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
Laura.gitlin@jefferson.edu
Prepared for Rosalynn Carter Institute Webinar
August 16, 2010
Outline

The evidence – who benefits?

What is Skills2Care™ ?

Training Requirements

Organizational requirements

How to sustain the program?

Questions
A NEW NAME
Environmental Skill-building Program is now
called
Skills2Care™
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
Who Benefits?
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),
368-374; 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.
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 CaregiverCare Recipient Dyad: Six-month Outcomes from the Philadelphia REACH Initiative. The
Gerontologist, 43(4), 532-546;
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.
WHAT IS Skills2Care™ ?
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
Core Treatment Principles

Client-centered

Culturally relevant

Tailored/customized

Active learning techniques

Problem-solving oriented
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
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)
Intervention Components

Problem solving:

Introduction of strategies tailored to caregiveridentified problem area
 Problem identification
 Problem solving and brainstorming strategies
 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
Caregiver Skill-building

ACTION PLAN
1. Simplify task
2. Communicate
3. Environment
4. Activity


Customized Action Plan
introduces four types of
strategies
When and how to
practice strategies
Introduced through role
play and demonstration
Session-by-Session Overview

Session 1






Session 2





Problem-solving/brainstorming process
Introduction and practice of strategies
On-going education
Strategies for taking care of self
Session 3-5





Assessment
Building rapport
Identification of problems most distressful to caregiver
Education about disease and caregiving
Stress reduction technique
Refine strategies for first problem area
Identify new problem/ problem-solving/brainstorming process
On-going education
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
Case Examples
Reducing Confusion and
Dependence
Caregiver Concerns
•Confusion
•Inappropriate dress
•Decreased function
Use of Color Coding
Strategies:
•Color contrast
•Object Placement
•Previous habits
Outcome:
•Increased independence
Visual Cues
White commode on white wall
Disorienting cue
Red duct tape for color contrast
Visual Cues
Visual Cue to prevent egress
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
Use of turban
•Culturally appropriate
•Preservation of role
•Reduce distraction
Enhancing Caregiver
Communication Skills
Strategies
-Tactile cueing
-Short 1 to 2 step
commands
Case Scenario
•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
Training Requirements
Requirements

Licensed occupational therapists

Training and certification in program

License agreement with agency
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
 E-mail support also available
Training Costs

Certification
 $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
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?
Reimbursement Potential of Skills2Care™
National
Family
Caregiver
Act
Skills2Care
(caregiver
only)
Medicare Part A
Skills2Care
Embedded
in Patient
care
Medicare Part B
Skills2Care
Embedded
in Patient
care
Gitlin et al., in press TG
New Dementia
Care Service
-Skills2Care as
part of a
comprehensive
dementia care
service
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
Contact Information for Training
Catherine V. Piersol, MS, OTR/L, Clinical
Director, Jefferson Elder Care
Catherine.piersol@jefferson.edu
215-503-9509
QUESTIONS
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: 10.1093/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), 408-414.
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), 368-374.
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., 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, 59-71.
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, 6169.
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, 50-58.