Enhancing Quality of Life in Functionally Vulnerable Older Adults: From Randomized Trial to Standard Care

Difficulty performing everyday tasks is a common experience among older adults. Currently 42% of Medicare enrollees 65 years and above have functional limitations (Federal Interagency Forum on Aging-Related Statistics, 2009). Overall, the number of older adults with disability will exceed 12 million by 2030 (Spillman, 2004; Manton, 1997).

Functional difficulties with activities such as bathing, dressing, and toileting can increase the risk of anxiety, depression, fear of falling, frailty, dependence, relocation, higher service utilization, cost, and mortality. (Spillman, 2004; Gill and Kurland, 2003; Fried and Guralnick, 1997).

Typically, older adults with functional difficul-ties do not receive homecare unless an acute episode or hospital admission triggers referral. Even then, rehabilitative therapies focus on restoring pre-morbid function, not performance challenges older adults find problematic. Helping functionally vulnerable older adults perform valued activities with improved safety and efficiency remains a public health priority. We describe a novel intervention to address this public health problem, and its pathway from randomized trial to sustainable program (Figure 1).

Figure 1.

Trajectory from Problem Identification to Sustainability of a Proven Program

Advancing Better Living for Elders Program

Advancing Better Living for Elders or ABLE is a home-based intervention for functionally vulnerable older adults based on the Lifespan Theory of Control (Schulz, Heckhausen, and O’Brien, 1994).

An active phase of the intervention involves five occupational therapy sessions and one physical therapy home session (90 minutes) over six months. Occupational therapists (OTs) meet with participants and conduct a semi-structured clinical interview to identify and prioritize functional concerns. For each targeted area, OTs observe and evaluate participants’ performance level, safety, and efficiency, supportive or deterrent role of the physical environment, and participant readiness to use compensatory behavioral strategies including adaptive equipment. In subsequent sessions, OTs engage participants in problem-solving as a teaching tool to identify specific modifiable contributors to performance difficulties and possible solutions. Specific strategies are derived and equipment options explored.

In the fourth session, physical therapists (PTs) provide balance and muscle strengthening and fall recovery techniques. In session five (via telephone or at the patient’s home), OTs reinforce strategy use, make needed adjustments, and train in use of provided equipment. In a final session, OTs review progress, strategy use, and provide additional educational resources.

Thus, for each identified problem area, ABLE provides: 1) education and problem-solving; 2) environmental modifications and adaptive equipment; 3) instruction in energy conservation; and 4) balance and muscle strengthening and fall recovery techniques. A maintenance phase involves three brief check-in calls over the next six months to reinforce strategy use and generalize their use to newly emerging problems (Gitlin et al., 2006).

Although ABLE is based on OT/PT therapeutic principles, it differs from traditional homecare in several areas. First, ABLE focuses exclusively on areas participants themselves report as problematic (Wolff et al., 2009), while in traditional homecare, the focus is on acute functional problems. Second, ABLE therapists help participants problem-solve and offer strategy choices that optimize personal control, whereas homecare is more directive and prescriptive.

Program Outcomes

In a randomized trial with 319 participants 70 years and older, we showed statistically significant reductions in functional difficulties and fear of falling, and enhanced performance in activities of daily living. Use of strategies that enhanced personal control was also increased and fewer home hazards observed (Gitlin et al. 2006).

Of significance, ABLE reduced mortality by 9% at 12 months. Moreover, those admitted to a hospital within one year of study entry had an even greater survivorship advantage; 0% mortality rate for ABLE versus 21% for control group participants (Gitlin et al., 2006b). The survivorship advantage was statistically significant for up to 2 years, with mortality rates remaining lower up to 3.5 years from study entry for ABLE participants (Gitlin et al., 2009). Equally important is that ABLE provided the greatest benefit to adults 80 years and older, showing that individuals at any age can learn new strategies to engage in valued activities (Gitlin et al., 2008).

The average total cost for ABLE compares favorably to other programs and costs associated with hospitalization or treatment for injurious falls (Jutkowitz et al., 2009). Including equipment, therapist time, and training, the cost was $941.88 per participant.

Translation

Characteristics of the ABLE trial heighten its translational potential. Criteria for study inclusion were broad; the sample included close to 50% white and African American older adults, which suggests it is generally applicable across these populations. ABLE used a flexible visit schedule; session number and length of visit was based on participants needs, reflecting the real-world reimbursement and service delivery environment.

Nevertheless, moving ABLE from randomized trial to practice setting (Figure 1) is challenging. First, ABLE requires delivery by OTs trained in its protocols. While OTs (and PTs) have the requisite knowledge-base (person-environment fit) and skills (activity analysis, environmental redesign), to implement ABLE, two training days are required to learn assessments, the client-centered approach, and integration of ABLE into traditional care models. A related point is that the need to use OTs may be challenging for some settings or geographic areas in the USA due to cost for personnel and workforce shortages.

A second challenge is that the USA lacks an adequate infrastructures to support referrals and payment for preventive services such as ABLE (Bodenheimer, 2008; Mongan, Ferris, and Lee, 2008). Nevertheless, within current healthcare systems, ABLE may be reimbursable under Medicare Part B with physician prescription, if a home safety or functional concern exists, in keeping with Centers for Medicare & Medicaid Services guidelines.

A third challenge is time required to tailor written strategies. Therapists review assessment outcomes and, using lay language, summarize assessment results and recommended strategies in written action plans. While tailoring is critical to program success, it is labor-intensive and potentially costly. Another challenge is lack of funding for home modifications as they often are out-of-pocket expenses.

Next Steps

We are currently addressing these challenges in translation of ABLE for delivery in a continuing care retirement community that qualifies for Medicare Part B reimbursement. To meet reimbursement requirements, we modified ABLE by: a) refining and embedding assessments in traditional OT evaluation and treatment; b) shortening session length (90 to 60 minutes) and increasing sessions per week so that dose/intensity is similar to original trial but meets Medicare delivery structure; c) expanding the role of the OT to include balance testing and fall recovery training with referral to PTs if warranted; and d) developing written strategies for common problems (bathing, leisure) to minimize therapist time creating action plans.

The next steps (Figure 1) involve implementing ABLE on a larger scale and sustaining it as standard care. Challenges include scaling up training, roll-out procedures, and monitoring structures for fidelity and program effectiveness.

In summary, ABLE is low-cost, offsets functional difficulties, and reduces mortality. It should be considered standard care in homecare, independent living, Medicaid Waiver, and aging long-term care services. Moving ABLE into standard care requires additional steps beyond the randomized trial which present methodological challenges driven by practice setting, workforce and payment exigencies.