Aging Gracefully in Place

Project Funder: Archstone Foundation, the Harry and Jeanette Weinberg Foundation, the U.S. Department of Housing and Urban Development (HUD).

Project Partners: Community Housing Solutions of Guilford, Inc., Catholic Social Services of the Diocese of Scranton, Cathedral Square Corporation, Inc., and the Family Health Centers of San Diego.

Project Contact: Jonathan Wilson, jwilson@nchh.org, 443.539.4162

Project Description

By the year 2030, the older U.S. adult population (age 65-plus) will double to more than 70 million individuals. Policymakers and practitioners are grappling with the need for safe and healthy housing that matches this important demographic. NCHH collaborated with Johns Hopkins University (JHU) and organizations in four communities around the country to conduct the Aging Gracefully in Place (“Aging Gracefully”)¹ study, evaluating the replicability of JHU’s “Community Aging in Place, Advancing Better Living for Elders”© (CAPABLE) intervention model. CAPABLE is a client-centered, home-based, unified set of interventions utilizing an occupational therapist (OT), a registered nurse (RN), and a home improvement professional to increase older adults’ mobility and physical function and improve their homes so they can more safely age in place.

The Aging Gracefully study fostered a learning community among the following four partners to collect vital information needed to scale up and sustain CAPABLE across the country:

In Greensboro, North Carolina, construction specialists from Community Housing Solutions of Guilford, Inc., a nonprofit organization whose mission is to “provide decent, safe, and affordable housing to low-income households,” teamed with OTs and RNs from Cone Health, one of the region’s largest health networks.
Catholic Social Services of the Diocese of Scranton (Wyoming Valley office, Wilkes-Barre, Pennsylvania), whose social programs assist in “strengthening family life and helping individuals reach their full potential,” teamed with OTs and RNs from Allied Services, a leading provider of healthcare for northeastern PA, along with home-repair workers from public and private organizations. The Area Agency on Aging for Luzerne and Wyoming Counties also helped identify and evaluate seniors in both public and private housing.
Vermont’s project team included both nursing and home repair staff from Cathedral Square Corporation, Inc., a nonprofit developer of “affordable, service-enriched housing communities for seniors and individuals with special needs,” with OT staff from the University of Vermont Medical Center.
In California, Family Health Centers of San Diego, a healthcare organization with a “special commitment to the uninsured, low-income, and medically underserved,” filled out their team with home improvement professionals from Rebuilding Together of San Diego and subcontracts with OTs.

These four partners implemented CAPABLE using different organizational structures, housing stocks, and client bases. Over a five-month CAPABLE service period, clients received an average of six OT visits and four RN visits. Home modifications and equipment generally centered around clients’ fall prevention goals, particularly in the bathroom, e.g., installation of grab bars, non-slip surfaces, raised toilet seats, and shower/tub chairs and transfer benches.

About one month after CAPABLE services were completed, clients experienced substantial improvements in six key health outcomes—Activities of Daily Living (ADL)² limitations score, quality of life, falls efficacy (fear of falling), Instrumental ADL (IADLs)³ limitations score, depression, and pain’s interference with normal activities. Clients sustained these improvements even seven months after completing CAPABLE and had fewer falls. During these same periods, a comparison group of older adults with similar characteristics but who received no CAPABLE services during the study period showed little if any change in these outcomes.

On average, clients reduced ADL limitations scores by two points (a reduction of one point is clinically meaningful). CAPABLE yielded a more than 20% increase in the percentage of clients who reported no difficulty with bathing, lower body dressing, getting in and out of beds and chairs, using the toilet, and walking across a small room. Clients with higher baseline ADL limitations scores experienced even greater improvements than those starting with lower scores. CAPABLE may have greater benefits for those who start with poorer function.

North Carolina, which had separate funding to conduct more expensive, intensive home repair (e.g., access ramps, plumbing and heating repairs, weatherization), saw greater reductions in ADL limitations scores than the other three partners. While the relative contribution of more intensive work to the overall health outcomes is unknown, in general, a holistic approach combining home repairs with CAPABLE may work well for both the client and the service provider, with more efficiency and less disruption.

Given the time-limited nature of CAPABLE, it’s promising that clients continued to experience physical and mental health improvements months after they finished the program. Anecdotally, we found that communications some partners continued with clients after CAPABLE services were completed may have contributed to the positive longer-term findings.

The JHU CAPABLE program proved feasible for partner teams in four micropolitan and urban locations to implement. The program greatly improved both physical function and mental health outcomes, while making homes safer for participants, even seven months after services ended. CAPABLE can be effectively implemented in both urban and micropolitan communities, with different and sometimes small-scale organizational healthcare support systems, varying housing types, and varying CAPABLE implementation strategies.

Notes

¹ Archstone Foundation and the Harry and Jeanette Weinberg Foundation co-funded CAPABLE services, and the U.S. Department of Housing and Urban Development’s Office of Policy Development and Research funded NCHH’s study.

² ADLs are defined as eight activities essential to daily self-care: walking across a small room, bathing, upper and lower body dressing, eating, using the toilet, transferring in and out of bed, and grooming.

³ IADLs are defined as eight independent living skills: using a telephone, shopping, preparing food, light housekeeping, washing laundry, traveling independently, taking medications independently, and managing finances independently.