- What is the CAPABLE Program?
CAPABLE is a client-directed home-based intervention to increase mobility, functionality, and capacity to “age in place” for older adults. CAPABLE consists of time-limited services from an occupational therapist, a nurse, and a handyman working in tandem with the older adult as an interprofessional team. A key component of this approach is having the older person drive the goal setting and brainstorming strategies with the team toward reaching goals. Each service builds on the others by increasing the participants’ capacity to function at home. This can decrease hospitalization and nursing home stays by improving medication management, problem-solving ability, strength, balance, mobility, nutrition, and home safety, while decreasing isolation, depression, and fall risk.
Participants work with the occupational therapist and nurse to identify three achievable goals per discipline. The team members use motivational interviewing to examine how to overcome barriers to independent living. The participant learns new skills, exercises, and how to work with additional tools/equipment/home modifications-- practicing in between visits. In the case of safe bathing, for example, barriers could include a slippery tub, muscle weakness, and lack of handrails which impact how to get safely into and out of the tub. In this example, the occupational therapist and client work together on safe ways to use the tub plus ways to conserve their energy, the registered nurse addresses medical or condition related factors that could affect balance, such as pain, and the handyman makes structural improvements needed to overcome these barriers, such as installing grab bars and repairing broken flooring.
- Is CAPABLE evidence-based?Yes. CAPABLE is approved by the National Council on Aging as an evidence based fall prevention program. CAPABLE has been tested in multiple small and large trials, each showing a benefit towards better function and lower hospitalization rates. The larger studies have also showed decreased nursing home admission. CAPABLE is being recognized by Federal and State agencies as an effective program in improving health and decreasing costs among older adults. As of August 2018, CAPABLE is being offered through programs in 22 organizations across 12 states in the U.S., and Australia.
- I am the Medical Director for a Medicare Advantage plan. If we have 10,000 covered lives over age 65, how many could benefit from CAPABLE?
Generally, in 10,000 people over 65, 40%-50% will have difficulty with at least one Activity of Daily Living (ADL). After subtracting the 10% who have dementia, there should be approximately 3,500 who can benefit from CAPABLE. This will, of course, depend on the composition and characteristics of your own population.
- What steps are involved in implementing CAPABLE?
To adopt the program, the organization(s) will need to identify and address the following at a minimum:
- Capacity, staff resources, workflow, and where the program will be “housed” within the organization(s)
- Training of the registered nurse (RN) and occupational therapist (OT) and identification and preparation of the handyman services to be engaged
- Funding for the program with an eye towards a sustainable business model
- How the program will be monitored and evaluated
With regard to the flow of the program, these are the key components and steps:
The occupational therapist (OT), registered nurse (RN), and handyman come to the home to deliver services over a 5-month period. In most cases, the OT makes 6 visits, the nurse makes 4 visits, and the handyman makes 1 to 2 visits. The program can be completed in fewer visits, though we recommend not less than 4 OT visits and 3 RN visits for participants to achieve benefit. Visits are spaced to enable older adults to practice new strategies learned in the previous visit. At times, a visit may need to be rescheduled given unforeseen circumstances. However, it is not recommended that the program extend for more than 6 months. There should be a clear “conclusion/graduation,” with the older adult understanding how to use their new skills and apply them to future situations.
CAPABLE home visits are key to meeting the participant “where they are.” The first visits for the OT and RN are usually 90 minutes each and the later ones are usually an hour each. The length of handyman visits depends of the scope of work.
- Initial Screening and Interview
- 1st OT visit – includes assessment and discussion of priority goals
- 2nd OT visit – includes examining the home and working with the participant to create goal-related work order for the Handyman.
- Handyman comes to make repairs and accessibility modifications. A scoping visit before home modification items (e.g., grab bars, railings) can be ordered may be necessary.
- 1st RN visit focuses on pain, strength, medication, communication with health care providers
- Additional OT visits to address priority goals
- 2nd RN visit to set goals, review exercises, consider how to improve communication with primary care provider
- Additional RN visits to review progress and use strategies, complete action plan
- The 6th OT visit is a wrap-up and for helping the participant generalize what they learned so that they can address new challenges. The number of OT visits may depend on the number of stated goals. For instance, if an individual is working on only 2 goals, the OT may only visit 5 times.
