CAPABLE: An ACL evidence based program that could be adapted for older Native Americans

1. CAPABLE: An ACL evidence based program that could be adapted for older Native Americans Sarah L. Szanton, PhD ANP FAAN Health Equity and Social Justice ProfessorJohns Hopkins School of Nursing Director, Center for Innovative Care in Agingsarah.szanton@jhu.edu

2. Older adults drive population health outcomes

3. Disability • Risk factor – poor outcomes, heavy utilization • Generally unaddressed in clinical practice • Most interventions ineffective • Person AND Environment

4. Mrs. B

5. Her Hazardous floor

6. Functional limitations are costly • Older adults’ health costs largely determined by their disability status. • Cost more strongly associated with “ADL limitations” than sociodemographic, psychosocial, and diagnosis variables. HHS, 2010, Closer look at Chronic conditions, Cutler and Meara

7. Relative Risk of Being in the Top 5% of Health Care Spenders, 2006

8. CAPABLE Approach • Age in place = person and house • Older adult is the expert • Professionals use specialized knowledge only to elicit, support what older adult wants • ↑Physical function ↓depression • ↓ hospitalization, ↓nursing home

9. Key components of person centered programs • What matters? Notwhat is the matter? • Addressing person and their environment • Training clinicians to listen and support with words and tangible changes

10. CAPABLE: key aspects • 4 month duration • Focused on individual strengths and goals in self-care (ADLs and IADL) • Handyman, Nurse and Occupational Therapist • OT: 6 visits, RN:4 visits, Handyman: $1300 budget • Total cost = $2825 (2014 dollars)

11. Table Month 1 Month 2 Month 3 Month 4

12. Before After

13. 27 Implementation Sites

14. Exhibit 1. Changes from Baseline to Follow-up in Activities of Daily Living Limitations and Instrumental Activities of Daily Living Limitations

15. Exhibit 2. Changes from Baseline to Follow-up in Depressive Symptoms and Home Hazards

16. ADL and IADL resultsCAPABLE RCT (N=300) Szanton et al JAMA Internal Medicine, 2019

17. 5 Month Reduction in ADL and IADL difficulty Szanton et al JAMA Internal Medicine, 2019

18. CAPABLE saves Medicare >10k per patient per year Hospitalization ED visit Medicare Expend ** p <0.05 From RuHealth Affairs, 2017

19. Driving the savings • In Ruiz et al (prior slide) driving the savings are • Reduced readmissions • Reduced observation stays • Decreased specialty care • Reduced nursing home admissions (see key on next slide)

20. Program Satisfaction: CAPABLE v. attention group after participation Szanton et al, 2019 JAMA Internal Medicine

21. MRS. D. • Confused, over medicated • 30 minutes to walk to the bathroom • Sat on commode all day as a chair • CAPABLE: Med schedule, chair along hall, chair at top of stairs, railing on both sides, bed risers, wider commode

22. MRS. H. • Asthma, DM, HTN, Arthritis • Breathless – limited ADLs, couldn’t walk up steps, or outside house • CAPABLE: • connected with PCP for long acting inhalers • Switched from Aleve to Tylenol • CAPABLE exercises • Easier to take a bath –> decreased pain • Super ear • Railings, repaired linoleum floor

23. If I had 10,000 tongues… • “If I had 10,000 tongues and they could all speak at the same time, I could not praise the CAPABLE program enough.”

24. Addressing Function • Poor function is costly • It’s what older adults care about • It’s virtually ignored in medical care • Modifiable

25. Why this improvement? • Function is modifiable • Person/environment fit • Unleashing participants’ motivation • Their own strengths and goals • Providing resources to achieve those goals • Builds self-efficacy for new challenges

26. PAYOR POSSIBILITIES(TRIPLE AIM) • CMS could scale –through PTAC • Accountable Care Organizations • Medicare Advantage • PACE • Medicaid waivers • Maryland Hospital Waiver

27. Policy levers • Chronic Care Act of 2018 • Flexibility to cover “non-medical” • Permanently authorizes SNPs • PTAC • HUD - appropriations

28. Questions and discussion