What forces older Americans from their homes into assisted living or full-time nursing facilities? It’s not necessarily declining health itself but how ailments prevent people from living independently.
Some researchers now believe that relatively small changes in people’s living spaces and daily strategies can keep them out of nursing facilities for months or even years, saving families – and, potentially, the nation – millions of dollars.
To prove that theory, a major research effort in the Baltimore area called the CAPABLE project – it stands for Community Aging in Place, Advancing Better Living for Elders – is sending handymen, nurses and occupational therapists into the homes of hundreds of low-income seniors aging in place to see how far $4,000 can go in preserving people’s independence.
The project’s initial success has captured nationwide media attention and piqued the interest of federal officials straining to hold down Medicaid costs. If it can be scaled up and tried nationwide, it could potentially save U.S. taxpayers millions of dollars. The average cost of nursing home care in the U.S. is $6,700 a month, much of it paid through Medicaid, so even postponing a move to a nursing facility by just a few months can have a major impact.
What Really Matters As We Age
While many of us focus on big-picture priorities when we plot a future of aging in place – living near family and quality doctors and maintaining our ability to drive, for example – experts on the ground have discovered that it is more often the little things, like being able to use kitchen utensils and navigate steps, that end up limiting our ability to remain independent.
Over the course of four months, a CAPABLE nurse visits a senior’s home four times to assess health risks, often finding correctable problems, such as someone taking all of his daily pills at once instead of at staggered points, potentially leaving him disoriented and fatigued. An occupational therapist appears six times, teaching basic movements and exercises to help maintain mobility, along with identifying household risks. In addition, handymen make up to $1,100 in home improvements, such as raising toilet seats, replacing patches of floor and installing ramps. The project also provides new, low-cost tools and utensils, including weighted cups that are easier for people with Parkinson’s disease to use.
“We see housing as a part of health care,” says project leader Sarah Szanton, Ph.D., an associate professor at the Johns Hopkins School of Nursing. “What one can do is a function of where one lives, so the home is a place worthy of health-care investment. What actually gets someone out of their home and into an institution are the functional consequences of disease – you can’t get your leg over the tub or you can’t stand long enough to cook.”
To that end, the professionals who visit CAPABLE participants’ homes are trained to focus on the subjects’ own goals, not a predetermined checklist. In medicine and nursing, Szanton says, “We usually determine goals for people.” But the CAPABLE staff starts by asking, “What do you want to be able to do?”
The answers are sometimes unexpected but can often be addressed in simple ways that translate to major quality-of-life improvements. “You’d be surprised how many people feel stuck in their homes,” she says.
Going to church or bingo games is important for a number of people in the CAPABLE test group, Szanton says. But while many can take advantage of municipal or volunteer ride services, those drivers are not generally allowed to help seniors get down the stairs and out of their homes, leaving residents alone to face one of their most anxiety-inducing everyday challenges. Physical therapy, improved lighting and the addition of a second banister on stairwells can help people regain confidence on the stairs. In testimonials about their CAPABLE experience, several subjects cited new banisters as helping them stop going up and down stairs on all fours.
The ability to bathe and cook are two areas that can directly extend the months or years people are able to age in place. Too many seniors in the program had been taking “birdbaths,” Szanton says, standing at the sink and washing whatever they could reach. Eventually, this practice could have medical ramifications. Many adults in the study admitted that bathing properly again was a major goal, Szanton says, and grip bars, secure floor pads and shower seats helped make that possible.
The ramifications of being unable to cook for oneself are also significant, so CAPABLE occupational therapists advise seniors on strength-building leg exercises and energy-management strategies so they can stand in the kitchen longer, while handyman crews install microwaves and lower cabinets and counters.
“Control is important to any adult,” Szanton says. Her teams have met seniors who put themselves in precarious positions, such as climbing on countertops to reach cabinets, or, in one case, to knock down a cobweb.
With just $1,100 budgeted for home repairs for each subject, CAPABLE crews were not able to alter door frames to accommodate a wheelchair, for example. But they could address curling linoleum corners on kitchen floors, secure rugs or hide loose wires. These steps can help people avoid the risks of becoming what Szanton calls “furniture walkers,” hanging on to chairs and tables as they gingerly make their way around the house. It may not be enough to guarantee complete safety and mobility for bathing and dressing, she says, but it still helps families extend a senior’s time at home, and it can make adult children feel more secure about their parent’s continued ability to age in place.
A National Impact?
Szanton believes interventions like CAPABLE could reduce the likelihood of admission to a nursing facility for participants by 40 percent over a year. Expanded study will help determine the exact figures, but she says many pilot participants were able to reduce the number of areas of daily living in which they were limited (cooking, bathing, stair navigation, etc.) from four to two, which is significant because some evaluators consider just two areas of limitation enough to make someone nursing home-eligible.
Szanton believes further research will find that hospitalizations decline in areas that adopt CAPABLE strategies because of the reduction of fall risks in participants’ homes. The average hospitalization cost for someone over age 65 who has a fall is $15,000, she says.
She emphasizes that the project is based on interventions piloted and studied elsewhere, although most have not combined nursing, occupational therapy and home repair as CAPABLE does. “There’s evidence for what we’re building on,” she says. “It’s common sense applied methodically, and we can measure health-care costs and people’s functional abilities to assess whether the investment is worth it.”
Under the Affordable Care Act, interventions receiving federal funding, like CAPABLE, which are determined to decrease net costs for the health-care system while improving medical outcomes for individuals can be scaled up, even to a national level, without Congressional approval. If the Johns Hopkins program can be proven to save the Medicaid system money by reducing nursing-home admissions and to benefit Medicare by cutting hospitalizations, it could achieve that threshold.
Such decisions are further down the line, Szanton says, but while federal actuaries examine the early results, several states, including Michigan, Maryland and Pennsylvania, are launching or considering CAPABLE-style programs to reduce their own Medicaid program costs. “It also seems to me that insurance companies who provide long-term care insurance might want to pay for CAPABLE for their insured,” she says.
And while much of the program’s budget is dedicated to the professionals who work in subjects’ homes, that cost could presumably be lowered as well, Szanton says: “There’s really untapped potential in terms of volunteers helping older adults retrofit houses for local older adults.”
“PBS NewsHour” recently visited with some of the beneficiaries of the CAPABLE project. View the segment below:
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