- What organizations can implement CAPABLE?
Many types of organizations are implementing CAPABLE. This includes: health care systems, Accountable Care Organizations, Area Agencies on Aging, Medicare Advantage health plans, insurance companies, PACE programs, state/county/city Department of Aging, Home and Community Based Services providers, skilled nursing facilities, nursing homes, Veterans Administration centers, home healthcare agencies, and non-profit organization in the healthcare and housing sectors. There is also potential for local startups to offer CAPABLE as a self-pay model.
- Can CAPABLE only be implemented in houses?
No, CAPABLE can be implemented anywhere older adults live.
- Private homes, condos, townhomes (pursuant to association rules)
- With clearance from the landlord:
- Apartment buildings
- Other non-home owner situations (e.g., participant lives in a relative’s home)
- Who is eligible to participate in CAPABLE?
Organizations generally determine participant eligibility criteria that fit the needs of their location. The evidence base of CAPABLE is with people who:
- Are older adults (over 60); although some health systems are including people as young as 50.
- Are cognitively intact or have only mild cognitive impairment
- Have some or a lot of difficulty in performing Activities of Daily Living (ADLs), such as bathing, dressing, grooming, or walking across a small room. This could apply to adults at any age with ADL difficulty.
- How do we find a handyman partner?
There are several possible sources for a handyman. For instance, we have worked with an AmeriCorps training site that trains handy people to do such work. Other possibilities include:
- hire one internally
- contract with an AmeriCorps training site
- contract with one of the many non-profits that provide home modifications for older adults.
Knowledge and experience with local code requirements is advantageous. There is currently no specific training for the handyman beyond a video in the training for the occupational therapists (OT). However we recommend orientation on the CAPABLE program, and basic skills in working with older adults, as well as background check and other organizational clearances to ensure the individual has the necessary credentials and does not pose a risk to the older adult.
- What are some typical services provided by the Occupational Therapist and Registered Nurse or objectives identified by the participant?
Environmental changes at home; decreasing falls hazards, improving balance, improving strength and mobility; reviewing medications and potential need for changes in working with the prescribing physician; providing self-care strategies for better management at home. Participants have also raised issues around incontinence/bladder control, fatigue, muscle weakness or stiffness, poor vision, and social isolation. Examples of approaches or strategies that have been helpful including showering later in the day when the body is less stiff to increase ease of bathing; identifying specific products like LED lights or medication reminder alarms. All services support achieving the patient-identified goals.
- Who determines the scope of work for home modifications?
The occupational therapist works together with the older adult to determine what will be modified. This is based on the participants’ goals for meaningful daily activities. The handyman may also add basic safety repairs if money remains after the agreed upon home modifications are completed.
- What are some typical modifications made by the handyman?They range from modifications, repairs, medical equipment, and everyday items. Here are examples of each.
- Install grab bars in the tub area to facilitate safe use of the tub
- Widen bathroom door for wheelchair access
- Fix hole in floor
- Staple down loose wall-to-wall carpet to avoid falls
- Raised toilet seat
- Night lamp for safe transfer from bed to bathroom at night
- Sturdy step stool to reach kitchen cabinets safely
Training and Staffing
- Is training required for the Registered Nurse and Occupational Therapist to implement the program?Yes. Registered Nurses and Occupational Therapists are required to be trained through the Hopkins CAPABLE training program, which consists of the following activities:
- Five 60 minute on-line learning modules (self-paced, recommended to complete modules over 2 weeks)
- Up to an 8 hour live (virtual) training. These virtual training sessions happen quarterly and participants only participate in one.
- Five coaching calls or webinars
- What are key skills for the Registered Nurse-Occupational Therapist team?
The training for CAPABLE provides team members training in motivational interviewing skills. They use these to build the self-efficacy of the older adults who have functional difficulty. While the older adult is in charge of what the goals are, the Registered Nurse and Occupational Therapist use their clinical knowledge and experience to support the older adult’s goals through a process of brain storming and action planning. This is crucial. These skills require critical thinking and experience in working with older adults in their own.
- Can we train and utilize staff from disciplines other than Occupational Therapy and Nursing for CAPABLE?
