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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.
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:
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.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| CAPABLE | Other | CAPABLE Intervention |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| CAPABLE: Community Aging in Place-Advancing Better Living for Elders | Behavioral | 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. |
| Measure | Description | Time Frame |
|---|---|---|
| Activities of Daily Living Limitations Score | The modified Katz Activities of Daily Living (ADL) Index is an 8-item questionnaire that was completed by participants to rate their ability to perform daily activities, such as bathing, toileting, eating, and dressing, across a 5-point Likert scale (1 = no difficulty, 2 = a little difficulty, 3 = moderate difficulty, 4 = a lot of difficulty, 5 = unable to do). Items are summed to obtain a score with minimum and maximum values of 8 to 40, respectively, whereby 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). |
| Instrumental Activities of Daily Living Score | 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). Items are summed to obtain a score with minimum and maximum values of 8 to 40, respectively, whereby higher scores represent greater difficulty performing ADLs. | 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). Items are summed to obtain a score with minimum and maximum values of 0 to 24, respectively, whereby higher scores represent greater depressive symptoms. | 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. Thus, higher scores indicate greater efficacy related to falls. |
| 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). A higher score indicates poorer self-rated quality of health. | Change in self-rated health from baseline to 6-month follow up (post-intervention). |
| Overall Quality of Life |
| Measure | Description | Time Frame |
|---|---|---|
| Proportion of Participants With Emergency Room Visits in Past 6 Months | History of emergency room visits during the past year assessed by asking: "How many times did you visit the emergency room in the past year (since the last survey)? | Proportion of participants with ER visits in past 6 months reported at 6-month follow up. |
Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Benjamin F Henwood, PhD | University of Southern California | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Skid Row Housing Trust | Los Angeles | California | 90021 | United States |
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| ID | Title | Description |
|---|---|---|
| FG000 | Immediate CAPABLE | 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. |
| FG001 | CAPABLE Waitlist Control Group | Randomized to a wait-list control group to also receive the CAPABLE intervention after a specified waiting period. |
| Title | Milestones | Reasons Not Completed | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Overall Study |
|
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| ID | Title | Description |
|---|---|---|
| BG000 | Immediate CAPABLE | 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. |
| Units | Counts |
|---|---|
| Participants |
|
| Title | Description | Population Description | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Denominator Units Selected | Denominators | Classes |
|---|---|---|---|---|---|---|---|---|---|
| Age, Continuous | Mean |
| Type | Title | Description | Population Description | Reporting Status | Anticipated Posting Date | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Time Frame | Units Analyzed | Denominator Units Selected | Arm/Group Information | Denominators | Classes | Analyses | |||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Primary | Activities of Daily Living Limitations Score | The modified Katz Activities of Daily Living (ADL) Index is an 8-item questionnaire that was completed by participants to rate their ability to perform daily activities, such as bathing, toileting, eating, and dressing, across a 5-point Likert scale (1 = no difficulty, 2 = a little difficulty, 3 = moderate difficulty, 4 = a lot of difficulty, 5 = unable to do). Items are summed to obtain a score with minimum and maximum values of 8 to 40, respectively, whereby higher scores represent greater difficulty performing ADLs. | Posted | Mean | 95% Confidence Interval | Score on a scale | Change of ability to perform activities of daily living from baseline to 6-month follow up (post-intervention). |
|
Adverse event data was collected during the study time period from December 2020 through September 2021. Data on adverse events for each participant were collected during the 6 month period while enrolled in the study.
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| ID | Title | Description | Deaths (Affected) | Deaths (At Risk) | Serious Events (Affected) | Serious Events (At Risk) | Other Events (Affected) | Other Events (At Risk) |
|---|---|---|---|---|---|---|---|---|
| EG000 | Immediate CAPABLE | Community Aging in Place-Advancing Better Living for Elders: 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. |
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Pilot study resulting in a small number of individuals assigned to each study arm and potentially limiting the ability to detect significant differences. Further, because assessments were based solely on self-report, objective measurements on outcomes such as hospitalization and health care utilization require additional investigation. This would allow for the development of a comprehensive picture of the intervention's potential to positively affect health and behavior outcomes.
