Strengthening recovery - integrating intrinsic capacity care into post-acute skilled nursing facilities

The National Institute on Aging awarded Hebrew Rehabilitation Center (doing business as Hebrew Senior Life) $729,000 on September 10, 2025, under the Aging Research program (CFDA 93.866) to adapt and pilot an Integrated Care for Older Persons (ICOPE) protocol for post-acute skilled nursing facilities.

The project will adapt existing community-based ICOPE protocols to align with skilled nursing facility workflows through semi-structured interviews with SNF staff, then test the adapted protocol in a feasibility pilot at a Massachusetts SNF. The protocol will be iteratively refined every five patients based on staff feedback and fidelity to an ICOPE-SNF core task checklist. Following feasibility establishment, a cluster randomized trial protocol will be tested across four Massachusetts SNFs. ICOPE operationalizes intrinsic capacity—the total measure of physical and mental capabilities—into six actionable domains: mobility, vitality, vision, hearing, cognition, and psychological function.

The research addresses outcomes following hospitalization, when over twenty percent of Medicare beneficiaries are discharged to SNFs for post-acute care and rehabilitation. Half of post-acute SNF care patients experience re-hospitalizations, long-term institutionalization, or death; most who have poor outcomes have underlying frailty marked by diminished intrinsic capacity.

Performance occurs in Roslindale, Massachusetts. The period of performance runs through June 30, 2030.

Abstract

The time after hospitalization is critical for older adults recovering from acute illnesses. To restore independence and function, over 20% of medicare beneficiaries are discharged to skilled nursing facilities (SNFS) for post- acute care and rehabilitation. While patients hope to 'get stronger and go home,' instead, half of post-acute SNF care patients have RE-hospitalizations, long-term institutionalization, or DIE. Intrinsic capacity is the total measure of an individual's physical and mental capabilities, which diminishes with aging. Most of the older adults who experience poor outcomes after post-acute SNF care have underlying frailty, a vulnerable state of diminished intrinsic capacity. To address negative health outcomes caused by declines in intrinsic capacity, the world health organization created integrated care for older persons (ICOPE). ICOPE operationalizes intrinsic capacity into 6 actionable domains to screen and manage: mobility, vitality, vision, hearing, cognition, and psychological function. This approach has successfully improved community function and may strengthen recovery for frail older adults in post-acute SNF care. The research objective of this proposal is to adapt and pilot ICOPE for integration into post-acute SNF care. First, existing community-based ICOPE protocols will be adapted to align with post-acute SNF workflows, guided by semi-structured interviews with SNF staff. The adapted protocol for ICOPE-SNF will then be tested in a feasibility pilot within a massachusetts SNF. In this pilot, the protocol will be iteratively refined every 5 patients based on SNF staff feedback and fidelity to an ICOPE-SNF core task checklist. After establishing the feasibility of implementing ICOPE-SNF, the feasibility of a cluster randomized trial protocol will be tested in 4 massachusetts SNFS. The specific aims are to: 1) adapt the ICOPE program into ICOPE-SNF - a comprehensive approach addressing intrinsic capacity in post-acute SNF care (NIH stage 1A); 2) establish the feasibility of implementing the ICOPE-SNF approach (NIH stage 1B); 3) establish the feasibility of conducting a 12-month parallel cluster randomized trial of an ICOPE-SNF intervention (NIH stage 1B). Impact: this proposal directly responds to imperatives outlined by the national institute on aging to prioritize and fund rigorous, translational research, identifying effective care-delivery models for nursing home patients with frailty. This award will support the principal investigator's (PI) long-term goal of becoming a national leader in developing and testing innovative geriatric post-acute SNF rehabilitation care. This proposal is well-supported by a collaborative team of highly experienced mentors and a rich research environment. As a geriatrician focused in post-acute SNF care, the PI will acquire knowledge in implementation science and skills as an interventionalist with expertise in the nursing home setting. Doing so will lead to the next logical step: a cluster randomized controlled trial of ICOPE-SNF for frail older patients in the post-acute SNF setting.