Abstract
Background:
CAPABLE is a time-limited, evidence-based intervention that helps older adults live independently. It has not been previously tested for use among formerly homeless adults in permanent supportive housing (PSH) who experience accelerated aging that can jeopardize their ability to live independently and age in place.
Methods:
A pilot randomized controlled trial with PSH tenants with an average age of 63 years old was conducted to examine the impact of CAPABLE on basic and instrumental activities of daily living (and other function-related parameters). Twenty-seven PSH tenants received the intervention and 30 PSH tenants were assigned to a waitlist control group.
Results:
Those who received the intervention showed improvements in five of seven health outcomes with small to medium effect sizes (Cohen’s d = .20–.47). When compared to the control group, the intervention group showed significantly greater improvements in two health outcomes—namely, reduction in limitations in instrumental activities of daily living (p = .03) and depression (p = .01)—and greater effect sizes (d = .17–.61).
Conclusions:
CAPABLE is an evidence-based practice that can be successfully implemented in PSH to improve outcomes in a population that experiences significant health disparities and premature decline. Further investigation with a larger sample is warranted.
Keywords: Homelessness, Housing first, Fall prevention, Older adults, Aging
Introduction
Permanent supportive housing (PSH) using a Housing First approach refers to access to affordable, independent housing combined with home- and community-based services for people experiencing homelessness.1 The U.S. federal government recognizes PSH as an evidence-based, “clear solution” to chronic homelessness.2 PSH increases quality of life and reduces overall public costs by placing individuals into independent community living.1 A significant portion of the population that now resides in PSH is at high risk of premature onset of geriatric conditions that can jeopardize independent living.3 Indeed, the target population of PSH includes chronically homeless individuals who are younger than 60 years old on average4 but experience significant accelerated aging.5,6,7 To date, however, there has been limited research on whether and how PSH programs can help tenants maintain independent living and age in community.8,9
A model of care known as Community Aging in Place, Advancing Better Living for Elders, or CAPABLE, is a person-directed, evidence-based intervention10 that has been used to address many geriatric conditions experienced by PSH tenants.3 It consists of a 10-session home-based program delivered over 5 months that involves individualized action plans developed by the older adult in conjunction with an occupational therapist (OT), registered nurse (RN), and home repair specialist. Across multiple clinical trials with low-income older adults living at home, CAPABLE has shown improvements in activities of daily living (ADLs), instrumental ADLs (IADLs) and depression.11,12 CAPABLE had not been implemented in PSH where tenants are on average younger and have higher rates of chronic mental health conditions than the target population for CAPABLE.
The goal of this study was to examine the impact of CAPABLE on ADL and IADL limitations. The study was conducted in Los Angeles County, which has the nation’s largest unsheltered homeless population13 and the most PSH placements in the United States.14 In a previous study of PSH tenants, researchers found that in a sample with an average age of 58 years old, 42% of tenants reported having ADL difficulty and 68% reported IADL difficulty.3 Accordingly, CAPABLE was identified as an intervention that could address tenant need and shared an underlying person-centered approach with PSH.15,16
Methods
Overview of the CAPABLE program implementation
Based on an increasing recognition that the current menu of homelessness services was not adequately prepared to meet the needs of an aging homeless population,17 county funds were allocated to support this pilot. An existing community–academic partnership with one of the largest PSH agencies in Skid Row facilitated the use of a randomized, wait-list controlled trial. The trial is registered on ClinicalTrials.gov (NLM Identifier: NCT04076319). The program was initially scheduled to begin in March 2020 but due to the onset of the COVID-19 pandemic was delayed until February 2021. During this time, study measures were updated to be maximally consistent with other CAPABLE studies in collaboration with Johns Hopkins School of Nursing (JHSN) that provided Electronic Data Capture (REDCap) data dictionaries. JHSN also provided an on-line CAPABLE training to RNs and OTs along with ongoing technical assistance phone calls throughout the project. For this pilot, the trained OT was a full-time staff member at the PSH agency, and the two trained RNs worked part-time through an online scheduling platform with oversight from a local federally qualified health center.
Participant recruitment and data collection
Starting in December 2020, the PSH support staff including the trained OT began to identify eligible participants for the CAPABLE program based on the inclusion criteria of being a PSH tenant older than 50 years with some or a lot of difficulty performing ADLs and is cognitively intact or has only mild cognitive impairment. Tenants who were perceived to meet these criteria received details about the CAPABLE program from the trained OT, who also asked whether tenants would be interested in participating in a study. Interested tenants were referred to the research team. The team screened each referral to confirm eligibility criteria, obtained informed consent, and randomly assigned individuals to either the intervention or waitlist control group using a random number generator.
