1. S ARAH L. S ZANTON, P H D, CRNP A SSOCIATE P ROFESSOR J OHNS H OPKINS U NIVERSITY S CHOOL OF N URSING 10.30.13 S HORTENING THE RESEARCH TRANSLATION PIPELINE THROUGH CURRENT POLICY OPPORTUNITIES

2. O UTLINE 1.Focus on function 2.Environment and individual 3.Tenets of the approach 4.Describe the approach 5.Our participants illustrate 6.Clinical, research and policy implications 7.Shortening the pipeline

3. H OME

4. Benefits of function in home Individual Family Societal Tax-payer or social policy

5. FUNCTIONAL LIMITATIONS COST 50% of community-living Americans have a chronic condition The 14% of Americans who have both chronic conditions and functional limitations account for 46% of all health care spending. Not counting nursing homes HHS, 2010, Closer look at Chronic conditions

6. M RS. B

7. C LINIC V ISIT FOR M RS. B. If we saw her in clinic, we would address her chronic conditions We would assign her self- management tasks

8. H ER C LOSET

9. H ER H AZARDOUS F LOOR

10. T WO T ENETS OF O UR CAPABLE A PPROACH 1.Functional abilities are limited by the gap between a person’s abilities and environment (Verbrugge and Jette, 1994) 2.Motivate self-management by focusing on participants’ own functional goals

11. SIMILAR TO “HARM REDUCTION” LENS Meet them where they “are” Start with their priorities Value neutral Focus on reducing or eliminating risk Immediate and realizable goals Client-directed (vs. client centered) and an emphasis on choice, (Marlatt, Larimer, and Witkiewiz, 2011)

12. H OW TO D ECREASE T HAT G AP ? CAPABLE CAP ABLE Community Aging in Place - Advancing Better Living for Elders

13. CAPABLE Approach the individual and environment at same time Handyman, Nurse and Occupational Therapist OT: 6 visits, RN:4 visits, Handyman: $1200 budget

14. Month 1 Month 2Month 3 Month 4 Start S EQUENCE OF V ISITS

15. Decreasing pain

16. Decreasing depressive symtoms

17. Decreasing functional limitations

18. P ARTICIPANTS I LLUSTRATE

19. M RS. D. Confused, over medicated 30 minutes to walk to the bathroom Sits on commode all day as a chair because can’t get out of bed US: Med schedule, chair along hall, chair at top of stairs, railing on both sides, bed risers, wider commode

20. Diabetic Not active since shoulder surgery Stopped going outside of home as couldn’t get dressed. CAPABLE exercises (modified Tai Chi and OTAGO) Reacher, leg lifter Railings, repaired linoleum floor M RS. H.

21. M RS. W. Limited to one floor by unsafe steps. CHF. 24 medications. We made list of all. Pt took to MD. MD removed 7 unnecessary meds.

22. Had been on Ibuprofen 800 mg round the clock prior to CAPABLE. Had TENS unit did not use. Through CAPABLE, learned focus on breath to walk Uses housecleaning as distraction, now chooses not to be any pain medication M RS. D

23. W HAT W E ’ VE L EARNED S O F AR

24. E FFECT OF N EIGHBORHOOD ON H EALTH Mrs. L did not call ambulance because of worry re neighbors

25. F OOD AND S ELF M ANAGEMENT Food dessert Standing - leg strength Planning for energy conservation Money Hand pain, joint problems Reaching items Fire hazard Family members - if reliant on them, don’t feel can dictate the menu Appetite “You can’t do that”

26. H OW WE M ODIFY E XERCISE Exercise at any level – even if only in bed or only in wheelchair We modify – if can’t stand, they exercise sitting Build on their functional goals to motivate Kegels

27. E MOTIONAL M ANAGEMENT Out into the community e.g. senior centers Visiting neighbors Shopping at thrift store Build on small victories Manage pain Frame all messages as positive Take time for self

28. I MPLICATIONS

29. C LINICALLY How to assess function so that we assess ability to self-manage What role do home and community environments have on function and self- management? Self management is how the person manages what the health care system has told them to do. Perhaps we should turn it around? Can their functional goals determine self-management priorities?

30. R ESEARCH Bi-directional relationships between function and self-management Best ways to increase ability to do both?

31. P OLICY – THE “ TRIPLE A IM ” Can we bend the cost curve While providing better care And improved quality of life?

32. H ISTORIC MOMENT NOW Affordable Care Act Demographics of older adults Medical costs skyrocketing Nurses poised to work at the top of their licenses

33. P OLICY Center for Medicare and Medicaid Innovations Center Take advantage of health care reform – ACOs – Capitated systems – PCORI

34. S TATE LEVEL P OLICY DHMH initiatives to change hospital payment

35. M RS. J ACKSON

36. A CKNOWLEDGEMENTS Study participants 1R01AG040100: National Institute on Aging CMS 330970-01: CMMI Robert Wood Johnson Nurse Faculty Scholars Program 1KL2RR025006-01 The John A. Hartford Building Academic Geriatric Nursing Capacity Program

37. M RS. W.