The CAPABLE Model for Aging in Community: - PowerPoint Presentation

1. The CAPABLE Model for Aging in Community: A Texas Demonstration ProjectAndrew Levack, MPH – Senior Program Officer, St. David’s Foundation

2. 7 million Medicare beneficiaries with modifiable disability live at home. Their costs are twice as high as similar beneficiaries without disability. The average 65-year old can expect to live 5+ years with disability.* *Source: Freedman & Spillman. Health Affairs; 2016.

3. Adult is the expertClinician supports adult’s goalsSupports provided by a team of:Registered NurseOccupational TherapistHandypersonThe CAPABLE Approach

4. 4

5. CAPABLE: Evidence Base* More Than 6X Return on InvestmentRoughly $3,000 in program costs yielded more than $30,000 in savings in medical costs driven by reductions in both inpatient and outpatient expenditures.Reduced Symptoms of DepressionSymptoms of depression, as well as the ability to grocery shop and manage medications also improved.* Ruiz et. al, 2017; Gitlin et. al, 2019; Szanton et. al, 2017Improved MotivationThe change in physical environment further motivates the participant. Addressing both the people and the environment in which they live allows the person to thrive.Halved Difficulties in FunctionParticipants had difficulty with an average of 3.9 out of 8.0 Activities of Daily Living (ADLs) at baseline, compared to 2.0 after five months.

6. Program Satisfaction: CAPABLE v. Attention Group after Participation Szanton et al JAMA Internal Medicine, 2019

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

8. We can reduce costs by up to one-third.*Ruiz et al., Health Affairs, 2017$918PMPM savings over a 2-year periodCAPABLEMatched comparisonCMS-funded analysis of CAPABLE’s impact on Medicare costs among duals, published in a top-tier peer-reviewed journalAnnual Medicare Costs

9. 45 Implementation Sites, 20 States9

10. Why this worksUnleashes people’s motivation Honors their strengths and goalsProvides resources to achieve those goalsBuilds self-efficacy for new challengesLimited function can be modified!

11. Community Aging in Place Advancing Better Living for EldersStephanie Houghton-Bowman RN, BSN, BSW-RN Program Manager, MOWCTX CAPABLE Program

12. Meals on Wheels Central TexasCAPABLE Program 2021-2022CAPABLE was the perfect addition to MOWCTX programs- 50 years of assisting under resourced older adults to age in placeProviding more than a meal from in-home care to home repair.Service delivery that is data driven and tested.JHU has the recipe for successful implementation-JHU support through every step of the processCollaboration with all stakeholders for morale building and problem solvingStrong MOWCTX senior leadership support for the MOWCTX CAPABLE programMOWCTX CAPABLE Team-Experienced, professional, caring-

13. Identifying and Recruiting MOWCTX CAPABLE ParticipantsEligibility-MOWCTX CAPABLE program participants meet the following eligibility criteria:Difficulty with 1 activity of daily living (ADL) or 2 instrumental activities of daily living (IADL)>60 years old<250% povertyWithout a diagnosis of Dementia or Alzheimer Disease Participant cannot be currently receiving hospice servicesParticipant reside in an underserved part of the county MOWCTX Case Managers primary source of CAPABLE referralsManaged care partners provide referrals; Providers, PTs/OTs, RNs, case manager, social workersWord of Mouth-Program benefits are beginning to be shared in the greater community!!!

14. -Case study #1-Ms. C “Ms. C is a 61 yo African American female who reported experiencing a right side stroke, cervical spine surgery and carpal tunnel surgery all in 2021.Participant’s income is <$900/moDual Medicare/Medicaid eligibleParticipant has multiple medical diagnosis including hypertension, Hepatitis C, peripheral arterial disease, carpal tunnel syndrome and spinal stenosis and suffers from anxiety related to inability to make end meet compounded by multiple health conditions that effect her daily life and well beingParticipant lives in subsidized housing which she reports provides her with a sense of stability and safety.Participant is a MOWCTX client who was referred to the CAPABLE program by her MOWCTX case manager due to her functional and health care challenges