Between December 2020 and January 2021, 75 PSH tenants were referred to the research team; 15 people declined to participate, resulting in 60 individuals who answered a survey-administered baseline assessment and were randomized into the intervention or waitlist control group. The CAPABLE team then received the list of 30 tenants randomized to initially received the intervention. Two individuals decided they no longer wanted to participate in the program and one person could not be reached (the team later discovered this person had died), leaving 27 who received the intervention starting in February 2021. In June 2021, the 30 people in the waitlist control group completed a follow-up research assessment, along with the 17 people who had finished the CAPABLE intervention at that time. By September 2021, the remaining 10 people all completed the CAPABLE program but only nine completed the follow-up research assessment; one person declined to complete but was contacted 6 months later and completed the follow-up assessment. See Consort Diagram (Figure 1) for details on the screening and randomization process.
Figure 1.
CONSORT diagram of study participation.
Most intervention visits occurred in person at the participant’s residence (a few visits by the nurse were conducted by phone if the individual was able to share progress and could follow guidance through this format). All research data collection was conducted by telephone as part of COVID-19 safety protocols. PSH tenants received a $20 gift card for completing the baseline assessment and a $25 gift card for completing the follow-up assessment.
Data entry and management
Data were collected and managed using the REDCap platform.18,19 Measures collected only at baseline included basic demographics, years in current PSH unit, and cumulative years spent homeless (lifetime). Participants were also asked about the number of falls, emergency room (ER) visits, and hospitalizations during the past year at baseline; these same questions were asked at follow-up but used only a 6-month retrospective. Seven health-related outcomes were measured at baseline and follow-up. This included an 8-item scale each for both ADL20 and IADL limitations21 on which 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). For 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.22 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).23 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).24 Self-rated health was measured on a 5-point scale (1 = excellent, 2 = very good, 3 = good, 4 = fair, 5 = poor).25 Finally, 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). We exported REDCap data into SAS for data management and Stata for data analysis.
Data Analysis
To assess the balance between the intervention and control groups at baseline we used Fisher’s exact test for nominal variables, the Cochran–Mantel–Haenszel test for ordinal variables, and two-sample t-tests for continuous and count variables. Given that the main analytic goal of this pilot study was to consider the effect size of the intervention, we calculated within- and between-group standardized mean differences (Cohen’s d) between time points. These tests were also used to compare differences in falls, ER visits, and hospitalizations between the groups at follow-up. To consider statistically significant changes in key outcomes in each group (i.e., intervention and control) between baseline and follow-up, we also used a paired t-test. Between-group analyses included a two-sample t-test to test whether the mean change in outcomes between baseline and follow-up differed between the intervention and control groups.
Results
As shown in Table 1, our sample had an average age of 63.4 years old, 63% of participants were male, 12% identified as non-Hispanic White. The mean years in their current housing unit was more than 7 years and the mean time experiencing homelessness was close to 6 years. In this sample, 78% of participants had three or more chronic health conditions. There were no differences in reported falls, ER visits, or hospitalizations during the past 12 months between groups.
Table 1.
