Reducing Disability Following Hospital Discharge in Vulnerable Older Adults: The CAPABLE Intervention

Currently, there is no evidence-based approach to improve post-hospitalization functional
decline. CAPABLE uses a novel inter-professional team involving an occupational therapist,
nurse, and handyman to improve ADLs in older adults post-hospitalization.

In a Center for Medicare & Medicaid Innovation (CMMI) demonstration project, CAPABLE
demonstrated a 45% reduction of ADL difficulties in older adults from baseline to five
months.The significance of this improvement could make the difference between aging at home
independently and relocating to institutional care. While these results are encouraging,
CAPABLE needs evaluation in real world health delivery contexts with more ethnic
diversity.The purpose of this study is to test the effectiveness of CAPABLE in older adults
in an active community health care program.

Interventions: CAPABLE Intervention: Participants in the treatment group will receive up to
10 in-home sessions (≤6 visits with an occupational therapist and ≤4 visits from a nurse)-and
up to $1500 in safety and modification services from a licensed handyman. Each treatment
participant will receive each intervention component (education, assessment, and
identification of functional goals, specific strategies tailored to goals and based on
protocols). Usual Care Group: Participants in the usual care group will not receive visit
from study clinicians and will continue to receive their usual VNSNY CHOICE benefits and
healthcare. After baseline, all study participants will be reassessed at 20 weeks and
possibly a third interview at 52 weeks. Assessments will be completed by a research assistant
masked to treatment condition.

Inclusion Criteria:

- Aged ≥ 65 years old;

- Are 60 days post-hospitalization in an acute care setting and have had a Visiting
Nurse Service of New York (VNSNY) visit;

- Have difficulty with at least one activity of daily living (ADL);

- Are a member of the VNSNY CHOICE Medicare Advantage Health Plan;

- Are able to stand with or without assistance; and

- Are available during the intervention period

Exclusion Criteria:

- Have significant cognitive impairment identified by the Callahan screening tool;

- Do not speak English or Spanish;

- Have had more than 3 hospitalizations within the past 12 months;

- Are actively receiving radiation or chemotherapy;

- Have plans to relocate in less than one year;

- Have diagnoses of the following: Dementia, Alzheimer's, Other Cerebral Degeneration,
and serious cognitive impairment or OASIS assessment level 3 response on M1034
"serious progressive conditions that could lead to death within a year"