A Personalized Approach to Aging in Place

a hand holding a home

Sarah Szanton knows that it often doesn’t take much to allow an older person to remain living safely at home, performing daily functional tasks like bathing, dressing, moving around and eating – and that’s become more
important than ever in the COVID-19 era, with millions of the vulnerable elderly being urged to shelter in place to avoid infection.

Sometimes it’s as simple as installing a grab bar in the bathtub, modifying medications and purchasing a sturdy step stool to reach the kitchen shelves. Other times, it might entail fixing the front steps, learning how to conserve physical energy, and installing nonskid mats and better lighting throughout the person’s home.

Each older person’s needs and goals are unique, Szanton notes, but equipped with a budget of $1,300 and the collaborative support of a nurse, an occupational therapist and a handyperson, older people can take the lead in developing and implementing a personalized plan that will allow them to thrive as they “age in place” in the comfort and familiarity of their own homes. That’s the guiding force behind CAPABLE (Community Aging in Place – Advancing Better Lives for Elders), an innovative program that Szanton co-developed a decade ago at Johns Hopkins, with Laura Gitlin, that is now in use at 29 sites in 15 states.

“The power of CAPABLE has to do with listening to what an older person wants to be able to do, and then making the small adaptations to make that possible,” says Szanton, who is director of the Center for Innovative Care in Aging at the Johns Hopkins University School of Nursing.

The results of the program are impressive. A clinical trial published last year showed that participants in the CAPABLE program had a 30 percent drop in disability scores over five months, compared with those who only had social visits from a researcher. Participants also see improvements in symptoms of depression and in participants’ ability to grocery shop and manage their medications, studies show.

The benefits don’t end there. “It turns out that improving these kinds of functional outcomes ends up saving health care costs” by reducing emergency room visits and hospitalizations, and by preventing the need for nursing home care, notes Szanton. “In fact, we’ve been able to show seven times the return on investment,” she says, pointing to studies showing that costs of about $2,825 per participant saved the Medicare program about $22,000 over two years.

“It’s important to think of older adults as a gift, not a burden, and they are a naturally growing resource. We need to do everything we can to help them continue to contribute to society.” – Sarah Szanton

CAPABLE is gaining the attention of policymakers, health care administrators and aging advocates across the country. Last fall, Szanton was honored with a prestigious award from the Heinz Family Foundation, which annually lauds recipients for finding solutions in five critical areas. Szanton’s unrestricted $250,000 prize was awarded in the “human condition” category.

Around the same time, a federal advisory board recommended that CAPABLE be tested as a Medicare payment model, which would vastly expand its reach. Already, CAPABLE can be covered under Medicare Advantage plans, which may offer benefits for some nonmedical services that frequently address what are known as social determinants of health – access to food and transportation, for instance, and the ability to pay for medications. These factors are now known to have a profound impact on patients’ health and to drive as much as 80 percent of health outcomes, according to the Centers for Medicare and Medicaid Services.

“This is the way that health care should have always been done, but with the nation’s fee-for-service model, it wasn’t incentivized,” says Szanton. As health care reform in the United States shifts health care to a value-based care model, which rewards providers for health outcomes and high-quality care, she says, “the financial incentives are being aligned with health in a much more holistic way, and CAPABLE is part of that stream of innovation.”

Adds Szanton: “More and more frequently, health care insurers are coming to us to discuss how CAPABLE could fit into the services they are already providing. We’re also working with Habitat for Humanity, Meals on Wheels and some regional departments of aging.”

The timing for CAPABLE couldn’t be better. With the aging of the baby boom generation, the nation is seeing 10,000 adults turn 65 every day. “It’s important to think of older adults as a gift, not a burden, and they are a naturally growing resource,” says Szanton. “We need to do everything we can to help them continue to contribute to society.”

The home adaptations that CAPABLE team members make possible – like repairing the front steps and adding a handrail, or making the interior easier to negotiate – have allowed participants to get out to volunteer at local schools and to safely care for grandchildren and foster children, she says.

“This is truly personalized medicine,” says Szanton. “We don’t come in with a checklist. And CAPABLE is person directed, not just person centered. The clinician is there only to elicit their goals, to understand what they want. The older adult is in charge. If they drive the goals, then they’re going to be invested in implementing what they come up with.”

Before becoming a nurse practitioner, Szanton worked to help vulnerable people with housing challenges – migrant farm workers and the adult homeless – and then as a lobbyist. “So, I come at this with a real policy bent and am continually asking: How can we frame our efforts for maximal benefit to society?” By saving money on health care costs for the aged, CAPABLE frees up funding to invest in other parts of the health care system and other parts of society, she notes.

Szanton sees supporting function in older adults as nothing short of a moral imperative. “Being functional is foundational to a meaningful life,” she says. “We all want to have control over our lives, and that doesn’t change as we age. Older adults should be able to age with dignity.”