Fragile older people find a way to live independently

Pauline Jeffery had let things slip since the death of her husband. His room was messy. His bathroom was disorganized. She often stumbled on carpets in her living room and dining room.

"I was depressed and I was just complaining," said the 85-year-old Denver resident.

But Jeffery's inertia has faded when she joined a program aimed at low-income frail elderly people: Community Aging in Place – Improving the quality of life of the elderly (CAPABLE). In the last months of last year, an occupational therapist visited Jeffery and discussed the issues she wanted to address. A handyman has installed a new carpet. A visiting nurse gave her the feeling of being neat.

In no time, Jeffery arranged his room, cleaned his bathroom and began to feel more optimistic. "There are a lot of people like me who just need a boost and someone to make them feel that they are worth something," she said. "What they did for me, it motivated me."

New research shows that CAPABLE provides considerable help to vulnerable seniors who have difficulties with "activities of daily living" – taking a shower or bath, getting dressed, going to bed and going out, going to toilet or move easily to the house. According to a randomized clinical trial – the gold standard for research – published this month in the JAMA Internal Medicine magazine, program participants had 30% fewer difficulties with such activities.

"If anyone discovered a drug reducing 30% disability in the elderly, we were constantly hearing about it on television," said John Haaga, director of the Division of Behavioral and Social Research. the National Institute of Aging, which provided: funding for research.

The positive results are particularly remarkable given the population studied: 300 elderly people more or less poor, nearly 90% women, more than 80% blacks, with an average age of 75 years and multiple chronic diseases such as heart disease, arthritis and chronic diseases. obstructive lung disease. In the United States, about one-third of seniors need help with one or more daily activities, but disability rates and related health care costs are higher in this struggling population.

Half of the seniors participating in the trial benefited from the CAPABLE intervention, which includes six visits by an occupational therapist, four visits by a registered nurse, and repair and modification services. housing worth up to $ 1,300. The control group received 10 visits of equal length from a research badistant and was encouraged to use the internet, listen to music, play board games or reminisce about the past, among other activities .

Both groups experienced improvements at five months, but seniors who participated in the CAPABLE program received significantly greater benefits. Eighty-two percent strongly agreed that the program had made their lives easier and their homes safer. Nearly 80% said that it allowed them to live at home and allowed them to better manage daily challenges.

Sarah Szanton, who developed CAPABLE and runs the Johns Hopkins School of Nursing's Innovative Care Center for Aging, attributes positive results to several elements of the program. Instead of telling an older person what is wrong with her, a pillar of medical practice, CAPABLE staff ask seniors what they would like to do but can not do now.

Older people often say that they want to cook for themselves, prepare their beds, use the stairs, get out of the house more easily, walk around painlessly or go to church.

The focus is then on finding practical solutions. For someone who wants to cook but whose legs are weak, it can mean cutting vegetables by sitting down before getting up in front of the stove. It may be necessary to raise a bed on the risers and place a support bar between the mattress and the box spring so that a person can stand up more easily. A nurse may also need to review her medications and recommend any changes to the attending physician.

"Why does it work, because we are guided by what people want and in order to improve, you have to improve: it must be important to you," said Amanda Goodenow, CAPABLE at the Colorado Visiting Nurse Association, the agency that helped Jeffery. In Colorado, CAPABLE was funded by a local foundation and Habitat for Humanity, which supports the program in six markets.

Hattie Ashby, 90, has been living in the same two-story home in Aurora, a nearby Denver town for 43 years, told Goodenow last summer that she wanted to go up and down more stairs. easily and walk around the outside of the house. . Ashby suffers from hypertension and COPD.

"They gave me a walker and arranged for me to put my oxygen tank so that I could go to the mall," she said, recalling some of the staff's actions. of CAPABLE. "They fixed the wall of my bathroom and put something I could hold to get in and out of my tub, and to go up and down my stairs, they put another rail on the wall that I could stand on. "

"It's a great service for a senior to be encouraged, helped, supported in this way," Ashby said.

It also turns out to be a profitable investment. Research conducted by Szanton and others has shown that for every dollar spent on CAPABLE, Medicare and Medicaid total nearly $ 10 in combined savings, mainly because of hospitalizations and nursing home placements. (Many CAPABLE participants are eligible for both government health insurance programs because of their low incomes.) The average cost of the program per person is $ 2,825, well below the average monthly cost of $ 7,441. a semi-private room in a retirement home in 2018.

With a new grant of nearly $ 3 million from the Rita & Alex Hillman Foundation, Szanton is taking a closer look at the development of CAPABLE across the country. Currently, the program is available at 26 sites in 12 states and Medicaid programs in Mbadachusetts and Michigan have adopted a version for some members. Obtaining financing is a major challenge, as public and private insurers do not generally pay for this type of service. Until now, funding for foundations and grants has been a major source of support.

Szanton hopes to convince Medicare Advantage plans, which cover about 19 million Medicare beneficiaries and can now offer a range of non-medical benefits to members, so that they can adopt CAPABLE. In addition, Johns Hopkins and Stanford Medicine have submitted a proposal for the traditional Medicare program to offer the program in the form of a bundle of services. Responsible care organizations, hospital groups and physicians who bear financial risks to the health of their patients are also interested, given the potential benefits and cost savings.

Another priority will be how to extend the impact of CAPABLE over time. Since the benefits of the newly published clinical trial decrease over a 12-month period, additional elements of the program – phone calls, additional visits and follow-up evaluations – will be probably necessary, said Dr. Kenneth Covinsky, professor of geriatrics at the University of California-San Francisco and co-author of an editorial on CAPABLE that accompanied the study.

He is optimistic about CAPABLE's prospects. "As clinicians, when we see older patients with conditions that we can not reverse, we must understand that we are not short of things we can do," Covinsky said. "Returning patients to a program like CAPABLE is one thing that could make a big difference."

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