CAPABLE: Supporting Older People with Disabilities to Improve Health and Well-Being at Home

The Community Aging in Place ― Advancing Better Living for Elders (CAPABLE) is a participant-driven model that improves function by addressing the home environment and using the strengths of the older adults themselves. It provides time-limited in-home support by an occupational therapist, registered nurse and handy worker. The interdisciplinary team uses motivational interviewing, active listening, and coaching communication methods to enable the participant to achieve goals they develop and prioritize themselves.

In Baltimore, the CAPABLE program is offered through Johns Hopkins Hospital to help older people with chronic conditions return home safely. The program helps recently discharged individuals with activities of daily living (ADLs), such as dressing, bathing, and preparing meals. Their functional abilities may have declined due to the hospital stay. They can become socially isolated and depressed, at risk for falls, and may not take their medications as directed.

In addition, the physical features of their home, such as slippery bathtubs and lack of stairway railings, can heighten their health risks and potential for hospital readmission and emergency department visits. Not addressing the functional challenges people face at home can lead to higher health care costs for payers as well as for providers in financial risk contracts.

In July 2017, The Johns Hopkins Hospital in Baltimore launched a new CAPABLE program to offer intensive support to older, low-income people with Medicare or Medicaid coverage to enable them to better manage their conditions and thrive in their own homes. Most but not all Johns Hopkins Hospital Care Management clients enter the program after a hospital discharge. The CAPABLE program deploys a registered nurse (RN), an occupational therapist (OT), and a handy worker to each participant’s home for 10 sessions over four to five months. Through motivational interviewing, the RN and OT help participants identify the issues that the older adults themselves want to solve.

For instance, CAPABLE staff worked with an 85-year-old woman who suffered from asthma and arthritis. She was depressed because she couldn’t go up and down the stairs in her home, and thus couldn’t go out to see her friends. The staff worked with the primary care team to change her medications and inhaler, got her a hearing device, and modified her home to create more places for her to sit down and rest, including along the stairway. She regained her ability to navigate the stairs and see her friends again.

“Part of the purpose of the program is to give people the skills to become their own problem-solvers,” said Alice Bonner, PhD, RN, FAAN, CAPABLE’s Director of Strategic Partnerships.

Background

Sarah Szanton, PhD, MSN, FAAN, ANP, now Dean of Johns Hopkins University School of Nursing, and Laura Gitlin, PhD, now Dean of the Drexel University College of Nursing and Health Professions, conceived the program more than a decade ago. As a nurse practitioner seeing homebound older adults, Szanton observed their makeshift solutions for dealing with their disabilities, such as crawling into the kitchen because their wheelchair wouldn’t fit through the door.

The Johns Hopkins Hospital Care Management Division agreed to fund the CAPABLE program for its patients in Baltimore because the staff identified loss of functional status as a key factor in hospital readmissions.

The CAPABLE program in Baltimore serves about 100 clients a year, at a cost of about $3,000 per person, including salaries for one registered nurse and one occupational therapist, fees for the handy worker, home modification supplies, and travel costs.

Meanwhile, the CAPABLE staff at the Johns Hopkins School of Nursing has worked with other health systems, community organizations, and payers to launch CAPABLE programs around the country. There are currently more than 40 CAPABLE program sites in 20 states, some of which serve clients without regard to hospital discharge. The Johns Hopkins staff has developed an online, 14-hour training module for RNs and OTs. Participating organizations must sign a business agreement with Johns Hopkins to become licensed as a CAPABLE site.

The goal is to establish CAPABLE programs in all states, and have Medicare and Medicaid programs and private health plans pay for CAPABLE services as a covered benefit. Two states have gotten approval from the Centers for Medicare & Medicaid Services (CMS) to use American Rescue Plan Act (ARPA) money to fund CAPABLE programs, and the Massachusetts Medicaid program is implementing CAPABLE as part of a Section 1915 waiver, Bonner said.

In addition, several Medicare Advantage plans are considering making CAPABLE a covered benefit, she added. CMS must approve it before Medicare Advantage plans can offer the program for the next benefit year.

As of December 2021, at least five community organizations, including a United Way, intend to launch a CAPABLE program through grants from the U.S. Department of Housing and Urban Development.

Implementation

Older adults in Baltimore are referred to the CAPABLE program, primarily after hospital discharge, by Johns Hopkins Hospital case managers and social workers, as well as by their primary care physicians. To be eligible, people must be age 50 or older, live in Baltimore, and have one or more functional limitations. Many of the referred older adults are predominantly women with low incomes, who are dually eligible for Medicare and Medicaid.

