Functional disability is a major adverse outcome of age-related chronic diseases. It is associated with diminished capacity to perform activities of daily living, increased fear and risk of falling, depression, higher service utilization and health care costs. The proposed intervention study is a two-group (intervention vs. control) randomized trial which tests the effectiveness of a home-based, client-tailored, environmental modification program that targets functionally vulnerable older adults. This theoretically-guided intervention is based on principles from a competence-environmental press framework and personal control theory. It involves instruction in a combination of behavioral and environmental strategies that provide primary mechanisms of control over the environment and the ability to perform basic and instrumental activities of daily living. Strategies include use of assistive devices and home alterations, energy conservation, proper body mechanics, safe fall and fall recovery methods, and task breakdown techniques that are designed to minimize the impact of functional limitations and afford personal efficacy. Strategies are selected based on assessment, personal goals and environmental and performance risk factors. The program involves a 6-month active phase that consists of 5 home visits and 1 telephone contact by a health professional in which strategies are implemented. A 6-month maintenance phase follows involving 1 home visit and 3 telephone contacts to reinforce and refine environmental strategy use. The study will enroll 318 community-living elders 70 + years of age from the waiting lists of the Philadelphia Corporation for Aging, the Area Agency on Aging. Subjects will be stratified by gender and living arrangement (alone vs. live with other) and randomized to either a usual care control group or the experimental group. All participants will be assessed at baseline (Tl), 6 months (T2) and 12 months (T3) post-baseline. The specific study aims are to: 1) Test the immediate effect (T1-T2) of intervention on functional status, self-efficacy and home safety; 2) Test the maintenance effect (T2-T3) of intervention on functional status, self-efficacy and home safety; 3) Evaluate the cost-effectiveness of the intervention or the net cost of intervention to improvement of functional status and reduction of health and human service utilization. A secondary aim is to evaluate the impact of intervention on rate of falls and depressive symptomatology. Another secondary aim is to explore the differential impact of intervention and whether the above outcomes are moderated by gender, living arrangement, and baseline efficacy beliefs and depression. Last, we seek to describe the intervention process and specifically, the therapeutic techniques that are used, the staying power of each environmental strategy and the process of developing a therapeutic relationship using a client-centered approach.
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