The CAPABLE program: description and policy possibilities · 1/15/2014 · The CAPABLE program:...
Transcript of The CAPABLE program: description and policy possibilities · 1/15/2014 · The CAPABLE program:...
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The CAPABLE program: description and policy possibilities
Sarah L. Szanton, PhD CRNP Associate Professor
Johns Hopkins University School of Nursing Principal Faculty, Center for Innovative Care in Aging
January 15, 2014
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Home as ultimate translational context
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Mrs. B
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Clinic visit for Mrs. B
• Focus on her chronic conditions • But what keeps her out of a nursing
home?
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Functional limitations are costly
• 50% of community-living Americans have a chronic condition
• The 14% of Americans who have both chronic conditions and functional limitations account for 46% of all health care spending.
• Not counting nursing homes
HHS, 2010, Closer look at Chronic conditions
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Benefits of function in home
• Individual • Family • Societal • Tax-payer or social policy
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Mrs. B
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The problem in the U.S.
• 42% of current older adults report a functional limitation or disability
• Absolute number will increase as the population ages
• These disabilities are the primary modifiable predictor of nursing home admission
• Nursing homes cost $150 billion/year
Clemans-Cope, 2011, Martin, Friedman et al, 2010
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Disability as a gap
• The gap between a person’s abilities and their environment (Verbrugge and Jette, 1994)
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If disability is the gap, how to approach?
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• What you can do determines where you can
live. • The conditions of where you live can
determine what you can do. • CAPABLE targets both at once.
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CAPABLE
• Focused squarely on individual strengths and deficits and goals in self-care (ADLs and IADL)
• Client-directed as opposed to client-centered • Handyman, Nurse and Occupational Therapist • OT: 6 visits, RN:4 visits, Handyman: $1000
budget
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Month 1 Month 2 Month 3 Month 4 Start
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Pilot Study design
• Randomized control pilot study (N=41) • Baseline and 4 month follow-up • Low-income functionally vulnerable older adults
(≥ 1 ADL or ≥ 2 IADL limitations) • Cognitively intact • Intervention group received all three
interventions • Control group received equivalent amount of
“attention.” Szanton et al, 2011 JAGS
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Pilot Sample
• Approx 80% lived alone • 80% African-American • Average age 79 (range 66-92) • Average ADL limitations were 2.3 • Average EuroQOL of 0-100 = 60
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Attention control
• Mirror the amount of social attention, empathy and engagement provided to experimental group
• Participants reminisce with RAs about lives • Sedentary activities of choice (e.g. scrapbooks,
pictures, cookbooks)
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CAPABLE pilot participants’ evaluation
How much did participation in CAPABLE…. Control Intervention
“a great deal” “some” “a great deal” “some”
Helped them take care of selves 53% 15% 72% 17%
Made life easier 15% 38% 83% 11%
Benefited them 31% 62% 83% 17
Believe CAPABLE would help others 31% 38% 78% 22%
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CAPABLE pilot results
Control
Intervention
Baseline 24 week Change Baseline 24 week Change
Difficulty with ADLs (0-5 possible score)
2.6 (1.4) 2.1 (2.3) Improve
(19%) 2.1(1.2) 0.7 (0.8) Improve
(67%)
Difficulty with IADL (0-5 possible score)
2.0 (1.1) 1.8 (1.9) Improve
(10%) 2.3 (1.4) 1.2(1.3) Improve
(48%)
EuroQOL 5-D (out of 100) 63 55
Decline (13%) 57(18.7) 78(15.8)
Improve (37%)
(average change by group) from 0-24 weeks
Szanton et al, JAGS, 2011
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Project funded by CMS
• Planned N =500 people with Medicaid and Medicare
• No control group • Comparison group • If deemed successful, can become national
policy • Nursing home care in U.S. averages $75,000
per year. CAPABLE costs $4,000 one time.
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Decreasing Pain
9
38
5 7
33
12
0
5
10
15
20
25
30
35
40
Extreme Moderate None
Num
ber o
f Par
ticip
ants
Participant EuroQOL Pain Rating at Baseline and 5 Months for Completed CMS/NIH-Eligible Participants (n=52)
Baseline
F/U
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Decreasing Depressive Symptoms
0
510
1520
25P
HQ
9 S
core
Baseline 5 MonthReassess.
Study Visit
PHQ9 Scores at Baseline and 5 Months for CompletedCMS/NIH-Eligible Participants with Baseline Score >4 (n=35)
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Decreasing Functional Limitations 0
24
68
Num
ber o
f AD
L D
iffic
ultie
s
Baseline 5 MonthReassess
Study Visit
Number of ADL Difficulties at Baseline and 5 Monthsfor Completed CMS/NIH-Eligible Participants (n=52)
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7.692
13.46
78.850
2040
6080
Per
cent
of P
artic
ipan
ts
Decline Stay the Same Improve ADL Status
ADL Status of Participants at Reassessment
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15.38
21.15
63.46
020
4060
Per
cent
of P
artic
ipan
ts
Decline Stay the Same Improve IADL Status
IADL Status of Participants at Reassessment
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Larger CAPABLE RCT currently
• R01 from NIH • Planned N= 300 • Same design as pilot but also measuring 52
week outcomes and health care costs for both arms
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Historic Moment Now
• Affordable Care Act • Demographics of older adults • Medical costs skyrocketing • Nurses poised to work at the top of their
licenses
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State Level Policy
• DHMH Initiative to change hospital payment • MI-CAPABLE in Michigan –
– Pilot will start in 2014 – Roll out likely in 2015 statewide
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Mrs. Jackson
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Acknowledgements
• Study participants • CMS 330970-01: CMMI • 1KL2RR025006-01 • Johns Hopkins Population Center Early Career
Award • The John A. Hartford Building Academic Geriatric
Nursing Capacity Program • 1R01AG040100: National Institute on Aging
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Study staff and students
• Alice Delaney, Jill Roth, Laura Fisher, Allyson Evelyn-Gustave, Allysin Bridges, Wanda Clark-Smith, Karen Harrison, Amelia Ozemoya, Raquel Jarrett, Ashley Lawrence, Gerry Shorb, Felicia Smith, Manka Nkimbeng, Jessica Savage, Laken Roberts, Jolene Lambertis,
• CivicWorks
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Co-investigators
• Laura Gitlin Jack Guralnik • Emily Agree Ibby Tanner • Carlos Weiss Cynthia Boyd • Bruce Leff Roland Thorpe • David Bishai Jeri Allen • Qian-Li Xue Jennifer Wolff • Claire Twose
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Next Public Health Practice Grand Rounds
February 19, 2014