By: Lisa Remington, President Remington Health Strategy Group, and Publisher, The Remington Report

imageDifficulty with everyday physical functioning—the ability to perform both basic (for example, dressing, bathing, and walking) and instrumental (such as going shopping or managing one’s medications) activities of daily living—is a major cost driver that is typically overlooked and unaddressed in traditional medical care.

  • The number of Americans who need help with ADLs and other activities such as paying bills or taking medications (collectively called “long-terms services and supports” or “LTSS”) is expected to rise from 12 million today to over 27 million in 2050.
  • According to the Congressional Budget Officer (CBO), 20 percent of individuals over age 65 and 41 percent of individuals over age 85 need assistance with at least one ADL.
  • People with functional limitations and chronic conditions are more than four times more likely than the general population to be among the 5 percent top of users of all health services.1
  • An estimated $219 billion is spent annually on long-term services and supports for people unable to function independently.2

The Center for Medicare and Medicaid Innovation (CMMI) is funding innovative programs that seek to improve the quality of health care, reduce the cost of care, and improve the US population’s health by addressing non-medical factors. The hypothesis driving these investments is that many high-cost users have problems that are unaddressed in traditional health care models, which ultimately leads to avoidable health care utilization. Sarah Szanton, a nurse practitioner in West Baltimore, and an associate professor of health policy and management at Johns Hopkins University, was the lead investigator and creator of CAPABLE. She said the program hinges on two ideas. One is that environment influences health and the second is that seniors should set goals to improve their health. Seniors in her study were less depressed when they needed to rely less on others, she said.

Program Overview
The program called Community Aging in Place, Advancing Better Living for Elders, or CAPABLE for short, was a five-month structured program delivered by an occupational therapist, who made six visits to each participant; a nurse, who made four visits; and a handyman, who contributed up to a full day’s work—providing home repairs, installing assistive devices, and making home modifications. Participants worked with the therapist and nurse to identify three achievable goals per discipline and examined the barriers to achieving those goals.

The CAPABLE program targeted functional goals (for example, to get upstairs, take a shower, and walk out the front door) that each participant identified as most important to him or her and the barriers that interfered with achieving these goals. The program was made available to eligible residents of all but the wealthiest neighborhoods in Baltimore, Maryland.

Study Results

Of the 234 participants whose data was analyzed, 83 percent were women, and 80 percent were African American. As required by the eligibility criteria, all of them lived at home with or without family members. Forty-five percent lived alone.

On average, participants had difficulty with 3.9 (standard deviation: 3.04) of the 8.0 ADLs at baseline. This difficulty was reduced among 75 percent of participants during the five-month CAPABLE program (Exhibit 1)The average reduction was from difficulty in 3.9 activities to difficulty in 2.0 activities (SD: 2.0), a 49 percent improvement in physical functioning.


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  • Difficulties with instrumental ADLs decreased in 65 percent of participants (Exhibit 1) The average decrease in difficulty was from 4.1 activities (SD: 2.09) to 2.9 activities (SD: 2.22). In multivariate models, age, race, and symptoms of depression at baseline were not significant predictors of functional improvements.
  • Depressive symptoms improved in 53 percent of the participants (Exhibit 1). Home hazards decreased from an average of 3.3 hazards (SD: 1.83) to 1.4 hazards (SD: 1.14) (data not shown).
  • Participants benefited equally from the CAPABLE program whether or not they had been hospitalized in the previous year.
  • The average cost of delivering the program was $2,825 per participant. This included all ten clinician visits, mileage, care coordination, supervision, home repair and modification (including parts and labor), and assistive devices, as well as overhead paid to the handyman organization. This is lower than the costs previously reported14 because costs were reduced with experience.

The Future of CAPABLE
A version of CAPABLE is being studied in Michigan as a potential cost-saving program, and Szanton envisions it being incorporated into Medicare Advantage plans, accountable care organizations and Medicaid Waiver programs aimed at keeping people out of nursing homes.