As COVID-19 numbers rise heading into winter, U.S. policymakers and senior care advocates continue to explore new, innovative models that support aging in place.
One such model is CAPABLE, an interdisciplinary program out of the Johns Hopkins School of Nursing that combines nursing care, occupational therapy and handyman services. While CAPABLE, which stands for “Community Aging in Place — Advancing Better Living for Elders,” had already seen explosive growth prior to the public health emergency, interest in the model is now at an all-time high.
“This is really shining a light on, ‘Boy, we don’t want to have institutions of 100 people down a hall,’” Sarah Szanton, the Johns Hopkins School of Nursing professor who helped create the program, told Home Health Care News. “This is really showing the value of CAPABLE, beyond even what we were seeing before COVID.”
Since its first pilot location in Baltimore more than a decade ago, CAPABLE has expanded to more than 25 cities, including Chicago, Boston, Houston and several other major metropolitan areas. Soon to be included in that total, Szanton pointed out, are nine Veteran Affairs (VA) sites in Pennsylvania.
“Smaller, one-off sites are continuing, too,” she added. “There’s a new site in Alaska that’s getting off the ground.”
To expand the CAPABLE program, Szanton and her team typically join forces with another organization. Current partnership examples include an accountable care organization (ACO), a PACE program and home health agencies, plus a Meals on Wheels agency and private philanthropies.
During the coronavirus pandemic, it’s those partnerships with home health agencies that have been particularly impactful.
“Almost all of the CAPABLE programs stopped, taking a pause in March and April, because everyone was only doing things that were essential,” Szanton said. “The ones that are continuing are the ones that are home health agencies actually, partly because they’re used to being in the home and they’re used to taking precautions.”
Teaming up with VillageMD
Generally, CAPABLE’s three-pronged strategy combining nursing care, occupational therapy and handyman services is meant to tackle all aging-in-place barriers. That could mean having an OT show somebody how to safely enter and exit a bathtub, or it could mean asking a handyman to fix a shaky step to prevent falls.
That approach has been proven to both improve functional ability and lower health care spending: For every $1 spent on CAPABLE, the program sees combined savings of nearly $10 to Medicare and Medicaid, past research has found.
A more recent report in the New England Journal of Medicine likewise highlighted the cost-effectiveness of CAPABLE. In it, the authors noted how the model lowered activity-of-daily-living (ADL) disability scores by 30% while reducing depression and saving Medicare $922 per member per month.
“We started CAPABLE because I was a house calls nurse practitioner, providing regular medical care,” Szanton said. “That was fine. It was convenient for people. But what I was seeing was people falling down because of old floors or banisters. I realized being able to take a bath or get to your mailbox might be more on people’s minds than whether their glucose was under control for their diabetes.”
The steady stream of results for CAPABLE has landed it plenty of interest in 2020.
In March, the Johns Hopkins School of Nursing received a $4.3 million grant from the National Institute on Disability, Independent Living and Rehabilitation Research (NIDILRR) to launch a national center dedicated to improving care for people with disabilities. Part of that funding will be used to strengthen CAPABLE’s data-collection abilities and to create a model tailored to the needs of individuals living with dementia.
Additionally, some of the funding will be used to explore how to best integrate CAPABLE with doctor house call practices, according to Szanton.
That latter goal is important, considering one of CAPABLE’s latest partners is VillageMD, the value-based primary care practice that runs a sizable house calls division.
The leadership teams of VillageMD at Home and CAPABLE first met in Baltimore in early 2020, a VillageMD spokesperson told HHCN. That meeting resulted in a partnership to offer the CAPABLE program to a population in VillageMD’s Houston market.
“The CAPABLE program will be an extension of VillageMD’s comprehensive care model, resulting in improved quality of life for patients and their caregivers and reduced health costs by enabling patients to remain at home and avoid unnecessary hospitalizations and nursing home placements,” the spokesperson said.
Providing ‘critical peace of mind’
Apart from new partnerships, 2020 has also been an exciting year for CAPABLE in regard to being in the national media spotlight. In July, the U.S. turned its attention to the model after presidential candidate Joe Biden mentioned it during a speech on the campaign trail.
“Simple steps save lives, save money and provide critical peace of mind,” Biden said, referring to CAPABLE’s approach.
The Buttigeig and Bloomberg campaigns likewise touted CAPABLE, prior to Biden. Szanton was unaware the former vice president was going to highlight CAPABLE.
“My phone started to blow up driving in rural Virginia, coming home from a family trip,” she said. “It turned out that Biden had just been giving a speech mentioning CAPABLE. It was a big surprise. To hear him really describe it was thrilling.”
Moving forward, Szanton and her team are focused on advancing policy measures that would help sustain the CAPABLE model on a national level.
At the beginning of the year, U.S. Department of Health and Human Services (HHS) Secretary Alex Azar tasked the CMS Innovation Center to look into how a dedicated payment mechanism would work.
“I have asked [the center] to explore how the CAPABLE model could be incorporated into new risk-sharing arrangements available through the CMS Innovation Center’s new payment and service delivery models,” he said at the time.
In June 2019, the Physician-Focused Payment Model Technical Advisory Committee (PTAC) voted unanimously to recommend that CMS test CAPABLE on a larger scale “to inform payment model development.”
“From what we can tell, CMS is viewing CAPABLE as already possible to be included in value-based mechanisms like Primary Care First or Medicare Advantage plans,” Szanton said. “It doesn’t need anything, in particular, beyond what already exists in terms of the overall policy environment.”
Still, she hopes CMS can create something like a reimbursable bundle that’s similar to surgical bundles, for example, which could help support CAPABLE under traditional Medicare until the shift toward value-based care gains more momentum.
“We’re working with all of our partners and their representatives to make sure that Congress and CMS are educated about what’s going on in their districts,” Szanton said.