Parent Award: This application seeks funding to expand the research objectives for the National Institute on Aging-funded Mentored Patient-Oriented Research Career Award, entitled: ?Characterizing and Optimizing the Skilled Nursing Facility (SNF) to Home Transition? (K23 AG058757). This K23 parent award aims to develop and test an SNF-to-home care transitions intervention. We are requesting additional funds to enable us to examine the feasibility of this intervention among older adults with dementia. Background: Every year SNFs admit 250,000+ older adults with Alzheimer?s disease and related dementia (ADRD) for post-acute care. Compared to those without ADRD, SNF residents with ADRD are more likely to have poor post-SNF discharge outcomes. A community-based intervention consisting of a nurse, occupational therapist, and handyman (Community Aging in Place, Advancing Better Living for Elders (CAPABLE)) delivered a package of interventions to harness an older adult?s motivation by addressing functional goals that the older adult prioritizes as well as modifying home factors in support of these goals and to improve home safety. Although CAPABLE reduced functional impairment, home hazards, and use of inpatient services among functionally impaired older adults, it excluded older adults with frequent hospitalizations or cognitive impairment. Original Objectives: We have adapted CAPABLE to serve as a foundation for a new intervention ? CAPABLE Transitions, which occurs within a Medicare-certified home health agency (CHHA) to help those with recent acute medical needs transition home. The primary objective is to conduct a feasibility study to test and refine procedures relating to: 1) Participant screening, enrollment, and retention, 2) fidelity to and perceived benefit of the intervention, and 3) data completeness for our outcomes. The secondary objective is to obtain preliminary data on home time, quality of life, and medical services use at 3 and 6 months following SNF discharge. The original design did not address the particular needs of older adults with ADRD and their caregivers. Expanded Objectives: Additional funds from this supplement will enable us examine the feasibility of CAPABLE Transitions specifically among those with ADRD and their caregivers. More ADRD Participants: With additional funds, we will provide CAPABLE Transitions to a total of 24 people with ADRD discharged from an SNF, a large enough subgroup to facilitate ADRD-specific feasibility analyses. Enhanced Innovation: More ADRD participants will allow us to examine whether we can deliver a multidisciplinary, CHHA-based in-home intervention to people with ADRD and their caregivers. Increased Impact: Additional funds will provide the resources needed to examine CAPABLE Transitions? feasibility among those with ADRD and to obtain ADRD-specific data that would be instrumental for future grant applications (e.g., R34, R01) to test the mechanisms and efficacy of CAPABLE Transitions.

Public Health Relevance

More than a million older adults are admitted to skilled nursing facilities (SNFs) for post-acute care annually, many of whom eventually return to their homes in the community. Older adults, particularly those with dementia, who are admitted to SNFs for post-acute care are vulnerable and struggle with transitioning back to the community. This Alzheimer?s-focused administrative supplement proposal therefore seeks to examine and optimize the feasibility of a novel SNF-to-home transition intervention among older adults with dementia.

National Institute of Health (NIH)
National Institute on Aging (NIA)
Mentored Patient-Oriented Research Career Development Award (K23)
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Neuroscience of Aging Review Committee (NIA)
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Fazio, Elena
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University of Rochester
School of Medicine & Dentistry
United States
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