Participant Characteristics at Baseline
| Characteristic | All | Intervention | Waitlist | |
|---|---|---|---|---|
| (N = 60) | (n = 30) | (n = 30) | p | |
| Age, years, M (SD) | 63.4 (7.0) | 64.1 (6.8) | 62.7 (7.2) | .43 |
| Gender, cis-man, n (%) | 38 (63.3) | 17 (56.7) | 21 (70.0) | .28 |
| Income, M (SD) | 884.36 (562.01) | 924.98 (647.75) | 847.79 (480.47) | .61 |
| Race and ethnicity, n (%) | ||||
| Non-Hispanic White | 7(11.7) | 4 (13.3) | 3 (10.0) | .69 |
| Non-Hispanic Black | 31 (51.7) | 19 (63.3) | 12 (40.0) | .07 |
| Asian, American Indian, or Alaska Native | 6 (10.0) | 2 (6.7) | 4 (13.3) | .39 |
| Latino only | 2 (3.3) | 0.0 | 2 (6.7) | .15 |
| Biracial, multiracial, or multiethnic | 14 (23.3) | 5 (16.7) | 9 (30.0) | .22 |
| Education (%) | ||||
| Less than HS diploma | 18 (30.0) | 6 (20.0) | 12 (40.0) | .09 |
| HS diploma or GED | 11 (18.3) | 8 (26.7) | 3 (10.0) | .10 |
| Some college | 25 (41.7) | 14 (46.7) | 11 (36.7) | .43 |
| Bachelor’s degree or more | 6 (10.0) | 2 (6.7) | 4 (13.3) | .39 |
| Years living in current home, M (SD) | 7.87 (6.73) | 8.53 (7.55) | 7.20 (5.85) | .45 |
| Years of homelessness, M (SD) | 5.91 (7.53) | 6.15 (8.54) | 5.68 (6.51) | .81 |
| Moderate or severe pain, n (%) | 43 (71.7) | 21 (70.0) | 22 (73.3) | .77 |
| Three or more chronic health conditions. n (%) | 47 (78.3) | 22 (73.3) | 25 (83.3) | .88 |
| Falls in past year, M (SD) | 8.47 (17.0) | 7.17 (12.02) | 9.54 (20.46) | .65 |
| Proportion of people with falls in the past year, M (SD) | 0.73 (0.45) | 0.67 (0.48) | 0.80 (0.41) | .25 |
| ER visits in past year, M (SD) | 2.22 (4.13) | 2.10 (4.67) | 2.35 (3.57) | .82 |
| Overnight hospitalizations in past year, M (SD) | 1.10 (2.36) | 1.23 (2.87) | 0.97 (1.72) | .67 |
Note: GED = graduate equivalency degree; HS = high school.
As shown in Table 2, upon completion of CAPABLE, the intervention group showed improvements in five of seven health outcomes, leaving pain interference and self-rated health as the only outcomes that did not show improvement. For the five outcomes that did improve, effect sizes were small to medium (d = .20–.47). Compared to the outcomes that improved for the intervention group, the control group only showed improvement in ADL limitations. When compared to the control group, the intervention group showed greater effect sizes (d = .17–.61) and significantly greater improvements in two health outcomes—namely, IADL limitations (p = .03) and depression (p = .01). Despite no differences emerging between groups in the number of falls during the past year at baseline, the intervention group reported significantly fewer falls during the past 6 months at follow-up.
Table 2.
Changes in Key Health Outcomes from Baseline to Follow-Up
| Outcome (range) | Intervention group | Control group | Between group | ||||||
|---|---|---|---|---|---|---|---|---|---|
| n | Baseline M [95% CI] | Follow-up M [95% CI] | d | n | Baseline M [95% CI] | Follow-up M [95% CI] | d | d | |
| Mean ADL limitations scorea (8–32) | 27 | 17.07 [14.34, 19.80] | 14.67 [12.63, 16.70] | −.39* | 30 | 14.47 [12.58, 16.35] | 13.17 [11.52, 14.80] | −.28* | .25 |
| Mean IADL limitations scorea (8–36) | 27 | 18.44 [15.09, 21.80] | 15.96 [13.30, 18.63] | −.32* | 30 | 15.07 [12.8, 17.33] | 15.17 [12.82, 17.50] | .02 | .50* |
| Mean PHQ depression scorea (0–24) | 27 | 11.78 [8.75, 14.81] | 8.93 [6.11, 11.75] | −.47* | 30 | 9.23 [7.49, 10.98] | 9.47 [7.26, 11.68] | .05 | .61* |
| Mean quality of lifeb (1–11) | 27 | 6.48 [5.21, 7.75] | 7.71 [6.32, 9.09] | .37* | 28 | 6.46 [5.42, 7.51] | 6.68 [5.52, 7.84] | .07 | .34 |
| Mean falls efficacyb (10–100) | 27 | 64.59 [53.39, 75.80] | 69.78 [60.47, 79.09] | .20 | 30 | 74.73 [66.16, 83.31] | 73.8 [65.05, 82.55] | −.02 | .30 |
| Pain interference w/usual activitiesa (0–10) | 27 | 6.26 [4.82, 7.70] | 6.28 [5.04, 7.53] | .01 | 30 | 5.8 [4.54, 7.06] | 5.44 [4.10, 6.79] | −.08 | .17 |
| Self-rated quality of healtha (0–5) | 27 | 3.44 [2.99, 3.90] | 3.44 [2.99, 3.90] | .00 | 30 | 3.97 [3.65, 4.28] | 3.67 [3.31, 4.02] | −.49 | .38 |
| Proportion of people w/ falls in past 6 months | 27 | -- | 0.52 [0.32, 0.72] | -- | 30 | -- | 0.63 [0.45, 0.82] | -- | .23 |
| Number of falls in the past year or 6 months (1–50) | 27 | -- | 1.22 [0.35, 2.10] | -- | 29 | -- | 2.67 [1.06, 4.28] | -- | .42 |
| Proportion of people w/ ER visits in past 6 months | 26 | -- | 0.35 [0.15, 0.54] | -- | 29 | -- | 0.35 [0.16, 0.53] | -- | .00 |
| Number of ER visits in past 6 months (0–8) | 26 | -- | 0.85 [0.18, 1.51] | -- | 29 | -- | 0.90 [0.19, 1.60] | -- | .03 |
| Proportion of people w/ hospitalizations in past 6 months | 26 | -- | 0.23 [0.06, 0.40] | -- | 29 | -- | 0.21 [0.05, 0.36] | -- | .06 |
| Number of hospitalizations in past 6 months (0–30) | 26 | -- | 1.77 [−0.66, 4.19] | -- | 29 | -- | 0.31 [0.06, 0.56] | -- | .35 |
Note. CI = confidence interval; ADL = activities of daily living; IADL = instrumental activities of daily living.
