laura n. gitlin, ph.d. director, jefferson center for applied research on aging and health
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Environmental Skill-building Program ( Skills 2 Care™) A Proven Home-based Occupational Therapy Intervention for Families of Individuals with Dementia. Laura N. Gitlin, Ph.D. Director, Jefferson Center for Applied Research on Aging and Health Thomas Jefferson University, Philadelphia - PowerPoint PPT PresentationTRANSCRIPT
Environmental Skill-building Environmental Skill-building Program (Program (SkillsSkills22Care™) Care™)
A Proven Home-based A Proven Home-based Occupational Therapy Intervention Occupational Therapy Intervention
for Families of Individuals with for Families of Individuals with DementiaDementia
Laura N. Gitlin, Ph.D.Laura N. Gitlin, Ph.D.Director, Jefferson Center for Applied Director, Jefferson Center for Applied
Research on Aging and HealthResearch on Aging and HealthThomas Jefferson University, PhiladelphiaThomas Jefferson University, Philadelphia
[email protected] for Rosalynn Carter Institute Prepared for Rosalynn Carter Institute
Webinar August 16, 2010Webinar August 16, 2010
OutlineOutline
The evidence – who benefits?The evidence – who benefits? What is SkillsWhat is Skills22Care™ ?Care™ ? Training Requirements Training Requirements Organizational requirements Organizational requirements How to sustain the program?How to sustain the program? QuestionsQuestions
A NEW NAMEA NEW NAME
Environmental Skill-building Program is now Environmental Skill-building Program is now calledcalled
SkillsSkills22Care™Care™
Funding SourcesFunding SourcesOriginal Randomized Trial ResearchOriginal Randomized Trial Research:: National Institute on AgingNational Institute on Aging National Institute on Nursing ResearchNational Institute on Nursing Research National Institute of Mental HealthNational Institute of Mental Health PA Dept. of Health, Tobacco Settlement FundsPA Dept. of Health, Tobacco Settlement FundsTranslational ResearchTranslational Research:: Carter/Johnson & JohnsonCarter/Johnson & Johnson Administration on AgingAdministration on Aging Farber Family FoundationFarber Family Foundation
Who Benefits?Who Benefits?
Benefits to Individuals with Benefits to Individuals with DementiaDementia
Decrease frequency of Decrease frequency of behavioral occurrences behavioral occurrences Reduced functional Reduced functional dependencedependence Enhanced engagement Enhanced engagement and quality of lifeand quality of life
Gitlin, et al., (2005). Gitlin, et al., (2005). Maintenance of effects of the home environmental skill- building program for Maintenance of effects of the home environmental skill- building program for family caregivers and individuals with Alzheimer’s disease and related disorders. family caregivers and individuals with Alzheimer’s disease and related disorders. Journal of Journal of Gerontology: Medical Sciences, 60A(3)Gerontology: Medical Sciences, 60A(3), 368-374; Gitlin, et al., (2001). A randomized, controlled trial of , 368-374; Gitlin, et al., (2001). A randomized, controlled trial of a home environmental intervention: Effect on efficacy and upset in caregivers and on daily function of a home environmental intervention: Effect on efficacy and upset in caregivers and on daily function of persons with dementia. persons with dementia. The Gerontologist, 41The Gerontologist, 41, 4-14., 4-14.
Benefits to Family Caregivers Benefits to Family Caregivers Enhances family caregiver:Enhances family caregiver:
• Skill to use effective communicationsSkill to use effective communications• Skill using simplification strategiesSkill using simplification strategies• Confidence managing day-to-dayConfidence managing day-to-day• Well-being (particularly for spouses and women)Well-being (particularly for spouses and women)
Reduces family caregiver:Reduces family caregiver:• Upset with behaviorsUpset with behaviors• Burden and depression Burden and depression • Time spent “on duty” for male caregivers in Time spent “on duty” for male caregivers in
particularparticular
Gitlin, et al. (2003). Gitlin, et al. (2003). Effects of the Home Environmental Skill-building Program on the Effects of the Home Environmental Skill-building Program on the Caregiver-Care Recipient Dyad: Six-month Outcomes from the Philadelphia REACH Caregiver-Care Recipient Dyad: Six-month Outcomes from the Philadelphia REACH Initiative. Initiative. The GerontologistThe Gerontologist, , 43(4),43(4), 532-546; 532-546; Gitlin, et al., (2001). A randomized, controlled trial of a home environmental Gitlin, et al., (2001). A randomized, controlled trial of a home environmental intervention: Effect on efficacy and upset in caregivers and on daily function of persons intervention: Effect on efficacy and upset in caregivers and on daily function of persons with dementia. with dementia. The Gerontologist, 41The Gerontologist, 41, 4-14., 4-14.
