Aging in Place: Innovative Teams
Sarah L. Szanton
As a nurse practitioner providing house calls, I had one patient I could not get out of my mind. We will call her Annie Lee. She was 100 years old, lived by herself in an apartment, could not read, and could not get her wheelchair through the doorway into her kitchen. This barrier in her environment caused her to crawl from the doorway to her refrigerator. Despite these challenges, she had a wonderful spirit, gave wisdom freely, and was philosophical about what she could and could not do. Her diabetes and hypertension were not well controlled. How could they be? And how could I as a health care provider think that was her most important priority? I provided house calls to low-income residents throughout West Baltimore who found it difficult to leave their homes to see a primary care provider (PCP). One of my patients had to crawl to answer the door. Many could not get up their stairs to sleep in their own beds. And several could only eat snack foods because they were unable to prepare light meals for themselves.
This experience was life-changing for me. I initially approached the visits as a classically trained nurse practitioner. Intent on leveraging my therapeutic relationship with these older adults to help them self-manage their current conditions, I had not been trained to observe their environment and the ways in which it either supported or inhibited them. I had not been trained to observe their overall life goals and how their chronic conditions fit within those.
In this work, it was only too clear that holes in floors, shaky banisters, shelves that were too high to reach, and the mismatch between what people needed and what the environment required of them were inhibiting their health and their ability to age where they wanted to, which for almost everyone was at home. I had not yet studied aging theory, but this experience made me viscerally understand the idea of “person–environment fit,” the theory that Powell Lawton developed in the 1970s (Lawton & Nahemow, 1973), which Miss Lee demonstrated well. Her abilities and her kitchen doorway did not fit. This made the home environment for her stressful, which impacted her health and function.
I knew that people like Miss Lee were important because they were my patients. I did not yet understand how much their experiences represent policy histories and opportunities to change current policy. Demographic shifts make these policy decisions that much more important; by 2050, the percentage of the U.S. population over 65 years of age will be double what it is now (Ortman, Velkoff, & Hogan, 2014). The vast majority of older adults prefer to “age in place” in their home community rather than age in an institution. As a society, we will need to develop multiple ways of helping older adults age in place depending on their individual strengths and needs. Because the number of older adults in the United States is projected to continue growing (U.S. Census Bureau, 2013), it is increasingly urgent to identify ways to support aging with independence.
Aging with independence is important for multiple reasons. It affords better quality of life for older individuals and their families (Schwanen & Ziegler, 2011) and is a foundational American value that, when achieved, saves resources for society to use in other ways.
However, for almost everyone, at every income level, aging brings functional challenges that can compromise independence. These functional challenges result from interactions between an individual’s health and his or her surrounding environment. Low-income older adults face even greater challenges to independence, as they are likely to have more comorbidities (Green et al., 2003), experience more functional limitations as a result (Fuller-Thomson, Nuru-Jeter, Minkler, & Guralnik, 2009; Minkler, Fuller-Thomson, & Guralnik, 2006), and, by definition, have fewer resources to modify their home environments. This combination places them at even greater risk for reduced activity levels, social isolation, falls, and other adverse events.
I studied and obtained my PhD from Johns Hopkins University to learn the research skills to leverage my clinical insights into policy-relevant research. When the 2007 deep recession hit, the National Institutes of Health put out a call for proposals for innovative team members in areas including those hardest hit by the recession. I thought hard about “handymen” (or women)—home repair specialists who do odd jobs and repairs—and about how much good they could do for the patients I had seen in West Baltimore.
