Aging-in-Place Program from Johns Hopkins on the Verge of ‘Exponential Growth’

CAPABLE — the innovative program developed out of the Johns Hopkins School of Nursing that combines nursing care, occupational therapy and handyman services — is on the verge of “exponential growth” and one step closer to becoming Medicare-reimbursable.

It’s also another example of how complex and comprehensive in-home care is becoming.

Since its first pilot a decade ago, the CAPABLE program has expanded to more than two dozen different sites across 14 states, according to Sarah Szanton, the Johns Hopkins School of Nursing professor who developed the program, building on colleague Laura Gitlin’s work from the 2000s. The maturation of accountable care organizations (ACOs) and the evolution of Medicare Advantage (MA) is helping to drive that expansion.


“The world is moving in this direction,” Szanton told Home Health Care News. “CAPABLE fits really nicely into this stream of innovation.”

CAPABLE, which stands for “Community Aging in place — Advancing Better Living for Elders,” is an evidence-based, four-month, interdisciplinary program designed to increase seniors’ mobility, functional ability and overall capacity to age in place by addressing multiple aspects of their health and well-being.

If a participating senior is having trouble with safe bathing, for example, the three-pronged CAPABLE team works to tackle barriers that could include a slippery tub, muscle weakness and structural inadequacies. An OT works with the senior on safe ways to enter the tub; a nurse looks at underlying issues, such as pain, that could affect balance; and then a handyman makes structural improvements, such as installing grab bars or repairing damaged flooring.


“It’s all wrapped around what that person says he or she wants to be able to do,” Szanton said.

While the program’s premise of solving for both physical and environmental problems may seem simple, its results have been eye-popping: For every $1 spent on CAPABLE, the program sees combined savings of nearly $10 to Medicare and Medicaid, in part due to a decrease in hospitalizations and nursing home placements, research from Szanton and others has found.

Among low-income older adults who participate in CAPABLE, the majority have seen functional and mobility improvements, with the average improvement being a roughly 50% reduction in their degree of disability.

About 1,000 individuals have gone through the CAPABLE program in total, according to Szanton.

“Our pilot results were astoundingly effective, so we got major funding from the National Institutes of Health (NIH) and from the Centers for Medicare & Medicaid Services (CMS) in 2012,” she said. “We then ran trials that finished in 2015 and 2017, which also highlighted some impressive results.”

Provider opportunity

CAPABLE was developed out of the Johns Hopkins School of Nursing, but it’s sometimes administered locally by at-home care organizations and their partners. The Visiting Nurses Association of Colorado helps manage the program in Denver, with Habitat for Humanity providing support from the handyman angle.

“That’s one of our flagship programs,” Szanton said.

Meanwhile, Habitat for Humanity likewise spearheads the program in the Twin Cities’ metro area with Allina Health.

Moving forward, additional opportunities for home health and home care providers may arise due to expanded MA flexibilities. CMS announced in 2018 that certain in-home services and supports would be allowed as supplemental benefits in 2019, then doubled down on that move this year for the 2020 plan year.

Those expanded flexibilities include home modification.

Outside of the CAPABLE model, some home care providers have made handyman and home-mod services core components of their business mix. Newton, Massachusetts-based HouseWorks LLC — which employs about 350 caregivers and more than a dozen handymen — is one such provider.

The private-pay home care company started out as a home modification company about 20 years ago. Today, HouseWorks’s home modification arm makes up about 10% of the company’s revenue, CEO Andrea Cohen previously told HHCN.

“What we’re seeing lately is an increase in the number of home care clients who really want home adaptation and are asking for it,” she said.

CAPABLE in 2019

In December 2018, CAPABLE was awarded a $3 million grant courtesy of the Rita & Alex Hillman Foundation to support the program in its nationwide expansion and training efforts. The additional funding also helped the program hire a director of strategic partnerships plus a director of implementation and evaluation, according to Szanton.

But that’s not the most exciting recent update for CAPABLE.

In June, the Physician-Focused Payment Model Technical Advisory Committee (PTAC) voted unanimously to recommend that CMS test CAPABLE on a bigger scale “to inform payment model development.” The CAPABLE team first submitted a PTAC application last summer.

Broadly, PTAC was set up to make comments and recommendations to the U.S. Department of Health and Human Services (HHS) on proposals for new payment models. The HHS secretary is then required by law to review PTAC’s comments and recommendations on proposals and post a detailed response on CMS’s website.

There are many more hurdles to clear before CAPABLE has the chance to be reimbursed by Medicare, but getting PTAC’s support is an important first step, according to Szanton.

“[It doesn’t mean] any physician or nurse practitioner can write a prescription anywhere in the country at any time [for CAPABLE],” she said. “But more so it’s recommending CMS to study it further and at a larger scale. … Then what CMS does it up to CMS.”

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