Implementing CAPABLE in PSH

Study Overview
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Brief Summary
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This pilot project seeks to implement an intervention known as CAPABLE (Community Aging in Place-Advancing Better Living for Elders) for formerly homeless adults living in permanent supportive housing. This home-based intervention that consists of time-limited services (no more than 6-months) from an occupational therapist, a nurse, and a handyman is intended to improve functioning and decrease falls among this population that prematurely ages and is at increased fall risk.

Detailed Description
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Permanent supportive housing (PSH) using a housing first approach is an evidence-based intervention to end chronic homelessness by providing low-barrier affordable housing paired with flexible health and social services. In Los Angeles County (LAC), where the number of PSH units is expected to increase dramatically over the next 10 years, clinical guidelines and/or standards for support services are lacking. This is especially problematic given the that the target population is older and prematurely aging. The chronically homeless population in the United States has an average age approaching 60 years old and experiences accelerated aging, including an elevated prevalence of geriatric syndromes such as functional impairment, falls, and urinary incontinence that can jeopardize PSH tenants' ability to live independently and age in place. Current support services are not equipped to address these needs, which ultimately jeopardizes the success of PSH to maintain high rates of housing stability while tenants age in place. The investigators propose conducting a pilot project to implement the CAPABLE model in PSH. CAPABLE, which stands for Community Aging in Place-Advancing Better Living for Elders is a client-directed home-based intervention that consists of time-limited services (no more than 6-months) from an occupational therapist, a nurse, and a handyman working collaboratively with the older adult client. CAPABLE was developed to target older adults who are returning to independent living after hospitalization and has been shown to improve functioning (activities of daily living - ADLs and instrumental activities of daily living - IADLs), decrease falls and nursing home admissions, and reduce healthcare costs based on multiple studies including several randomized control trials. CAPABLE has the potential to be used in PSH as a model of support services that can address needs of prematurely aging tenants, which could help transform PSH from an intervention that ends homeless to an intervention that addresses homelessness and supports successful aging in place. The specific aims of this study are to: Examine the impact of CAPABLE on PSH client outcomes (e.g. ADLs, IADLs, falls). This aim will be accomplished using a pre-/post-design with a wait-list control group. Determine what adaptations, if any, need to be made to implement CAPABLE in PSH. The investigators will accomplish this aim using the Dynamic Adaptation Process (DAP) implementation approach, which was designed to allow for an evidenced-based practice to be adapted in a planned and considered, rather than ad hoc, manner. Important to note is that this project was conducted during the COVID-19 pandemic so that adaptations to CAPABLE may be due to the context of the pandemic as opposed to being implemented in PSH.

Official Title
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Implementing CAPABLE in Permanent Supportive Housing

Conditions
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Accidental Fall, Frailty, Depression, Activities of Daily Living, Housing Problems

Intervention / Treatment
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* Behavioral: CAPABLE: Community Aging in Place-Advancing Better Living for Elders


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Older than 50 years in age cognitively intact or have only mild cognitive impairment have some or a lot of difficulty performing ADLs tenant of Skid Row Housing Trust Exclusion Criteria: see above

Ages Eligible for Study
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Minimum Age: 50 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Supportive Care
Intervention Model: Single Group Assignment
Interventional Model Description: Waitlist control design
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Other: CAPABLE<br>CAPABLE Intervention | Behavioral: CAPABLE: Community Aging in Place-Advancing Better Living for Elders<br>* CAPABLE is a client-directed home-based intervention that consists of time-limited services from an occupational therapist, a nurse, and a handyman working collaboratively with the older adult client. In most cases, the OT makes 6 visits, the RN makes 4 visits, and a handyman makes 1 to 2 visits to make any modifications to a person's home during a 6-month period. The first visits for the OT and RN are usually 90 minutes each and the later ones are usually an hour each. Visits are spaced to enable older adults to practice new strategies learned in the previous visit. There should be a clear conclusion/graduation, with the older adult understanding how to use their new skills and apply them to future situations.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Activities of Daily Living | The modified Katz Activities of Daily Living (ADL) Scale will be used to rate ability to bathe, dress, transfer, toilet, and eat using five categories; participants rated their ability to perform daily tasks on a 5-point scale (1 = no difficulty, 2 = a little difficulty, 3 = moderate difficulty, 4 = a lot of difficulty, 5 = unable to do). Higher scores represent greater difficulty performing ADLs | Change of ability to perform activities of daily living from baseline to 6-month follow up (post-intervention). | 
| Brief Instrumental Functioning | The Brief Instrumental Functioning Scale will be used to assess ability to perform in six functions: bathing, dressing, going to toilet, transferring, continence, and feeding. Each area is assessed on a five point scale; participants rated their ability to perform daily tasks on a 5-point scale (1 = no difficulty, 2 = a little difficulty, 3 = moderate difficulty, 4 = a lot of difficulty, 5 = unable to do). Higher scores represent more issues with functioning. | Change of ability to perform IADLs from baseline to 6-month follow up (post-intervention). | 
| Depression | Eight of the nine items in the Patient Health Questionnaire-9 were used to measure depression, rated on a 4-point scale of how frequently participants were bothered by the eight problems during a 2-week period (0 = not at all, 1 = several days, 2 = more than half the days, and 3 = nearly every day). | Change in depression symptoms from baseline to 6-month follow up (post-intervention). | 
| Falls Efficacy | participants rated their confidence they could do each of 10 activities without falling on a 10-point scale, with total scores ranging from 10 (not very confident) to 100 (very confident) using the Tinetti Falls Efficacy Scale. | Change of falls efficacy from baseline to 6-month follow up (post-intervention). | 
| Pain interference with normal, everyday activities | Pain interference with normal, everyday activities was measured using a 3-item brief pain inventory relative to the past week on a 10-point scale for describing pain (0 = no pain; 10 = pain as bad as you can imagine); pain that interfered with enjoyment of life (0 = does not interfere; 10 = completely interferes); and pain that interfered with general activity (0 = does not interfere; 10 = completely interferes). | Change in pain from baseline to 6-month follow up (post-intervention). | 
| Falls | History of falls during the past year and since last assessment period by asking: Did you fall to the ground in the past year (since the last survey)? | Falls reported at baseline and at 6-month follow up (post-intervention). | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Self-rated health | Self-rated health was measured on a 5-point scale (1 = excellent, 2 = very good, 3 = good, 4 = fair, 5 = poor). | Change in self-rated health from baseline to 6-month follow up (post-intervention). | 
| Quality of life | Quality of life from the 12-item Short Form instrument was scored on a 10-point scale (1 = worst possible quality of life; 10 = best possible quality of life). | Change in quality of life from baseline to 6-month follow up (post-intervention). |