WHAT IS SkillsWHAT IS Skills22Care™ ?Care™ ?
A Program to enhance skills of A Program to enhance skills of family caregivers to provide care family caregivers to provide care for individuals with dementia for individuals with dementia and manage the everyday and manage the everyday challenges of caregivingchallenges of caregiving Theory-driven:Theory-driven:
Stress process theoriesStress process theories Competence-environmental press and Competence-environmental press and
environmental vulnerability environmental vulnerability frameworksframeworks
Tested using randomized trial Tested using randomized trial methodology:methodology: Community-based families in Community-based families in
Philadelphia regionPhiladelphia region Over 1000 families of individuals with Over 1000 families of individuals with
mild to moderate/severe dementiamild to moderate/severe dementia
Core Treatment Principles Core Treatment Principles Client-centeredClient-centered
Culturally relevant Culturally relevant
Tailored/customized Tailored/customized
Active learning techniques Active learning techniques
Problem-solving orientedProblem-solving oriented
Delivery Characteristics Delivery Characteristics Home-basedHome-based Flexible visit schedule Flexible visit schedule
depending upon service depending upon service contextcontext Recommended 6 session but can Recommended 6 session but can
range up to 10 sessions over 3 to range up to 10 sessions over 3 to 6 months6 months
Each session 60 to 90 minutesEach session 60 to 90 minutes Sessions scheduled flexibly Sessions scheduled flexibly
based on caregiver needs, OT based on caregiver needs, OT training considerations and training considerations and service setting requirementsservice setting requirements
3 to 5 caregiver-identified 3 to 5 caregiver-identified problem areas are typically problem areas are typically addressed addressed
Intervention ComponentsIntervention Components Assessments Assessments
HomeHome• SafetySafety• Supportive featuresSupportive features
Individuals with dementia Individuals with dementia • Functional decline Functional decline • Activity engagement Activity engagement • Behavioral challengesBehavioral challenges
CaregiversCaregivers• Emotional well-beingEmotional well-being• Daily routinesDaily routines• Areas of concern Areas of concern • Understanding of dementiaUnderstanding of dementia
Communication (dyadic interactions) Communication (dyadic interactions)
Intervention ComponentsIntervention Components Problem solving:Problem solving:
Problem identificationProblem identification Problem solving and brainstorming strategiesProblem solving and brainstorming strategies
Introduction of strategies tailored to caregiver-Introduction of strategies tailored to caregiver-identified problem areaidentified problem area Communication (removal of negative and practice of Communication (removal of negative and practice of
positive tactile, verbal and written cueing)positive tactile, verbal and written cueing) Environment (low cost adaptive equipment, removal of Environment (low cost adaptive equipment, removal of
clutter, rearrangement of physical objects)clutter, rearrangement of physical objects) Tasks (simplifying everyday activities)Tasks (simplifying everyday activities) Activities (pleasant activities graded to abilities)Activities (pleasant activities graded to abilities)
Taking care of self Taking care of self (Healthy behaviors; Stress reduction)
Education about dementiaEducation about dementia
Caregiver Skill-buildingCaregiver Skill-building
Customized Action Customized Action Plan introduces four Plan introduces four types of strategies types of strategies
When and how to When and how to practice strategiespractice strategies
Introduced through Introduced through role play and role play and demonstrationdemonstration
ACTION PLAN
1. Simplify task 2. Communicate3. Environment4. Activity
Session-by-Session OverviewSession-by-Session Overview Session 1Session 1
AssessmentAssessment Building rapportBuilding rapport Identification of problems most distressful to caregiverIdentification of problems most distressful to caregiver Education about disease and caregivingEducation about disease and caregiving Stress reduction techniqueStress reduction technique
