CAPABLE: A Model of Empowering Older Adults to Remain Independent
CAPABLE stands for Community Aging in Place – Advancing Better Living for Elders. It is a restorative services model: person-centered, holistic services that help individuals remain independent in their homes, reducing their need for institutional long-term services and supports (LTSS). Restorative or “re-ablement” services are common in other countries but have limited reach in the United States.
CAPABLE is, by design, a time-limited, short-term intervention and is not designed for older adults living in a residential care setting or a nursing home. In fact, CAPABLE cost savings are often measured in comparison to potential nursing home costs, with the idea being that CAPABLE as an intervention may delay or prevent entirely the need for an expensive nursing home stay. Research has suggested that if CAPABLE could delay a nursing home stay by even three weeks, it could be cost neutral to public payers.
How It Works
CAPABLE’s approach relies on three professionals working in conjunction with the participating older adult to identify and deliver services and supports in the home over a five-month period: a registered nurse, an occupational therapist, and a handyperson. The registered nurse (RN) makes four home visits and helps the participant with medical-oriented goals. The occupational therapist (OT) conducts six home visits and helps the participant achieve goals related to functional tasks. The OT also helps identify potential environmental barriers in the person’s home to develop a scope of work for the handyperson, who makes those identified repairs/installations with a budget of up to $1,300.
The first major CAPABLE trial began in 2012 with funding from the National Institutes of Health and the Centers for Medicare & Medicaid Services (CMS). Through the CMS Health Care Innovation Award program, more than 100 Baltimore community residents received CAPABLE support. Research from this pilot found that the participants, a majority of whom were Black women, had success in improving their activities of daily living (ADL) performance and decreased home hazards by about half. This pilot also studied participant cost savings and found that CAPABLE saved public payers about $22,120 per participant.
An evaluation of CAPABLE in 2021 studied results in six pilots from across the country. This included urban and rural communities, multiple payers financing the services, six states, and a participant pool inclusive of Black, Hispanic, and white older adults. Each pilot found that CAPABLE reduced limitations on ADLs, and on instrumental activity of daily living (IADL) among participants. Some pilots also found improvements in falls efficacy, pain management, and depression among participants.
Where CAPABLE Exists
CAPABLE has spread to new locations across the country and, importantly, has seen growth in the growth in the types of organizations that offer the intervention, including at least one Medicare Advantage plan and one Program of All-Inclusive Care for the Elderly (PACE) organization. The Department of Veterans Affairs (VA) has adopted the intervention on a pilot basis with plans to deploy it to nine sites throughout Pennsylvania. The VA’s dual role in financing and providing care for veterans they serve may position the department to fully realize the model’s potential both for consumers and for its own cost savings.
The types of entity that currently deliver the CAPABLE model include:
- Medicaid HCBS (home and community-based services) waivers
- Medicare Advantage plans
- PACE organizations
- Components of the VA health network
- Meals on Wheels/nutrition delivery programs
- Primary care clinics
- Home care agencies
Limitations on the Model
Recent research suggests that the foremost restraint on the growth of CAPABLE is financing, specifically a lack of a financing mechanism for this model in the current payment environment. While CAPABLE is focused on functional improvement, payment systems like Medicare and Medicaid do not necessarily reimburse or incentivize efforts in that area, which are neither disease-focused medical interventions nor long-term services focused on maintenance. CAPABLE’s services are restorative.
Among public payers, there is also potential for misalignment between which programs pay for CAPABLE and which save from it. In integrated Medicare-Medicaid managed care plans, for example, researchers have identified a so-called “wrong-pocket” problem in which the participant’s Medicaid coverage pays for CAPABLE services, but the savings are realized through less Medicare spending, benefiting one program (at least on paper) and not both. Similar questions exist in other areas where CAPABLE may exist, including for those with one or more coverage sources.
CAPABLE may have better capacity to grow in models where payment and delivery are integrated. In PACE, for example, one entity receives a capitated payment and then in turn is responsible for all care delivery. A PACE organization that deploys CAPABLE would be able to realize any associated cost savings. Threading the needle between cost savings and provider payment is critical to CAPABLE’s scaling.
Also, as Medicare Advantage plans continue to expand among the Medicare population, and those plans have greater flexibility to offer supplemental benefits to their beneficiaries, plans could add CAPABLE to those benefits and deliver restorative services to more people.
The same goes for others in a payer role, including the VA and even private insurance plans. Each has the demonstrated capacity to bring CAPABLE to new communities, and with the right implementation, the model could reach older adults nationwide.
Additionally, the 2021 American Rescue Plan (ARPA) provided states with enhanced federal funding for Medicaid home and community-based services (HCBS). As states continue to spend those dollars, monitoring how they invest in and implement CAPABLE will be critical.
Flinn, Brendan and Susan Reinhard. CAPABLE: A Model of Empowering Older Adults to Remain Independent. Washington, DC: AARP Public Policy Institute, December 8, 2022. https://doi.org/10.26419/ppi.00180.001.
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