CAPABLE staff conduct a phone screening to make sure the clients do not have dementia or cognitive deficits, because they must be capable of making the decisions that guide the goal setting and action plans. They also must be able to understand the program and be willing to accept the intervention. There is no financial screening.

For clients with cognitive deficits, CAPABLE staff soon will be referring them to a new study program called CAPABLE Family. In addition, the staff may refer them to other agencies.

If clients currently accepted into CAPABLE are receiving traditional home health, the CAPABLE staff holds off on providing services until after the home health episode of care is completed.

The CAPABLE nurse interviews each client to identify their clinical goals, whether it’s better pain management, improved mood, dealing with sexual health or incontinence, improved strength or mobility, or something else. The OT goes through the home with the client to identify specific goals for better functional status and any needs for home modification, such as stairway railings, uneven floor surfaces, shower grab bars, or additional lighting.

Based on the client’s goals, the OT then sends a home modification work order to the program’s general contractor, Civic Works, a not-for-profit that trains high school students in construction skills. The contractor and student go to the home to make measurements and order supplies, then go out a second time to do the installation. The average per-client budget for home modification is $1,300.

Impact

CAPABLE programs in Baltimore and 11 other locations across the country have resulted in substantial improvements in participants’ functional status for basic ADLs and instrumental ADLs (IADLs), such as housecleaning and managing medications, according to a review of six peer-reviewed studies published in July 2021 in the Journal of the American Geriatrics Society.

In an earlier Center for Medicare and Medicaid Innovation (CMMI) demonstration of CAPABLE, the savings from reduced hospitalizations and emergency department use associated with the program were $22,120 on average per Medicare beneficiary over two years, according to a 2017 Health Affairs study.

For low-income older adults dually eligible for Medicare and Medicaid, participation in the CAPABLE program led to a decrease in difficulty with ADLs from an average of 3.9 of 8 activities to 2 activities after five months, according to a 2017 study published in the Journal of the American Geriatric Society. Difficulty with IADLs, like food preparation, decreased on average from 4.1 of 8 activities to 2.1 activities. Symptoms of depression improved in 52.9% of patients.

That study found total Medicaid savings per dual-eligible beneficiary between the CAPABLE group and the comparison group of $867 per month, including inpatient and outpatient care, home health, pharmacy, and long-term care.

“There are significant savings for health plans and health systems with CAPABLE,” Bonner said. “For people with disabilities, the program can save on the total cost of unnecessary hospital days and redeploy those monies to take care of more older people.”

Insights

Guiding older adults to set their own goals is key.

It’s important to listen and let clients identify what they want to do in terms of changing long-standing behaviors, said Suzanne Havrilla, DPT, Director of Home Support at Johns Hopkins Home and Community Based Services. For instance, participants brainstorm with staff about what’s causing the problem in getting into the shower. Initially they may say they need a grab bar, then later recognize that they need to build up leg strength through exercise. “That will always be more successful than someone telling them this is what you have to do,” she said.

The five-month length of the program gives clients time to make behavior change.

Compared with the standard, compressed schedule of home health care, CAPABLE’s “special sauce” is spacing out the 10 visits by the nurse and the occupational therapist over five months, Havrilla said. That gives clients time to think about what’s holding them back and to adopt new coping strategies.

Generating referrals requires consistent outreach to hospital case managers, primary care providers, and others in the community.

Hospital staff and physicians tend to focus on peoples’ clinical issues rather than challenges with ADLs when they return home, and they need to be reminded about home-and-community-based support programs that are available, Havrilla said.

Enrolling people requires sensitive outreach, including using family members or community health workers they trust.

Older adults often feel overwhelmed when they leave the hospital. And they may be wary about getting phone calls from people they don’t know. It may help to first talk to the patient’s family member or care partner, and then have a three-way phone call with the client and family member, Havrilla said.

Finding program funders and partners can be challenging.

Larger health systems may be interested in partnering with community organizations to launch a CAPABLE program but may need help in identifying which organizations are best suited to be effective partners, Bonner said. Health systems and community organizations also must figure out how to sustain a CAPABLE program after a grant ends.

The business case for launching a CAPABLE program, she argues, is strongest for payers and providers that bear the total cost of providing care to older adults with functional disabilities and stand to save money by keeping people healthier and more functional at home.

Acknowledgements

Thank you to Alice Bonner and Brian Fitzek, Johns Hopkins School of Nursing; Suzanne Havrilla, Johns Hopkins Home and Community Based Services; and Diane Lepley, Johns Hopkins Hospital for help in informing this profile.

* Author Harris Meyer is a freelance journalist who has been writing about health care policy and delivery since 1986.