Setting Realistic Expectations for an Innovative Program of Home-based Care for Vulnerable Older Persons

When first introduced in 2011, the Community Aging in Place, Advancing Better Living for Elders (CAPABLE) program provided a new and innovative model of home-based care designed to promote functional independence and aging in place among a vulnerable population of disadvantaged older persons.¹ Now, nearly ten years later, Szanton and colleagues have summarized the accumulated evidence from several studies that support the benefit of CAPABLE,² including two traditional randomized clinical trials with attention control groups,^{1, 3} a randomized clinical trial with a waitlist control group,⁴ and three demonstration projects (one of which is unpublished).^{5, 6}

CAPABLE is a 10-session home-based program delivered over 5 months, which provides tailored action plans based on coordinated assessments by an occupational therapist (OT) and registered nurse (RN). One of the novel aspects of the program is the provision of handy worker services to address potential home hazards and other environmental impediments to independent function. Participants receive up to six 1-hour home sessions with the OT, up to four 1-hour home sessions with the RN, and up to $1300 of home repairs, modifications, and assistive devices. The total cost of delivering CAPABLE is approximately $3000 per person, including visits, supplies, team coordination, mileage, parts, and labor. The program has focused almost exclusively on disadvantaged populations of low-income older persons, with overrepresentation of women and African Americans. To date, persons with cognitive impairment, the subgroup at highest risk for functional decline and subsequent long-term nursing home admission, have not been evaluated.

Given the nature of the intervention, which focuses most intently on addressing deficiencies at the interface of physical capabilities and the home environment,⁷ it not surprising that the greatest and most consistent benefit of CAPABLE has been observed in activities of daily living, including self-care and house-hold mobility. In the efficacy trial,³ which provides the most rigorous evaluation of CAPABLE, disability in these activities of daily living was reduced by 26% at 5 months in participants who were randomized to the intervention versus attention control group. This clinically meaningful benefit, which was accompanied by a smaller and non-significant reduction in disability in instrumental activities of daily living, was not maintained at 12 months.

Perhaps reflecting the pent-up demand for new and innovative models of home-based care, implementation of CAPABLE outside of traditional clinical trials has been impressive. The investigators report that there are currently 33 CAPABLE program sites in 17 states across the country, with a trained staff of 72 OTs and 63 RNs. The evidence from the waitlist control trial and three demonstration projects, which have been collectively implemented in many different settings and supported by both state and federal agencies in addition to private foundations, has confirmed the benefit of CAPABLE in reducing disability in activities of daily living. These additional findings from “real world” settings are important because results from prior efficacy trials of home-based interventions that have successfully reduced functional decline and disability have not been translated into clinical practice.⁸

In their review,² the investigators provide evidence that the CAPABLE intervention may improve other outcomes, including instrumental activities of daily living, depression, pain, and falls efficacy, while saving costs. These findings, however, should be interpreted cautiously for several reasons. As noted earlier, the efficacy trial did not demonstrate reductions in instrumental activities of daily living, and it is uncertain how this home-based intervention, as described more completely in Table 1 of the initial pilot trial report,¹ would improve several of these activities, including using the phone, shopping, traveling independently, and managing finances, among persons who are cognitively intact. Neither pain nor depression was evaluated as an outcome in the pilot or efficacy trials,^{1, 3} so the mixed evidence of benefit was based on studies that did not include blinded outcome assessments or that lacked a control group. Although the CAPABLE intervention could conceivably improve falls efficacy, the “positive” results from the pilot trial did not include statistical comparisons,¹ and results for this outcome were not reported in the efficacy trial.³

While evaluators from the Centers for Medicare & Medicaid Services (CMS) estimated an average cost savings to Medicare of $22,000 per CAPABLE participant over 2 years based on a nonrandomized evaluation of the investigators’ CMS Innovation Center demonstration project,⁵ it’s not clear how these savings were accrued, and only 171 (60.9%) of the 281 participants were included in the cost analysis.⁹ In a separate cost analysis of the same demonstration project,¹⁰ the investigators reported an average monthly cost savings to Medicaid of $867 per CAPABLE participant over an average of 17 months. Although there was some reduction in long-term care costs, the savings were primarily attributable to reductions in hospitalization expenditures. Without additional information, it’s not clear how CAPABLE reduced hospitalizations, a finding that is at odds with the CMS analysis, which found no reduction in hospitalizations.⁹ Given the inherent challenges in identifying suitable comparison groups for nonrandomized comparisons of costs, it is unfortunate that a formal cost-effectiveness analysis was not completed as part of the efficacy trial.³

Nonetheless, the absence of cost savings should not diminish the value of CAPABLE. Older persons consistently rate the maintenance of independent function as their top health care priority,¹¹ and the evidence provided in the current review convincingly demonstrates that CAPABLE is effective in achieving this goal, at least for the duration of the intervention, at a relatively modest cost.² As the investigators have previously suggested,³ booster visits will likely be required to retain the effectiveness of the program over time and, in turn, reduce the need for long-term care.

Given the complexity of the disabling process,¹² it may not be realistic to expect that a single program such as CAPABLE, which is based on a model of chronic rather than acute disability, will reduce health care costs. Because disability is commonly precipitated or worsened by acute illnesses and injuries leading to hospitalization,^{13, 14} CAPABLE may need to be integrated with programs of post-acute rehabilitation.

In summary, Szanton and colleagues are to be commended for developing, rigorously testing, widely implementing, and iteratively evaluating an innovative program of home-based care for vulnerable older persons. If it can be successfully modified to retain its effectiveness over time and adapted to accommodate persons with cognitive impairment, CAPABLE has the potential to facilitate aging in place.