requirementsservice setting requirements

3 to 5 caregiver-identified 3 to 5 caregiver-identified problem areas are typically problem areas are typically addressed addressed

Intervention ComponentsIntervention Components Assessments Assessments

HomeHome• SafetySafety• Supportive featuresSupportive features

Individuals with dementia Individuals with dementia • Functional decline Functional decline • Activity engagement Activity engagement • Behavioral challengesBehavioral challenges

CaregiversCaregivers• Emotional well-beingEmotional well-being• Daily routinesDaily routines• Areas of concern Areas of concern • Understanding of dementiaUnderstanding of dementia

Communication (dyadic interactions) Communication (dyadic interactions)

Intervention ComponentsIntervention Components Problem solving:Problem solving:

Problem identificationProblem identification Problem solving and brainstorming strategiesProblem solving and brainstorming strategies

Introduction of strategies tailored to caregiver-Introduction of strategies tailored to caregiver-identified problem areaidentified problem area Communication (removal of negative and practice of Communication (removal of negative and practice of

positive tactile, verbal and written cueing)positive tactile, verbal and written cueing) Environment (low cost adaptive equipment, removal of Environment (low cost adaptive equipment, removal of

clutter, rearrangement of physical objects)clutter, rearrangement of physical objects) Tasks (simplifying everyday activities)Tasks (simplifying everyday activities) Activities (pleasant activities graded to abilities)Activities (pleasant activities graded to abilities)

Taking care of self Taking care of self (Healthy behaviors; Stress reduction)

Education about dementiaEducation about dementia

Caregiver Skill-buildingCaregiver Skill-building

Customized Action Customized Action Plan introduces four Plan introduces four types of strategies types of strategies

When and how to When and how to practice strategiespractice strategies

Introduced through Introduced through role play and role play and demonstrationdemonstration

ACTION PLAN

1. Simplify task 2. Communicate3. Environment4. Activity

Session-by-Session OverviewSession-by-Session Overview Session 1Session 1

AssessmentAssessment Building rapportBuilding rapport Identification of problems most distressful to caregiverIdentification of problems most distressful to caregiver Education about disease and caregivingEducation about disease and caregiving Stress reduction techniqueStress reduction technique

Session 2Session 2 Problem-solving/brainstorming processProblem-solving/brainstorming process Introduction and practice of strategiesIntroduction and practice of strategies On-going educationOn-going education Strategies for taking care of selfStrategies for taking care of self

Session 3-5Session 3-5 Refine strategies for first problem areaRefine strategies for first problem area Identify new problem/ problem-solving/brainstorming processIdentify new problem/ problem-solving/brainstorming process On-going educationOn-going education Stress reductionStress reduction

Session 5-6Session 5-6 Refine strategiesRefine strategies Validation and evaluation of what works and whyValidation and evaluation of what works and why Generalize strategies learned to new problem areas and future challengesGeneralize strategies learned to new problem areas and future challenges

Case ExamplesCase Examples

•Decreased function

Reducing Confusion and Dependence

Caregiver Concerns

•Confusion

•Inappropriate dress

Strategies:

•Color contrast

•Object Placement

•Previous habits

Outcome:•Increased independence

Use of Color Coding

Disorienting cue

Red duct tape for color contrast

White commode on white wall

Visual Cues

Visual Cues

Visual Cue to prevent egress

Case Scenario•Distractible•Poor eating•Fear of malnutrition

First Set of Strategies•Red placemat •White plate•One food item•Cereal•Spoon

Enhancing Nutritional Intake and Eating Independence

Use of turban

•Culturally appropriate

•Preservation of role

•Reduce distraction

Strategies

-Tactile cueing

-Short 1 to 2 step commands

Enhancing Caregiver Communication Skills

Strategies •Activities with repetitive motion•Simplify all task•Set up objects in field of vision•Preserve wife’s role as homemaker

Case Scenario•Caregiver has no time for self•Does not know how to occupyWife•Concerned about poor quality of life

Training Requirements Training Requirements

RequirementsRequirements

Licensed occupational therapistsLicensed occupational therapists Training and certification in program Training and certification in program License agreement with agencyLicense agreement with agency

4 Training Components4 Training Components Assigned targeted readings based on Assigned targeted readings based on

knowledge test (about 4 hours knowledge test (about 4 hours independent readings)independent readings)

Individual completion of up to eight (8) Individual completion of up to eight (8) hours of on-line web-based asynchronous hours of on-line web-based asynchronous trainingtraining

1½ days of face-to-face training on site 1½ days of face-to-face training on site at agency at agency

Follow-up group conference calls for Follow-up group conference calls for coaching and case presentationscoaching and case presentations E-mail support also availableE-mail support also available

Training CostsTraining Costs CertificationCertification

$2,000 per occupational therapist trained$2,000 per occupational therapist trained After 2 years, $200 for recertificationAfter 2 years, $200 for recertification On-going access to website and all materials On-going access to website and all materials

AgencyAgency Free licensure agreement that outlines use of Free licensure agreement that outlines use of

program name and delivery restricted to OTs program name and delivery restricted to OTs trained and certified in programtrained and certified in program

Organizational ReadinessOrganizational Readiness Access to occupational therapists:Access to occupational therapists:

On StaffOn Staff Contracting with independent contractorsContracting with independent contractors Home care agencyHome care agency

Mechanism for outreach and enrolling families Mechanism for outreach and enrolling families Resources for local referrals for depression and Resources for local referrals for depression and

other related caregiver issues (financial other related caregiver issues (financial planning) that OTs can introduce if necessaryplanning) that OTs can introduce if necessary

Oversight of quality of delivery:Oversight of quality of delivery: SkillsSkills22Care™ has built in fidelity measuresCare™ has built in fidelity measures

Plan for sustainability – how will program be Plan for sustainability – how will program be supported over time?supported over time?