I conceived of combining nurse visits with handyman repair and assistive devices. In fleshing out my ideas, I looked at a program called Advancing Better Living for Elders (ABLE), which had already been proven effective in addressing similar challenges. ABLE had been previously evaluated through a randomized controlled trial of 306 older adults in Philadelphia. The program provided occupational and physical therapy sessions involving home modifications and training in their use, as well as instruction in problem-solving strategies, energy conservation, safe performance of basic and instrumental activities of daily living (ADLs and IADLs), fall recovery techniques, and muscle and balance training. The evaluation of this model provided strong evidence that a program focused on improving community-dwelling older adults’ function and control over their circumstances could help to promote aging with independence in these populations and even delay mortality (Gitlin et al., 2006, 2009). I wanted to build on the strengths of ABLE, while also modifying the intervention to address additional threats to aging with independence (such as perilous home environments and their interactions with underlying health issues) more explicitly.
Though not funded at that submission, we received useful critical feedback. I repurposed pilot funding money I had to pilot this new idea, which we called CAPABLE (Community Aging in Place, Advancing Better Living for Elders). This is another lesson in a research trajectory. Sometimes you have to do exactly what you propose and other times (often when working with foundations) if you have a new idea that is compelling to you and the funder, you can gain permission to change what it funds.
CAPABLE augmented ABLE by adding support for actual repairs to unsafe home environments (as opposed to strictly home modifications and adaptive equipment such as grab bars and raised toilet seats) and a nurse to comprehensively assess and address health concerns that could contribute to functional limitations within the home environment, such as pain, depression, medication reconciliation, and PCP advocacy and communication. These realms were added in the service of increasing clients’ capacity to perform their basic and IADLs.
Innovative teams can be important and must be guided by your theory of change or of the phenomenon in place. For example, the dominant theory for this work is person–environment fit, and it is about improving function to allow older adults to achieve their goals. This sort of model is a perfect fit for occupational therapists (OTs). OTs help people across the life span participate in the things they need and want to do (American Occupational Therapy Association, 2016). The American Association of Occupational Therapists states that OTs ask “What matters to you?” not “What’s the matter with you?” When adding team members from different disciplines, it is necessary to maintain a balance between what is essential and what will not make the program too unwieldy. In adding the OT component to my vision for a program that would aid the patients I had seen, I was influenced by this OT emphasis of “what matters to you?”; this perspective then informed the registered nursing aspect of the program we created, as well.
The CAPABLE intervention involves universal assessment of every client by an RN/OT team, which then allows an interdisciplinary team—including the client, nurse, OT therapist, and a home repair specialist (“handyman”)—to tailor an individualized plan that addresses potential threats to aging independence in the home environment while working toward functional goals set by the clients themselves. Table 13.1 summarizes the visits and their sequencing; for a more detailed overview of the nurse’s role in CAPABLE, see the article by Pho et al. (2012).
Our team conducted a randomized controlled pilot trial of CAPABLE in 2009–2010. In a sample of 40 low-income older adults, older adults who had been randomly assigned to receive the CAPABLE intervention showed improvement for all primary outcomes when compared to a control group. This resulted in less difficulty with ADLs and IADLs, less pain, and improved fall-avoidance efficacy (Szanton et al., 2011). Based on those findings, the CAPABLE team was funded by the National Institutes of Health to conduct a 300-person randomized clinical trial assessing whether the intervention improves function, well-being, and health care costs on a larger scale. Also, through the Center for Medicare and Medicaid Innovation, which was created by the Affordable Care Act, the team received funding to provide the CAPABLE intervention to 500 people and test whether the program delayed nursing home admission and reduced preventable hospital costs.
TABLE 13.1 CAPABLE Targeted Areas, Goals, and Treatment Approaches
Target: Approach and Goal
Housing safety: repair built environment to ↓ fall risk,↑ mobility, and ADLs/IADLs
Ability to access primary care and appropriate specialists
Person: Individual factors
Self-care: ↑ ability to independently conduct ADLs and IADLs
Communication with PCP: ↑ patient activation to facilitate better chronic disease management
Medication management: ↑ ability to adhere to medication regime
Intrinsic: Physiological factors
Strength/balance: ↑ ability to stand, balance, and recover from falls, near-falls
Depression: enhance skills for mood management
Pain: to decrease pain to facilitate function