Implementation of Post-Acute Rehabilitation at Home: A Skilled Nursing Facility-Substitutive Model.
Academic Article
Overview
abstract
BACKGROUND: Older adults with asthma have poorly controlled disease resulting from problems of self-management. Few interventions address asthma self-management for older adults and none have addressed the broad range of factors that impede self-management. We developed the Supporting Asthma self-Management Behaviors in older Adults (SAMBA) model, which involves screening for barriers to asthma control in older adults and addressing each individual barrier. OBJECTIVES: The aims of this study were to (1) compare clinical and asthma self-management behavior outcomes of the SAMBA intervention, delivered in the home or in clinic-based settings, with usual care; and (2) determine whether outcomes differ for patients receiving the intervention in the home and clinic, and in heterogeneity of treatment effects analyses, to determine whether the home-based intervention is superior to clinic-based for patients with functional or cognitive impairment or depression. METHODS: We conducted a 3-arm, pragmatic randomized controlled trial of SAMBA that compared (1) SAMBA delivered in the home by community health workers, (2) SAMBA delivered in clinics by care coaches, and (3) usual care (N = 406). Patients aged 60 years and older with moderate-severe asthma and a < 10 pack-year smoking history were recruited from clinical practices in East and Central Harlem and the South Bronx in New York City. The home- and practice-based SAMBA interventions were the same with the exception of site of service delivery: Patients underwent a comprehensive screening for barriers to asthma self-management and disease control and worked with their care coaches or community health workers to address the identified barriers during in-person and telephone encounters over 12 months. Primary outcomes were scores on the Asthma Control Test, Asthma Quality of Life Questionnaire, emergency department (ED) visits and hospitalizations for asthma, medication adherence measured with the Medication Adherence Rating Scale, and metered dose inhaler (MDI) and dry powdered inhaler technique. Most outcomes were measured at baseline, 3, 6, and 12 months and were tested using generalized linear models. RESULTS: Mean age was 67.8 years (SD, 7.4); 56% were Hispanic and 31% were Black. Retention at 12 months was 70.9%, 58.9%, and 70.3% for the home-based intervention, clinic-based intervention, and usual care arms, respectively. Asthma control, quality of life, MDI technique, and medication adherence were significantly improved over 12 months for intervention patients vs controls. The numbers of patients needed to treat (NNT) to achieve the minimal clinically important difference in asthma control and quality of life scores were 9 and 5, respectively, at 6 months, and 30 and 14, respectively, at 12 months. The proportion of patients with any ED visit at 12 months was lower among intervention vs control patients (6.2% vs 12.7%; adjusted odds ratio 0.8 [95% CI, 0.6-1.0]). No significant differences in outcomes were observed between patients receiving the intervention in home or practice settings. CONCLUSIONS: Older adults with asthma who received the SAMBA intervention had improvements in asthma control, quality of life, medication adherence, and inhaler technique, and they were the lower proportion of patients with any ED visit. LIMITATIONS: The study was conducted in a single geographic area, which may limit generalizability. There was a high rate of loss to follow-up in all study arms but more so in the intervention arms than in usual care.