Session 2Session 2 Problem-solving/brainstorming processProblem-solving/brainstorming process Introduction and practice of strategiesIntroduction and practice of strategies On-going educationOn-going education Strategies for taking care of selfStrategies for taking care of self
Session 3-5Session 3-5 Refine strategies for first problem areaRefine strategies for first problem area Identify new problem/ problem-solving/brainstorming processIdentify new problem/ problem-solving/brainstorming process On-going educationOn-going education Stress reductionStress reduction
Session 5-6Session 5-6 Refine strategiesRefine strategies Validation and evaluation of what works and whyValidation and evaluation of what works and why Generalize strategies learned to new problem areas and future challengesGeneralize strategies learned to new problem areas and future challenges
Case ExamplesCase Examples
•Decreased function
Reducing Confusion and Dependence
Caregiver Concerns
•Confusion
•Inappropriate dress
Strategies:
•Color contrast
•Object Placement
•Previous habits
Outcome:•Increased independence
Use of Color Coding
Disorienting cue
Red duct tape for color contrast
White commode on white wall
Visual Cues
Visual Cues
Visual Cue to prevent egress
Case Scenario•Distractible•Poor eating•Fear of malnutrition
First Set of Strategies•Red placemat •White plate•One food item•Cereal•Spoon
Enhancing Nutritional Intake and Eating Independence
Use of turban
•Culturally appropriate
•Preservation of role
•Reduce distraction
Strategies
-Tactile cueing
-Short 1 to 2 step commands
Enhancing Caregiver Communication Skills
Strategies •Activities with repetitive motion•Simplify all task•Set up objects in field of vision•Preserve wife’s role as homemaker
Case Scenario•Caregiver has no time for self•Does not know how to occupyWife•Concerned about poor quality of life
Training Requirements Training Requirements
RequirementsRequirements
Licensed occupational therapistsLicensed occupational therapists Training and certification in program Training and certification in program License agreement with agencyLicense agreement with agency
4 Training Components4 Training Components Assigned targeted readings based on Assigned targeted readings based on
knowledge test (about 4 hours knowledge test (about 4 hours independent readings)independent readings)
Individual completion of up to eight (8) Individual completion of up to eight (8) hours of on-line web-based asynchronous hours of on-line web-based asynchronous trainingtraining
1½ days of face-to-face training on site 1½ days of face-to-face training on site at agency at agency
Follow-up group conference calls for Follow-up group conference calls for coaching and case presentationscoaching and case presentations E-mail support also availableE-mail support also available
Training CostsTraining Costs CertificationCertification
$2,000 per occupational therapist trained$2,000 per occupational therapist trained After 2 years, $200 for recertificationAfter 2 years, $200 for recertification On-going access to website and all materials On-going access to website and all materials
AgencyAgency Free licensure agreement that outlines use of Free licensure agreement that outlines use of
program name and delivery restricted to OTs program name and delivery restricted to OTs trained and certified in programtrained and certified in program
Organizational ReadinessOrganizational Readiness Access to occupational therapists:Access to occupational therapists:
On StaffOn Staff Contracting with independent contractorsContracting with independent contractors Home care agencyHome care agency
Mechanism for outreach and enrolling families Mechanism for outreach and enrolling families Resources for local referrals for depression and Resources for local referrals for depression and
other related caregiver issues (financial other related caregiver issues (financial planning) that OTs can introduce if necessaryplanning) that OTs can introduce if necessary
Oversight of quality of delivery:Oversight of quality of delivery: SkillsSkills22Care™ has built in fidelity measuresCare™ has built in fidelity measures
Plan for sustainability – how will program be Plan for sustainability – how will program be supported over time?supported over time?
