Home: Perhaps the Most Important “Care Setting”


By Sarah Szanton, NP, PhD, Johns Hopkins University, School of Nursing, and Deborah Paone, DrPH, MHSA, of the Special Needs Plan Alliance

Mrs. G., age 85, spent most of her days alone, and moved around her home by grabbing onto backs of chairs and other pieces of furniture. She couldn’t use her front steps because the railing was broken. Her bathroom and kitchen were not set up to accommodate her limited mobility. Mrs. G. increasingly felt like a prisoner in her own home.

Individuals with complex needs live in all sorts of places — institutional and assisted living residences, group or congregate homes, their own single-family homes, the homes of family or friends, and even shelters, vehicles, or on the street. Wherever it is, home is often the place where they spend most of their waking and sleeping hours, and, as in Mrs. G’s case, it can either augment or impair their ability to function well.

What does this mean for complex care programs?

Services cannot start at the door of the clinic, medical office, or hospital — particularly for people who have economic, functional, or cognitive limitations. Complex care must start with an understanding of the living situation of the person, rather than organizing care around the setting that works best for the provider.

Three special needs health plans are examining how they might weave additional home-based support into their care models for older adults living at home with functional limitations. The program, known as Community Aging in Place — Advancing Better Living for Elders (CAPABLE), is a client-directed home-based intervention to increase mobility, functionality, and capacity to “age in place” for older adults. It includes three key design elements — care self-management, professional care management, and community support. CAPABLE consists of time-limited services from an occupational therapist, a nurse, and a handyman working in tandem with the older adult.

These special needs health plans are working with the Johns Hopkins University (JHU) School of Nursing, CAPABLE’s developer, to adapt the program into existing enhanced professional care management practices that are already bringing enhanced care management and community support into patients’ homes. The work is supported by a planning grant from The SCAN Foundation and The Commonwealth Fund.

CAPABLE differs from traditional models in several ways. It focuses on maximizing patients’ abilities rather than accepting continuing decline, by both building the capability of the older adult as well as modifying the home environment.

It also puts patients in the driver’s seat. Usually, when a clinician conducts a comprehensive assessment of the older person, the clinician drives the encounter by identifying the person’s key areas of weakness to set goals and plan care. Instead, CAPABLE allows the older person to drive the goal-setting and brainstorming strategies with the team. The older adult works with the occupational therapist and nurse to identify three achievable goals per discipline. These professional team members use motivational interviewing techniques, including active listening, follow-up responses, and using the person’s own words in describing issues presented. In this conversational approach, the older person can tap into the team members' knowledge and expertise as they explore ideas for overcoming barriers to independent living. Each monthly visit and each service builds on the others by increasing the participant’s capacity to function at home. The older person, family caregiver (if there is one), and three “professional” team members — including the handyman — work in sync.

Building skills and self-efficacy (belief and confidence in one’s own abilities) are core components of this approach. The older person learns new skills, exercises, and how to work with additional tools and equipment. Instead of practicing in a “home-like” unit in a health care or rehab facility, they can practice in-between visits in the actual home environment. For example, in the case of safe bathing, barriers could include a slippery tub, muscle weakness, and lack of handrails. The handyman can make structural improvements needed to overcome these barriers, and the older adult learns tips for safely moving in and out of the tub.

The CAPABLE program has shown it can decrease hospitalization and nursing home stays by improving medication management, problem-solving ability, strength, balance, nutrition, and home safety, while decreasing isolation, depression, and fall risk.

How did the program work out for Mrs. G, the patient whose story we shared at the beginning of this piece?

After the four-month program, Mrs. G. now uses her new solidly built front railing to get to the mailbox and reconnect with neighbors. She safely gets in and out of bed and her shower with the help of assistive devices and training. She gets into and out of cars to go on excursions thanks to strength and balance training — exercises she safely did at home and has continued since the end of the four-month program. Her newly streamlined medication regimen makes it easier for her to take her medicines as prescribed, and her mood is improved now that she feels freer to live her life at home.

The CAPABLE program builds on previous work on managing care for people with complex needs. To explore more, you may be interested in the following resources:

Editor’s Note: This program is supported by a grant from The SCAN Foundation and the Commonwealth Fund — which are part of the six foundation collaborative behind the Better Care Playbook. More about the funders:

  • The SCAN Foundation advances a coordinated and easily navigated system of high-quality services for older adults that preserve dignity and independence. For more information, visit www.TheSCANFoundation.org.
  • The Commonwealth Fund is a national, private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice and policy. The views presented here are those of the author and not necessarily those of The Commonwealth Fund, its directors, officers, or staff.