Part of the Transforming Life as We Age Special Report
A modest program aimed at keeping older adults independent and in their own homes is showing promising results. Dubbed CAPABLE, for Community Aging in Place, Advancing Better Living for Elders, the program, which started in the Baltimore area, saved Medicare an average of $10,000 annually in health care costs per participant during a recent two-year trial. That trial program was supported by the Centers for Medicare and Medicaid Services (CMS). A second trial will wrap up this year, funded by the National Institutes of Health.
Worth noting: This surprisingly low-budget approach to care focuses on people who are at risk of becoming disabled, but not all of the help is medical in nature. Participants set their own goals for functioning and quality of life and the program helps them improve their home environment and their ability to do needed tasks.
Here’s how it works: Each client in the program gets at-home visits over a five-month period, four from a registered nurse and six from an occupational therapist. Based on the living situation and the client’s goals for improved functioning at home, the therapist contracts with a nonprofit handyman (or handywoman) service to install grab bars or handrails, repair loose linoleum or make other small fixes using a budget of just $1,000. Another $300 per client is available for items such as a shower chair, a heating pad or even toenail clippers. There is no out-of-pocket cost for clients themselves. Funds have come from the agencies supporting the CAPABLE trials. In total, the program spends $2,825 per participant.
“I just came out of a nursing home, and I thought it was great to have home care,” says Woody McLaughlin, 66, who was a CAPABLE participant last fall. His visiting care team showed him how best to position himself as he cooked and bathed, and how to safely move if he fell. “They were very helpful. They helped me get my strength back.”
Empowerment Is the “Secret Sauce”
In the CMS trial of CAPABLE, 75 percent of the 281 participants improved in their so-called activities of daily living, which are basic functions like bathing, dressing and eating. On average, they had trouble with four such activities to begin with, which dropped to just two at the end of their five months. A majority had a reduction in symptoms of depression. Nearly two-thirds improved their ability to manage medications, go grocery shopping and do other activities.
After going through an assessment tool together, nurse Jill Roth tells the client, 'Now is the time you decide what you want to work on.'
“One of the biggest pieces was they asked me questions like, ‘Was I depressed? Was anything bothering me?’” says McLaughlin, who is on dialysis, a regimen that often results in depression and isolation. “They were very insistent about that. They became like family after a while.”
The fact that clients set their own goals is key to the program’s success, says Sarah Szanton, a professor at the Johns Hopkins University School of Nursing who developed the CAPABLE program. Szanton is also a Next Avenue 2016 Influencer in Aging.
“The secret sauce is unleashing the motivation and power that each person has to do what [he or she] wants to do, whether to walk to Walgreens or down the steps into a daughter’s car to go to church. Doing those things is very powerful,” Szanton says.
Since the initial CAPABLE pilot in 2009, the program’s researchers have learned how important it is to follow the client’s lead. “Let’s say someone is a hoarder — [though] we don’t call them that ,” Szanton says. The care team might try to encourage people to get rid of clutter, but “it’s not going to go anywhere if they don’t want to change. That said, if someone makes good progress on something that’s not what we would choose, other things come into play.”
One example was a woman who hadn’t been out of her room in a year, Szanton says. The client’s goal was to go downstairs to wash her hair in the kitchen sink. Although the care team wouldn’t have made that a top priority, they focused their efforts on helping her achieve her goal. “By the end, she could get up and down her stairs,” says Szanton. “A couple months later, her daughter called and said they were taking her to Atlantic City.”
What Do You Want to Work On?
To help clients clarify their goals, CAPABLE’s visiting nurses target the areas that most often threaten the independence of older people. That includes pain, depression, falls and problems with medication management and communication with health care providers.
Jill Roth, a CAPABLE nurse in Baltimore, explains that after going through an assessment tool together, she tells the client: “Now is the time you decide what you want to work on.” The client chooses up to three goals with the nurse and another three with the occupational therapist.
McLaughlin’s main goal was to increase his strength so he could do more for himself. The team asked him so often about his goals, he jokes, that “it got on my nerves.” But repetition helped to cement what he had learned, and McLaughlin says he continues to practice those strategies to maintain his strength and independence.
He especially appreciated Roth’s expertise with medication management. After Roth contacted his cardiologist about problems she observed, McLaughlin was able to substitute aspirin for one medication and to decrease his dosage of another that had been making him dizzy and tired.
Equipped to Keep Solving Problems
Ally Evelyn-Gustave, a CAPABLE occupational therapist who works with Roth, was delighted when she learned that the program included handyman services.
“I’ve worked in home care for so many years,” she says. “You’d go see [people’s] homes and it would break your heart that they couldn’t afford to do the simplest things. I used to drive around with a toolbox to make tiny fixes along the way.”
The CAPABLE trials done so far have focused on lower-income adults, and in the CMS-funded trial, all of the participants were on both Medicare and Medicaid. Evelyn-Gustave and Roth have seen clients from 65 years old to a 100-year-old who lived on her own in a rowhouse.
“She was awesome,” says Evelyn-Gustave. “One of her goals was to get to her front door. She had a big step down and she didn’t want to leave the door unlocked if she was expecting someone. We were able to tweak how she was using her walker, and we put some railings up for her to get to the door.”
CAPABLE makes supportive home improvements, but it also equips clients with problem-solving strategies. “Our overall goal is to help the participant be their own lay practitioner in the future,” Evelyn-Gustave explains. “We give them a copy of their brainstorming and action plan so they can refer back to it.”
Researchers continue to analyze study results from participants who were enrolled during the 2012–2015 CMS trial. One question they’ve looked at is whether the program helps participants delay the day when they may need to move to a care facility. There are positive signs: Two years after they took part in the program, just 2 percent of CAPABLE participants had moved to a nursing home, compared with 5 percent of a similar group. Szanton will soon publish findings on CAPABLE’s role in reducing hospitalizations.
More Places Are Trying It
As evidence of CAPABLE’s cost savings and effectiveness mounts, other health systems are trying it.
In Michigan, the state Medicaid waiver program piloted CAPABLE in Flint, Saginaw and Detroit. Also in Michigan, Trinity Health System, a large national network of Catholic hospitals, will soon launch a pilot in Muskegon. The National Center for Healthy Housing, based in Columbia, Md., is funding pilots in Greensboro, N.C.; Wilkes-Barre, Pa.; Burlington, Vt. and San Diego. And in Denver, the Visiting Nurses Association received a grant to try CAPABLE, primarily with Kaiser Health patients. All of these projects will likely scale up if the pilots succeed as expected, says Szanton.
“It’s very gratifying to see these different kinds of [health care] systems try CAPABLE out,” she adds. “The idea of focusing on the home and what people want to be able to do, as much as on their symptoms and diseases, is really important.”
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