National Family

Caregiver Act

Skills2Care (caregiver

only)

Medicare Part A Medicare Part B

Reimbursement Potential ofReimbursement Potential of Skills2Care™Skills2Care™

Skills2Care Embedded in Patient

care

New Dementia Care Service

-Skills2Care as part of a comprehensive dementia care service

Skills2Care

Embedded in Patient

care

Gitlin et al., in press TG

Who is Using Who is Using SkillsSkills22Care™Care™ Fox Geriatric RehabilitationFox Geriatric Rehabilitation

For-profit company providing house calls using Medicare Part B:For-profit company providing house calls using Medicare Part B:

Holy Redeemer Home Care Agency using Medicare Part AHoly Redeemer Home Care Agency using Medicare Part A St. Augustine, Florida Social Service Organization using St. Augustine, Florida Social Service Organization using

combination of funding sourcescombination of funding sources University of Toronto OT group through grant support University of Toronto OT group through grant support Area Agency on Aging in NJ Mercer CountyArea Agency on Aging in NJ Mercer County

National Family Caregiver ProgramNational Family Caregiver Program Jefferson Elder Care, Thomas Jefferson UniversityJefferson Elder Care, Thomas Jefferson University

• Medicare Part BMedicare Part B• Private PayPrivate Pay• Foundation sources of supportFoundation sources of support

Contact Information for Contact Information for TrainingTraining

Catherine V. Piersol, MS, OTR/L, Catherine V. Piersol, MS, OTR/L, Clinical Director, Jefferson Elder Clinical Director, Jefferson Elder

CareCare Catherine.piersol@jefferson.edu

215-503-9509 215-503-9509

QUESTIONSQUESTIONS

Select Key ReferencesSelect Key References Gitlin, L. N., Jacobs, M., & Vause-Earland, T. (2010). Translation of a dementia caregiver

intervention for delivery in homecare as a reimbursable Medicare Service: Outcomes and lessons learned. The Gerontologist, doi: 10.1093/geront/gnq057.

Gitlin, L. N., Winter, L., Dennis, M. P. (Summer, 2010). Assistive devices to help manage behavioral symptoms of dementia: What do caregivers use and find helpful? Special issue in honor of Dr. Fozzard, Gerontechnology, 9 (3), 408-414.

Gitlin, L. N., Hauck, W. W., Dennis, M. P. & Winter, L. (2005). Maintenance of effects of the home environmental skill-building program for family caregivers and individuals with Alzheimer’s disease and related disorders. Journal of Gerontology: Medical Sciences, 60A(3), 368-374.

Gitlin, L. N., Winter, L., Corcoran, M., Dennis, M., Schinfeld, S. & Hauck, W. (2003). Effects of the Home Environmental Skill-building Program on the Caregiver-Care Recipient Dyad: Six-month Outcomes from the Philadelphia REACH Initiative. The Gerontologist, 43(4), 532-546.

Gitlin, L. N., Schinfeld, S., Winter, L., Corcoran, M. & Hauck, W. (2002). Evaluating home environments of person with dementia: Interrater reliability and validity of the home environmental assessment protocol (HEAP). Disability and Rehabilitation, 24, 59-71.

Gitlin, L. N. Winter, L., Dennis, M., Corcoran, M, Schinfeld, S. & Hauck, W. (2002). Strategies used by families to simplify tasks for individuals with Alzheimer's disease and related disorders: Psychometric analysis of the task management strategy index (TMSI). The Gerontologist, 42, 61-69.

Gitlin L. N., Corcoran, M., Winter, L., Boyce, A. & Hauck, W. (2001). A randomized, Gitlin L. N., Corcoran, M., Winter, L., Boyce, A. & Hauck, W. (2001). A randomized, controlled trial of a home environmental intervention: Effect on efficacy and upset in controlled trial of a home environmental intervention: Effect on efficacy and upset in caregivers and on daily function of persons with dementia. caregivers and on daily function of persons with dementia. The Gerontologist, 41The Gerontologist, 41, 4-14., 4-14.

Gitlin, L. N. & Corcoran, M. (2000). Making homes safer: Environmental adaptations for Gitlin, L. N. & Corcoran, M. (2000). Making homes safer: Environmental adaptations for people with dementia. people with dementia. Alzheimer’s Care Quarterly, 1Alzheimer’s Care Quarterly, 1, 50-58., 50-58.