| Title | Organization | Phone | Extension | |
|---|---|---|---|---|
| Dr. Benjamin Henwood | USC Suzanne Dworak-Peck School of Social Work | +1 (213) 821-0496 | bhenwood@usc.edu |
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| Type | Includes Protocol | Includes SAP | Includes ICF | Document Label | Document Date | Document Uploaded Date | Document File Name |
|---|---|---|---|---|---|---|---|
| Prot_SAP | Yes | Yes | No | Study Protocol and Statistical Analysis Plan | Feb 26, 2024 | Mar 1, 2024 | Prot_SAP_000.pdf |
| ICF | No | No | Yes | Informed Consent Form | Dec 28, 2020 | Feb 29, 2024 | ICF_001.pdf |
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| ID | Term |
|---|---|
| D000073496 | Frailty |
| D003863 | Depression |
| ID | Term |
|---|---|
| D010335 | Pathologic Processes |
| D013568 | Pathological Conditions, Signs and Symptoms |
| D001526 | Behavioral Symptoms |
| D001519 | Behavior |
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| ID | Term |
|---|---|
| C000713810 | elderberry extract |
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Waitlist control design
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|
| Change of falls efficacy from baseline to 6-month follow up (post-intervention). |
| Pain Interference With Usual Activities | Pain interference with usual activities was assessed using an item from the 3-item PEG to assess average pain intensity (P), interference with enjoyment of life (E), and interference with general activity (G) on a 10-point Likert scale from 0 (does not interfere) to 10 (completely interferes). | Change in the degree that pain interferes with usual activities from baseline to 6-month follow up (post-intervention). |
| Number of Falls in the Past Year or 6 Months | Mean number of falls to the ground during the past year. | Number of falls in the past year reported at 6-month follow up. |
Quality of life was assessed using a single item: "Overall, how would you rate your quality of life?" Response options ranged from 1 = worst possible quality of life to 11 = best possible quality of life. Thus, a higher value indicated greater self-rated quality of life. |
| Change in quality of life from baseline to 6-month follow up (post-intervention). |
| Number of Emergency Room Visits in Past 6 Months |
History of emergency room visits during the past year assessed by asking: "How many times did you visit the emergency room in the past year (since the last survey)? Outcome is the mean number of ER visits in past 6 months. |
| Number of ER visits in past 6 months reported at follow up. |
| Proportion of Participants With Hospitalizations in Past 6 Months | History of hospitalization during the past year assessed by asking: How many times did you stay overnight in a hospital in the past year (since the last survey)?" | Proportion of participants with hospitalizations in past 6 months reported at 6-month follow-up |
| Number of Overnight Hospitalizations in Past 6 Months | History of hospitalization during the past year assessed by asking: How many times did you stay overnight in a hospital in the past year (since the last survey)?" Outcome measure is the mean number of overnight hospitalizations in past 6 months. | Number of overnight hospitalizations in past 6 months reported at 6-month follow up. |
| BG001 | CAPABLE Wait-list Control Group | Randomized to a wait-list control group to also receive the CAPABLE intervention after a specified waiting period. |
| BG002 | Total | Total of all reporting groups |
| Years |
|
| Sex: Female, Male | Count of Participants | Participants |
|
| Race/Ethnicity, Customized | Count of Participants | Participants |
|
| Education | Count of Participants | Participants |
|
| Monthly Income | Average monthly income reported by participants in US Dollars. | Mean | Standard Deviation | US Dollars |
|
| Years living in current home | Mean | Standard Deviation | Years |
|
| Years of homelessness | Mean | Standard Deviation | years |
|
| Moderate or severe pain | Assessed using an item from the 3-item PEG to assess average pain intensity (P), interference with enjoyment of life (E), and interference with general activity (G) on a 10-point Likert scale from 0 (no pain) to 10 (pain as bad as you can imagine). Moderate to severe pain was defined as any score greater than or equal to 4 on the 0 to 10 scale. | Count of Participants | Participants |
|
| Three or more chronic health conditions | Count of Participants | Participants |
|
| Falls in the past year | Mean | Standard Deviation | Number of falls |
|
| Proportion of people with falls in past year | Mean | Standard Deviation | Proportion of participants |
|
| Emergency room visits in past year | Mean | Standard Deviation | Number of ER visits |
|
| Overnight hospitalizations in past year | Mean | Standard Deviation | Number of hospitalizations |
|
| OG001 | CAPABLE Wait-list Control Group | Randomized to a wait-list control group to also receive the CAPABLE intervention after a specified waiting period. |
|
|
| Primary | Instrumental Activities of Daily Living Score | 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). Items are summed to obtain a score with minimum and maximum values of 8 to 40, respectively, whereby higher scores represent greater difficulty performing ADLs. | Posted | Mean | 95% Confidence Interval | score on a scale | Change of ability to perform IADLs from baseline to 6-month follow up (post-intervention). |
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|
| Primary | 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). Items are summed to obtain a score with minimum and maximum values of 0 to 24, respectively, whereby higher scores represent greater depressive symptoms. | Posted | Mean | 95% Confidence Interval | score on a scale | Change in depression symptoms from baseline to 6-month follow up (post-intervention). |
