Across the athenahealth network and beyond, healthcare organizations are designing and implementing simple interventions with outsized impact on outcomes, satisfaction, and success. Here's another. 

The problem

A tremendous number of older people have one or more physical impairments that impact their activities of daily living: how they get around their house, how they make a meal, how they take a shower. 

Although 90% of seniors say they want to age in place, those with functional impairments have a higher likelihood of going into a nursing home, as well as higher healthcare costs, including hospitalizations. Yet function is rarely addressed in medical visits. 

The solution

Community Aging in Place Advancing Better Living for Elders (CAPABLE) is a home-based behavior and environment intervention program developed in 2009 at the Johns Hopkins School of Nursing by Dr. Sarah Szanton for lower-income, older adults to help them safely age at home. 

It sends a CAPABLE-trained nurse, occupational therapist, and handyman into a client's home for 10 sessions over the course of about four months. Working one-on-one with the older adult, the team finds ways to improve home safety, while decreasing isolation, depression, and the risk of falls associated with limited function. 

Environmental adaptations are determined by the client's own goals for doing meaningful daily activities. Lowering the heights of cabinets or adding a safety bar to a step ladder can help a client cook more safely, for example. Putting a railing on stairs and fixing uneven steps can help someone who walks to the store go outside more easily, while installing a loud doorbell can help a client know when friends come over to visit. 

“In nursing school, we don't learn how to allow the client to tell us what their needs are," says Alice Bonner, RN, Director of Strategic Partnerships for the CAPABLE program at Johns Hopkins University. “We go in and say, 'Oh, your blood pressure's high' or 'Your blood sugar's too high.'" The CAPABLE program turns that model upside down. “Here, we're starting by saying to an older person, 'What's the most important thing to you? We're going to help you set goals and reach those goals, and you're going to drive the process.'" 

An OT helps the client agree on a plan and works with them to adapt to home modifications constructed by the handyman. 

Then a nurse comes in to reconcile medications and tackle other issues the client identifies, like incontinence, pain, or nutrition, as those relate to activities of daily living. The nurse can report back to the client's primary care team and coach the older adult in communicating with their providers about their health going forward. 

The model was designed to be implemented by a number of groups, such as health systems, insurance companies, ACOs, and home healthcare agencies. Every organization hires staff and develops a staff communication system that works best for them. In addition to training, CAPABLE provides protocols, manuals, assessment and documentation forms, and items for the participants, such as tip books, and ongoing webinars for organizations. 

The outcome

CAPABLE is now in 14 states, and Bonner anticipates that the Medicare Advantage expansion will be advantageous in opening the door to CAPABLE, along with other programs that target high-risk populations in order to prevent avoidable utilization. Multiple EHR vendors have already partnered with CAPABLE to incorporate their data, and even more are exploring the possibilities of partnership. 

Small and large research trials show that CAPABLE participants had fewer difficulties with activities of daily living and fewer symptoms of depression and pain, while their ability to shop for groceries and manage medications improved. 

The larger studies have also showed lower hospitalization rates and decreased nursing home admissions. And according to CAPABLE's calculations, a $3,000 investment in this functional support results in $20,000 in saved medical costs, driven by reductions in both inpatient and outpatient expenses. 

That's not counting the effects of closing a communication gap between seniors and their regular care team. “I did office practice for several years," says Bonner. “And I can tell you, getting a call from a nurse or an OT who's in someone's home and who can give me really valuable information that I never would have been able to get through a clinic visit, that would really help me to take better care of my clients." 

Erin Graham is a frequent contributor to athenahealth's Knowledge Hub.