Negative change = improvement.
Positive change = worsening. d = Cohen’s d
A paired t-test was used to test the hypothesis that the mean changed from baseline to follow-up.
A two-sample t-test was used to test the hypothesis that mean changes were different in the intervention and control groups.
Indicates p<0.05.
Discussion
This is the first known study to demonstrate improved outcomes for formerly homeless adults living in PSH. This addresses a significant gap in the literature about how best to support aging in place among PSH tenants.8,9 This sample, which had an average age of 63 years that is younger than in previous studies of the CAPABLE intervention,11,16 showed clear signs of accelerated aging. Tenants had a high disease burden, with many having three or more chronic health conditions, high levels of ADL and IADL impairment, and frequent falls, which is consistent with previous research.3,26 This study suggest CAPABLE has potential to improve outcomes, particularly in terms of ADL and IADL limitations, depression, quality of life, and falls efficacy. This is consistent with other pilot work showing that formerly homeless older adults would benefit from aging specialists including OTs who could help PSH tenants function more safely in their homes.27,28 In this case, CAPABLE showed greater effect sizes in health-related outcomes and even produced significant improvements. Improvements in IADLs and depression were significant compared to a waitlist control group. It also appears that CAPABLE may have reduced the average number of falls compared to the control group, which may ultimately decrease ER visits and hospitalizations.10
Strengths and limitations
This study showed CAPABLE resulted in small to medium effect size differences in most outcomes of interest. The randomized controlled trial design of this pilot made clear that improvement in outcomes including IADL limitations and depression were significantly better than a comparison group. Difference between the 60 individuals who agreed to participate versus the 15 people who declined could not be investigated. This study did not investigate whether CAPABLE saved costs related to service utilization, as previously reported.10 Because assessment was solely based on self-report, objective measurements on hospitalization and health care utilization warrant investigation to develop a comprehensive picture of the intervention’s potential to positively affect health and behavior outcomes.29
Conclusion
CAPABLE is an evidence-based practice that can be successfully implemented in PSH with promise to improve outcomes in a population that experiences significant health disparities and premature aging. Further investigation with a larger sample size is warranted.
Key Points.
A randomized controlled trial was conducted to investigate the feasibility of implementing CAPABLE in permanent supportive housing.
Twenty-seven people who received CAPABLE showed improvements in five of seven health outcomes with small to medium effect sizes.
Compared with 30 people in a control group, the intervention group showed significantly greater improvements in two health outcomes—namely, limitations in instrumental activities of daily living and depression—and greater effect sizes.
Why does this matter?
Permanent supportive housing ends homelessness for a population that experiences accelerated aging through providing independent living with wraparound services. CAPABLE is an evidence-based intervention that helps older adults live independently but has not been implemented for adults living in permanent supportive housing. This randomized controlled trial showed CAPABLE improves outcomes for adults in permanent supportive housing.
ACKNOWLEDGMENTS
Sponsor’s role:
Sponsor provided funding for the research but had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclosures:
This project receiving funding through UL1TR001855 and UL1TR000130 from the National Center for Advancing Translational Science of the U.S. National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Footnotes
Trial Registration
Clinicaltrials.gov NCT04076319. Registered on 27 August 2019.
Conflict of interest disclosures: None to report.
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