15. Case Study: Ms. C’s Occupational Therapy GoalsMs. C’s Occupational Therapy functional goals:GOAL #1- Increase ability to get in and out of bed safely- “I have been sleeping on an air mattress for the last ten years and by the time I wake up it is out of air.”Ms. C received a new mattress and bedding to support her ability to get in and out of bed safely.GOAL #2-Improve kitchen safety- “I have one pan and the handle is broken so it very hard for me to cook meals I can afford and that are good for me, it has been like that for years.”Ms. C received a new set of pots and pans with safe handles for preparing mealsMs. C received oven mitts to help her be safer in the kitchen.Ms. C utilizes the grabber/reacher set provided to assist with limitation due to hemiparesis Goal #3-Improve performance and safety with showering- “I am afraid I am going to slip in the shower.”Worked with landlord to install grab bar to assist with safe entry and exit from tub.Provided shower bench to support safety during bathingMs. C received a hand held shower wand and shower curtain to keep water off the floorNon-slip bath tub mat, long handled sponge, non-slip tape inside shower

16. Ms C’s RN Goals and InterventionsMs. C’s Registered Nurse health goals:Healthcare Provider Communication- “I have missed several doctors appointment since my stroke because it is hard to ride the bus and I can’t drive.”RN and Ms. C called insurance company to and found out she is eligible for free medical rides to her doctors.Mood-”Since my stroke I get down on myself and I have anxiety because of my finances and health situation.”Ms. C started walking around her neighborhood again to lift her mood and expressed that the interventions she received by participating in the CAPABLE program decreased her anxiety.Medication management-Participant reported she had dropped her daily blood pressure medicine in the sink and had not been able to obtain a refill. “I haven’t taken my hydralazine in over a week.”RN and participant called local pharmacy who refilled the prescription and also had it delivered to her house for free along with other medications she had waiting. Participant was elated to learn that her pharmacy delivered.Ordered blood pressure cuff to enable client to monitor blood pressure and report to PCPOrdered reading glasses so client could read pill bottles and everything else, client was very happy with this intervention.

17. “CAPABLE changed my life. I was sleeping on the floor and they got me a bed. I had a stroke and the program helped me recover from that so I am in a much better place. They gave new pots and pans that replaced the bad ones. CAPABLE made me feel better about myself and helped me improve my home in many ways. The staff are wonderful people and want to thank them for making my life so much better.”-Ms. C

18. MOWCTX CAPABLE OUTCOMES2021-2022Since 2021 MOWCTX CAPABLE program has served 95 participants with at least one OT visit since 2021Of the 51 MOWCTX CAPABLE participants who have graduated and received pre and post assessments:69% improved ADL scores 69% improved IADL scores70% improved depression scores75% improved fall efficacy scores

19. Community Aging in Place Advancing Better Living for EldersCAPABLE PROJECT Rural County Initiative

20. CAPABLE Project Rural County InitiativeWhy the Area Agency on Aging of the Capital Area?“Good fit” for existing Area Agency on Aging MissionHistory - evidence-based programs, interdisciplinary approachPerson-centered, Client-Directed ExperienceLong History providing services to Rural-residing elders Commitment to reach the underserved – targeted outreach and broad-based, super local coalition building, DEI Focus

21. AAA Project DesignAAA oversees project administration – 1FTEVendor model of service delivery - cliniciansEvaluation of patient outcomes and project outcomesRural focus AAA – diversity, equity and inclusion Attention to scalability and sustainability – ROI analysisReferrals to AAA in-home services if ineligible for CAPABLE

22. Keys to successSolid experience in Care Coordination and Caregiver SupportWell established community referral partners Targeted outreach with super-local approaches and messagingHighly skilled clinical contractors Workforce flexibility – independent providers Ongoing Technical Assistance for the AAA and clinicians

23. Success Stories “I would not have reached out for these services because I thought I was doing fine, but now realize how much this program has helped me and I am so thankful for the social worker referring me to the CAPABLE Program.”

24. Interested in CAPABLE for your community Visit Johns Hopkins School of Nursing - CAPABLE website for project details Gather Community Champions Consider sustainability first – direct service vs. broker modelLook long and hard at workforce capacity – clinicians, home repair Value proposition for potential funders & data driven, ongoing evaluation Establish multiple outreach strategies for both referral sources and participants Conduct Return on Investment Analysis for agency & funders

25.

26. Contact InformationPatricia Bordie, Director Aging Services Capital Area Council of Governments pbordie@capcog.org512-916-6053