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| Primary | 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. Thus, higher scores indicate greater efficacy related to falls. | Posted | Mean | 95% Confidence Interval | score on a scale | Change of falls efficacy from baseline to 6-month follow up (post-intervention). |
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| Primary | Pain Interference With Usual Activities | Pain interference with usual activities was assessed using an item from the 3-item PEG to assess average pain intensity (P), interference with enjoyment of life (E), and interference with general activity (G) on a 10-point Likert scale from 0 (does not interfere) to 10 (completely interferes). | Posted | Mean | 95% Confidence Interval | score on a scale | Change in the degree that pain interferes with usual activities from baseline to 6-month follow up (post-intervention). |
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| Primary | Number of Falls in the Past Year or 6 Months | Mean number of falls to the ground during the past year. | Posted | Mean | 95% Confidence Interval | Number of falls | Number of falls in the past year reported at 6-month follow up. |
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| Secondary | Self-rated Health | Self-rated health was measured on a 5-point scale (1 = excellent, 2 = very good, 3 = good, 4 = fair, 5 = poor). A higher score indicates poorer self-rated quality of health. | Posted | Mean | 95% Confidence Interval | Score on a scale | Change in self-rated health from baseline to 6-month follow up (post-intervention). |
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| Secondary | Overall Quality of Life | Quality of life was assessed using a single item: "Overall, how would you rate your quality of life?" Response options ranged from 1 = worst possible quality of life to 11 = best possible quality of life. Thus, a higher value indicated greater self-rated quality of life. | Analytic sample consisted of participants with valid information on the item(s) (e.g., who are not missing on item(s)). Two participants in the control group were excluded due to invalid responses. | Posted | Mean | 95% Confidence Interval | score on a scale | Change in quality of life from baseline to 6-month follow up (post-intervention). |
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| Other Pre-specified | Proportion of Participants With Emergency Room Visits in Past 6 Months | History of emergency room visits during the past year assessed by asking: "How many times did you visit the emergency room in the past year (since the last survey)? | Analytic sample consisted of participants with valid information on the item(s) (e.g., who are not missing on item(s)). One participant in the treatment group and one participant in the control group were excluded due to invalid responses. | Posted | Count of Participants | Participants | Proportion of participants with ER visits in past 6 months reported at 6-month follow up. |
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| Other Pre-specified | Number of Emergency Room Visits in Past 6 Months | History of emergency room visits during the past year assessed by asking: "How many times did you visit the emergency room in the past year (since the last survey)? Outcome is the mean number of ER visits in past 6 months. | Analytic sample consisted of participants with valid information on the item(s) (e.g., who are not missing on item(s)). One participant in the treatment group and one participant in the control group were excluded due to invalid responses. | Posted | Mean | 90% Confidence Interval | Number of ER visits | Number of ER visits in past 6 months reported at follow up. |
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| Other Pre-specified | Proportion of Participants With Hospitalizations in Past 6 Months | History of hospitalization during the past year assessed by asking: How many times did you stay overnight in a hospital in the past year (since the last survey)?" | Analytic sample consisted of participants with valid information on the item(s) (e.g., who are not missing on item(s)). One participant in the treatment group and one participant in the control group were excluded due to invalid responses. | Posted | Count of Participants | Participants | Proportion of participants with hospitalizations in past 6 months reported at 6-month follow-up |
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| Other Pre-specified | Number of Overnight Hospitalizations in Past 6 Months | History of hospitalization during the past year assessed by asking: How many times did you stay overnight in a hospital in the past year (since the last survey)?" Outcome measure is the mean number of overnight hospitalizations in past 6 months. | Analytic sample consisted of participants with valid information on the item(s) (e.g., who are not missing on item(s)). One participant in the treatment group and one participant in the control group were excluded due to invalid responses. | Posted | Mean | 95% Confidence Interval | Number of hospitalizations | Number of overnight hospitalizations in past 6 months reported at 6-month follow up. |
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| 1 |
| 30 |
| 0 |
| 30 |
| 0 |
| 30 |
| EG001 | CAPABLE Waitlist Control Group | Randomized to a waitlist control group to also receive the CAPABLE intervention after a specified waiting period. | 0 | 30 | 0 | 30 | 0 | 30 |
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