1. Environmental Skill-building Program (Skills2Care™) 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
Prepared for Rosalynn Carter Institute Webinar August 16, 2010

2. Outline The evidence – who benefits? What is Skills2Care™ ?
Training Requirements
Organizational requirements
How to sustain the program?
Questions

3. Environmental Skill-building Program is now called
A NEW NAME
Environmental Skill-building Program is now called
Skills2Care™

4. Funding Sources Original Randomized Trial Research:
National Institute on Aging
National Institute on Nursing Research
National Institute of Mental Health
PA Dept. of Health, Tobacco Settlement Funds
Translational Research:
Carter/Johnson & Johnson
Administration on Aging
Farber Family Foundation

5. Who Benefits?

6. Benefits to Individuals with Dementia
Decrease frequency of
behavioral occurrences
Reduced functional
dependence
Enhanced engagement
and quality of life
Gitlin, et al., (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), ; 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 with dementia. The Gerontologist, 41, 4-14.

7. Benefits to Family Caregivers
Enhances family caregiver:
Skill to use effective communications
Skill using simplification strategies
Confidence managing day-to-day
Well-being (particularly for spouses and women)
Reduces family caregiver:
Upset with behaviors
Burden and depression
Time spent “on duty” for male caregivers in particular
Gitlin, et al. (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), ;
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 with dementia. The Gerontologist, 41, 4-14.

8. WHAT IS Skills2Care™ ?

9. A Program to enhance skills of family caregivers to provide care for individuals with dementia and manage the everyday challenges of caregiving
Theory-driven:
Stress process theories
Competence-environmental press and environmental vulnerability frameworks
Tested using randomized trial methodology:
Community-based families in Philadelphia region
Over 1000 families of individuals with mild to moderate/severe dementia

10. Core Treatment Principles
Client-centered
Culturally relevant
Tailored/customized
Active learning techniques
Problem-solving oriented

11. Delivery Characteristics
Home-based
Flexible visit schedule depending upon service context
Recommended 6 session but can range up to 10 sessions over 3 to 6 months
Each session 60 to 90 minutes
Sessions scheduled flexibly based on caregiver needs, OT training considerations and service setting requirements
3 to 5 caregiver-identified problem areas are typically addressed

12. Intervention Components
Assessments
Home
Safety
Supportive features
Individuals with dementia
Functional decline
Activity engagement
Behavioral challenges
Caregivers
Emotional well-being
Daily routines
Areas of concern
Understanding of dementia
Communication (dyadic interactions)

13. Intervention Components
Problem solving:
Problem identification
Problem solving and brainstorming strategies
Introduction of strategies tailored to caregiver-identified problem area
Communication (removal of negative and practice of positive tactile, verbal and written cueing)
Environment (low cost adaptive equipment, removal of clutter, rearrangement of physical objects)
Tasks (simplifying everyday activities)
Activities (pleasant activities graded to abilities)
Taking care of self (Healthy behaviors; Stress reduction)
Education about dementia

14. Caregiver Skill-building
Customized Action Plan introduces four types of strategies
When and how to practice strategies
Introduced through role play and demonstration
ACTION PLAN
1. Simplify task
2. Communicate
3. Environment
4. Activity
MARY

15. Session-by-Session Overview
Assessment
Building rapport
Identification of problems most distressful to caregiver
Education about disease and caregiving
Stress reduction technique
Session 2
Problem-solving/brainstorming process
Introduction and practice of strategies
On-going education
Strategies for taking care of self
Session 3-5
Refine strategies for first problem area
Identify new problem/ problem-solving/brainstorming process
Stress reduction
Session 5-6
Refine strategies
Validation and evaluation of what works and why
Generalize strategies learned to new problem areas and future challenges

16. Case Examples

17. Reducing Confusion and Dependence
Caregiver Concerns
Confusion
Inappropriate dress
Decreased function

18. Use of Color Coding
Strategies:
Color contrast
Object Placement
Previous habits
Outcome:
Increased independence

19. White commode on white wall
Visual Cues
White commode on white wall
Disorienting cue
Red duct tape for color contrast

20. Visual Cues
Visual Cue to prevent egress

21. Case Scenario Distractible Poor eating Fear of malnutrition
Enhancing Nutritional Intake and Eating Independence
Case Scenario
Distractible
Poor eating
Fear of malnutrition
First Set of Strategies
Red placemat
White plate
One food item
Cereal
Spoon

22. Use of turban
Culturally appropriate
Preservation of role
Reduce distraction

23. -Short 1 to 2 step commands
Enhancing Caregiver Communication Skills
Strategies
-Tactile cueing
-Short 1 to 2 step commands

24. Case Scenario Strategies Caregiver has no time for self
Does not know how to occupy
Wife
Concerned about poor quality
of life
Strategies
Activities with repetitive motion
Simplify all task
Set up objects in field of vision
Preserve wife’s role as homemaker

25. Training Requirements

26. Requirements Licensed occupational therapists
Training and certification in program
License agreement with agency

27. 4 Training Components
Assigned targeted readings based on knowledge test (about 4 hours independent readings)
Individual completion of up to eight (8) hours of on-line web-based asynchronous training
1½ days of face-to-face training on site at agency
Follow-up group conference calls for coaching and case presentations
support also available

28. Training Costs Certification Agency
$2,000 per occupational therapist trained
After 2 years, $200 for recertification
On-going access to website and all materials
Agency
Free licensure agreement that outlines use of program name and delivery restricted to OTs trained and certified in program

29. Organizational Readiness
Access to occupational therapists:
On Staff
Contracting with independent contractors
Home care agency
Mechanism for outreach and enrolling families
Resources for local referrals for depression and other related caregiver issues (financial planning) that OTs can introduce if necessary
Oversight of quality of delivery:
Skills2Care™ has built in fidelity measures
Plan for sustainability – how will program be supported over time?

30. Reimbursement Potential of Skills2Care™
National Family Caregiver Act
Medicare Part A
Medicare Part B
New Dementia Care Service
Skills2Care as part of a comprehensive dementia care service
Skills2Care
Embedded in Patient care
Skills2Care
Embedded in Patient care
Skills2Care (caregiver only)
Gitlin et al., in press TG

31. Who is Using Skills2Care™
Fox Geriatric Rehabilitation
For-profit company providing house calls using Medicare Part B:
Holy Redeemer Home Care Agency using Medicare Part A
St. Augustine, Florida Social Service Organization using combination of funding sources
University of Toronto OT group through grant support
Area Agency on Aging in NJ Mercer County
National Family Caregiver Program
Jefferson Elder Care, Thomas Jefferson University
Medicare Part B
Private Pay
Foundation sources of support

32. Contact Information for Training
Catherine V. Piersol, MS, OTR/L, Clinical Director, Jefferson Elder Care

33. QUESTIONS

34. Select 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: /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),
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),
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),
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,
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,
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 caregivers and on daily function of persons with dementia. The Gerontologist, 41, 4-14.
Gitlin, L. N. & Corcoran, M. (2000). Making homes safer: Environmental adaptations for people with dementia. Alzheimer’s Care Quarterly, 1,