National Family
Caregiver Act
Skills2Care (caregiver
only)
Medicare Part A Medicare Part B
Reimbursement Potential ofReimbursement Potential of Skills2Care™Skills2Care™
Skills2Care Embedded in Patient
care
New Dementia Care Service
-Skills2Care as part of a comprehensive dementia care service
Skills2Care
Embedded in Patient
care
Gitlin et al., in press TG
Who is Using Who is Using SkillsSkills22Care™Care™ Fox Geriatric RehabilitationFox Geriatric Rehabilitation
For-profit company providing house calls using Medicare Part B:For-profit company providing house calls using Medicare Part B:
Holy Redeemer Home Care Agency using Medicare Part AHoly Redeemer Home Care Agency using Medicare Part A St. Augustine, Florida Social Service Organization using St. Augustine, Florida Social Service Organization using
combination of funding sourcescombination of funding sources University of Toronto OT group through grant support University of Toronto OT group through grant support Area Agency on Aging in NJ Mercer CountyArea Agency on Aging in NJ Mercer County
National Family Caregiver ProgramNational Family Caregiver Program Jefferson Elder Care, Thomas Jefferson UniversityJefferson Elder Care, Thomas Jefferson University
• Medicare Part BMedicare Part B• Private PayPrivate Pay• Foundation sources of supportFoundation sources of support
Contact Information for Contact Information for TrainingTraining
Catherine V. Piersol, MS, OTR/L, Catherine V. Piersol, MS, OTR/L, Clinical Director, Jefferson Elder Clinical Director, Jefferson Elder
CareCare [email protected]
215-503-9509 215-503-9509
QUESTIONSQUESTIONS
Select Key ReferencesSelect Key References Gitlin, L. N., Jacobs, M., & Vause-Earland, T. (2010). Translation of a dementia caregiver
intervention for delivery in homecare as a reimbursable Medicare Service: Outcomes and lessons learned. The Gerontologist, doi: 10.1093/geront/gnq057.
Gitlin, L. N., Winter, L., Dennis, M. P. (Summer, 2010). Assistive devices to help manage behavioral symptoms of dementia: What do caregivers use and find helpful? Special issue in honor of Dr. Fozzard, Gerontechnology, 9 (3), 408-414.
Gitlin, L. N., Hauck, W. W., Dennis, M. P. & Winter, L. (2005). Maintenance of effects of the home environmental skill-building program for family caregivers and individuals with Alzheimer’s disease and related disorders. Journal of Gerontology: Medical Sciences, 60A(3), 368-374.
Gitlin, L. N., Winter, L., Corcoran, M., Dennis, M., Schinfeld, S. & Hauck, W. (2003). Effects of the Home Environmental Skill-building Program on the Caregiver-Care Recipient Dyad: Six-month Outcomes from the Philadelphia REACH Initiative. The Gerontologist, 43(4), 532-546.
Gitlin, L. N., Schinfeld, S., Winter, L., Corcoran, M. & Hauck, W. (2002). Evaluating home environments of person with dementia: Interrater reliability and validity of the home environmental assessment protocol (HEAP). Disability and Rehabilitation, 24, 59-71.
Gitlin, L. N. Winter, L., Dennis, M., Corcoran, M, Schinfeld, S. & Hauck, W. (2002). Strategies used by families to simplify tasks for individuals with Alzheimer's disease and related disorders: Psychometric analysis of the task management strategy index (TMSI). The Gerontologist, 42, 61-69.
Gitlin L. N., Corcoran, M., Winter, L., Boyce, A. & Hauck, W. (2001). A randomized, Gitlin L. N., Corcoran, M., Winter, L., Boyce, A. & Hauck, W. (2001). A randomized, controlled trial of a home environmental intervention: Effect on efficacy and upset in controlled trial of a home environmental intervention: Effect on efficacy and upset in caregivers and on daily function of persons with dementia. caregivers and on daily function of persons with dementia. The Gerontologist, 41The Gerontologist, 41, 4-14., 4-14.
Gitlin, L. N. & Corcoran, M. (2000). Making homes safer: Environmental adaptations for Gitlin, L. N. & Corcoran, M. (2000). Making homes safer: Environmental adaptations for people with dementia. people with dementia. Alzheimer’s Care Quarterly, 1Alzheimer’s Care Quarterly, 1, 50-58., 50-58.