Home-based intervention delivered by professionals (OTs) that modifies home environment and delivers caregiver education and skill development
Skills2care is a home-based environmental intervention designed to help family caregivers of persons with dementia learn specific strategies through education, skill-building, and environmental strategies. These strategies are designed to help caregivers in modifying their living space so that they develop a more supportive environment for the person with dementia. This intervention is based upon a competence-environmental press framework and personal control theory. In general, the intervention involves five 90-minute home visits by an occupational therapist who evaluates the home environment, observes performance of the person with dementia and the caregiving and communication style of the caregiver. Based on this assessment, the therapist provides basic education about dementia and the stressors of caregiving, and trains caregivers in specific strategies to help caregivers cope with daily care challenges. Strategies provided reflect simple modifications to the physical environment (e.g., removal of hazardous objects, use of a memory board or daily calendar) and social environment (e.g., communication techniques, cueing and approaches to simplifying everyday tasks). These strategies also include more resource dependent recommendations (e.g., installing grab bars or handrails), as well as basic problem solving and stress management techniques. All in all, the aim is for the person with dementia to exhibit fewer disruptive behaviors and experience a slower rate of decline and dependence in instrumental and basic activities of daily living (IADLs and ADLs).
In each subsequent home visit, the occupational therapist reviews the previous week’s assignment/homework, reinforces education about dementia through written materials and discussion, addresses a targeted problem area, observes the caregiver using previously recommended strategies, provides refinements to those strategies, and or offers new recommendations. The occupational therapist helps the caregiver generalize the process to newly emerging problem areas. In the process of providing verbal instruction and training, the therapist uses cognitive restructuring and validation to instill greater perceived control and confidence in the caregiver’s own abilities to manage the problem and to develop more realistic appraisals of the caregiving situation, dementia-related behaviors, and expectations.
In the final session, the occupational therapist reviews previously introduced strategies and how they might be applied to future potential problems.
Approximately 25 to 30 hours of training specific to the intervention is needed for an occupational therapist to deliver the intervention. Training covers the following topics 1) how to effectively collaborate with the caregiver, 2) how to understand the cultural tenets of the caregiver-patient dyad that structure and inform caregiving in the home environment, 3) how to develop strategies that are tailored to individual problems and which resonate with cultural values of the dyad, 4) how to validate caregiver efforts and reinforce use of strategies, and 5) a range of strategies for specific problem areas. Therapists are also introduced to the intervention protocol, specific strategies, and treatment documentation.
Caregivers of individuals with dementia and Alzheimer’s
At least 20 home care agencies; AAAs; and OTs in private practice; covered by Medicare.
Help family caregivers learn specific strategies through education, skill-building and environmental modification
Evidence of Outcomes
Several studies have shown evidence supporting the impact of this intervention on family caregiver functioning of persons with dementia (e.g., Corcoran et al., 2001; Gitlin et al., 2001; Gitlin et al., 2003; Gitlin et al., 2006). Specifically, from the original randomized controlled trial (RCT) with 202 dementia caregivers, Gitlin et al. (2001) found that at 3-month follow-up, intervention environmental recommendations resulted in improvements for both caregivers and care-recipients. Caregivers who received the intervention, compared with caregivers in usual care, reported less decline in instrumental activities of daily living, a trend toward fewer declines in self-care, dependency, and fewer behavior problems at 3-months post-intervention. Additionally, spouses who received the intervention reported less upset with behavioral manifestations, women reported enhanced self-efficacy in managing troublesome behaviors, and women and African American caregivers reported enhanced self-efficacy in managing functional dependency compared with their counterparts in the control group. Other research has shown that the intervention helps sustain caregiver affect for those enrolled for more than 1 year. Lastly, Chee and colleagues (2007) found that modifiable caregiver and treatment implementation factors, including active engagement of caregivers, were associated with adherence, whereas patient characteristics were not. Caregivers with poor health may be at risk for not benefiting from intervention and suggest that efforts, including instruction in preventative care and allocating time to attend to their own health care needs, be directed towards improving their health.
As part of the Philadelphia REACH study, Gitlin and colleagues (2003) more recently expanded upon the initial 3-month ESP caregiver intervention involving more occupational therapy time in the home, as well as the actual implementation of special equipment and other low-cost environmental strategies that had been recommended but not actually provided in their initial intervention. Compared with controls (n = 101), caregivers in the intervention group (n = 89) reported less upset with memory-related behaviors, less need for assistance from others, and better affect. Intervention spouses reported less upset with disruptive behaviors; men reported spending less time in daily oversight; and women reported less need for help from others, better affect, and enhanced management ability, overall well-being, and mastery relative to control group counterparts. Benefits from the intervention are apparent at both 3 and 6 month-follow-up. Caregivers have also been shown to be receptive and willing to try strategies offered during the intervention (total of 1,068) and subsequently use them independently post-intervention (869 strategies). Moreover, caregivers tended to use a greater number of strategies that modified the task and social environments than the objects layer of the environment. Of the problem areas facing these family caregivers, the most frequently identified as problematic included caregiver-centered concerns, catastrophic reactions, wandering, and incontinence. More recently, Gitlin and colleagues (2006) examined the impact of the program at 12-months and found that caregiver affect improved and there was a trend for maintenance of skills and reduced behavioral occurrences, but not on other outcome measures.
Description from Rosalyn Carter Institute for Caregiving: http://www.rosalynncarter.org/caregiver_intervention_database/dimentia/environmental%20skill-building%20program/
Chee, Y. K., Gitlin, L. N., Dennis, M. P., & Hauck, W. W. (2007). Predictors of adherence to a skill-building intervention in dementia caregivers. Journal of Gerontology: Medical Sciences, 62A(6), 673-678.
Corcoran, M., & Gitlin, L. N. (2001). Family caregiver acceptance and use of environmental strategies in occupational therapy intervention. Physical & Occupational Therapy in Geriatrics, 19(1), 1-20.
Gitlin, L. N., Corcoran, M., Winter, L., Boyce, A., & Hauck, W. 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., 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., Hauck, W. W., Winter, L,. et al. (2006). Effect of an in-home occupational and physical therapy intervention on reducing mortality in functionally vulnerable older people: Preliminary findings. Journal of the American Geriatrics Society, 54, 950-955.
Gitlin, et al. (2006). A randomized trial of a multi-component home intervention to reduce functional difficulties in older adults. Journal of the American Geriatrics Society, 54, 809-816.