The occupational therapist (OT) and registered nurse (RN) can not be substituted and have the program still be called CAPABLE. The training builds from the knowledge base and experience of occupational therapists and registered nurses. For instance, building from the education in occupational therapy, the focus is specifically about activity analysis and achieving the best fit between persons and their living environments to maximize daily function and home safety, and reduce difficulties with Activities of Daily Living (ADLs). The nurses use their pathophysiological knowledge in addressing pain, mood, and medication complexity. The critical thinking involved builds on how OTs and RNs are trained.
- Is social work part of CAPABLE?
Social work can be added as an addition to CAPABLE very successfully. This is especially useful in situations with complicated family dynamics or when access to benefits and other resources are needed. This does not take the place of the occupational therapist (OT) and registered nurse (RN).
- Do the Registered Nurse and Occupational Therapist have to be trained together?No.
- What is the appropriate caseload for a full time team?
One Registered Nurse (RN) and Occupational Therapist (OT) can have between 20-30 participants at a time. The RNs can have more because they have fewer visits (4 compared to 6 visits for the OT) so if you staff up more, you could have 3 OTs and 2 RNs for a caseload of 60.
- How much does the training cost and what does it include?
For small pilots with beta pricing, the training is $6,000 for one Registered Nurse and Occupational Therapist, which includes:
- license to provide CAPABLE for 3 years
- online modules
- virtual training
- follow up webinars for the Registered Nurse and Occupational Therapist in the first few months they start providing CAPABLE
- Certificate of completion
For larger projects and health systems, the license is provided to the site and we can provide a custom price depending on number of older adults to be served and number of occupational therapists and nurses to be trained.
- What is the overall cost to provide CAPABLE?
Costs may vary by region and organization, and configuration of specific CAPABLE teams, depending on decisions made about allowable expenses.
At Johns Hopkins, we found that all costs averaged $2,882 per CAPABLE participant in 2015.
This average cost includes:
- Registered Nurse and Occupational Therapist salaries, including home visits, driving time, coordination, follow-up
- mileage reimbursement to/from the home visits (may vary widely by region)
- home repair, modification, assistive equipment, and everyday items (e.g., Sturdy step stools). It is crucial that the system be able to pay for items needed to help older adults reach their self-identified functional goals and enhance their home safety that are not normally deemed “medically necessary” such as a sturdy step stool, a sturdy chair with armrests, a mailbox, or loud doorbell.
- supervision meetings
These did not include the tablets for data collection or Electronic Health Record (EHR) modification.
Sample start up budget available upon request.
- Can the services be covered by Medicare?
Not yet. This is a work in progress. In the meantime, good partners to pay for the visits, coordination, and handyman parts are those who will benefit from reducing hospitalization or nursing home admission.
- How are various implementation sites funding the intervention?
Accountable Care Organizations are using their global budget, Area Agencies on Aging are providing within Medicaid waivers, state/county/city Department of Aging, Home and Community Based Services providers are using their global budget, Veterans Administration is using pilot money, home healthcare agencies, and non-profit organization in the healthcare and housing sectors have worked together to start with philanthropic money. A hospital is using money to prevent readmissions. Managed care organizations designated as special needs plans are exploring how CAPABLE fits into their care and funding models for persons dually-eligible for Medicare and Medicaid. With new changes to how Medicare Advantage pays for “non-medical” items, Medicare Advantage companies are an excellent partner.
- What materials are provided to support the adoption of the CAPABLE program?
- Training manuals for the Registered Nurse and Occupational Therapist
- Documentation forms for home visits – both electronic and hard copy are available.
- Assessment, brainstorming, and action planning forms that the clinicians use with the participants
- Handbooks and handouts for the participants
- Access to other CAPABLE sites’ outcomes and experience through an online user group
Webinars for which learners can submit their questions. These are offered live and recorded, and archived by topic for later access. Those trained can access the full library of webinar
- How does the team communicate with each other between visits?
What works best for local needs depends on whether they are in the same base office or always on the road. Some CAPABLE teams use in-person coordination, others use email or phone calls, depending on the culture of the organization. Some organizations have electronic health information platforms and data systems that can support this interprofessional team communication. Johns Hopkins is working on an app which could handle all communication.
- Where can I read more about the program?
- Who should I contact with my follow up questions?