Innovative Models for Bringing Care to the Home and Community: Dr. Sarah Szanton, Dean of the Johns Hopkins School of Nursing

Caleb Furnas 

Hi, I'm Caleb Furnas, welcoming you to Raise the Line with Osmosis from Elsevier, an ongoing exploration about how to improve health and healthcare. Today, I'm happy to welcome someone to the show who's doing just that by pioneering a model of home care called CAPABLE that helps people age in place while achieving the best possible health status and quality of life. 

Dr. Sarah Szanton is also improving healthcare in her role as Dean of the Johns Hopkins School of Nursing, where she holds an endowed professorship of Health Equity and Social Justice. In addition to those posts, she has a joint appointment in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health and the Johns Hopkins School of Medicine, and is a member of the National Academy of Medicine and the American Academy of Nursing. 

Thank you so much for joining us today, Dr. Szanton.

Dr. Sarah Szanton 

I'm delighted to be here.

Caleb 

Great, so I'd like to start with learning more about you and what first got you interested in medicine and nursing in particular.

Dr. Szanton 

Thanks. I am from seven generations of physicians, many of whom used to do house calls.  I did not think I was interested in it, but in college, I majored in African -American studies and was really interested in social justice and thought that health is a way that a lot of Americans care about other people more than perhaps the prison system or the public education system. I think people have a sense that health...we're all bound up in it, maybe a little bit more than some of the other big systems in our country. 

I wasn't interested in nursing  but my first job after college was working on Capitol Hill on reproductive health with nurses, as it turned out. I took them around Capitol Hill, helping them stay on message and communicate what they did in daily life and how to translate that to policymakers. And it was through that that I thought, huh, maybe if I go to nursing school, I can be a good advocate like them, and that's how I first got interested.

Caleb 

Wonderful. And just in regard to your work on the CAPABLE program, what got you interested in issues of aging and in aging in place?

Dr. Szanton

Yeah, I was not interested in aging all through nursing school and nurse practitioner school, which were several years apart. I worked with migrant farm workers. I worked at Health Care for the Homeless. My grandmother lived with us when I was growing up and that was really difficult because she was quite ill with Parkinson's and depression and I was often alone with her after school and so I thought I was interested in everything but aging. 

But then I had a chance to shadow a nurse practitioner who was doing house calls with people who were homebound who were older, and just really fell in love with that and over time through working with older adults saw how wise they are and how many possibilities we disregard by kind of throwing away older people. Especially people who are homebound can do actually quite a lot if they can do a little bit more physically. So, that's what drew me to aging and particularly aging in the community.

Caleb 

Sarah, can you describe the CAPABLE program for us?

Dr. Szanton

Absolutely. CAPABLE is a time -limited program, it's four months, for older adults who have some difficulty with doing anything in their daily lives like difficulty dressing or difficulty preparing a meal, getting a bath, leaving their home. And it provides a nurse, an occupational therapist, and a handy worker. And so the handy worker addresses their home and the occupational therapist and the nurse address what their daily goals are that they would like to be able to do to age and place.

Caleb 

Very cool. In your experience, how does it differ caring for people in their homes rather than caring for people in more clinical settings?

Dr. Szanton

So caring for people in their homes really changes the power balance and it lets you know a lot more about them. So, in terms of the power balance, you're on their turf, literally, and there's less of a, you know, ‘I’m the clinician.’ You're visiting me in my space is the opposite. Plus, you've got the graduation pictures of their grandchildren, you've got their cat or their dog, you've got their setting, you can see the family dynamics, you can see what they're eating.

Caleb 

Right.

Dr. Szanton

You can see what their front steps look like and they become a much more whole person than if they come in to see you in a clinic. And that really got me interested in people's environment and how that affects their aging.

Caleb 

Nice. And it sounds like you built on that experience to launch the CAPABLE program. Could you tell us a little bit about that and sort of how it ties into some of these interests you talked about?

Dr. Szanton

Exactly. So when I was a nurse practitioner myself providing house calls with older adults who were homebound, I could see that what I was giving them -- which was my traditional clinical training of what was going on with their diabetes, what was going with their high blood pressure, were they getting exercise, were they taking their medications, those kinds of things that one looks at if someone comes to see you for a clinical visit,-- just really paled in comparison to what they needed as a person. 

For example, older adults would drop their keys from the second floor for me to find in the grass because they couldn't get down their stairs. Or sometimes someone would answer the door and I would see them on their hands and knees because what they really needed was a wheelchair and they couldn't get around their home except for on their hands and knees. I had people who sat just completely in one chair, not because they wanted to, but because they had holes in their floor and they were kind of scared to move. 

It's very humbling to be coming in thinking, ‘ta -da, I'm here to talk about your diabetes’ when someone's having trouble getting dressed or getting bathed or eating enough food or standing long enough to cook, which are all also part of health, right? Like, you might call them the real primary care or the pre -primary care in a way...that if we can't get ourselves dressed and fed and bathed and to sleep and off and on of toilets, it doesn't sound very interesting, but we all take it for granted every day.

Caleb 

Sure. No, it's almost like the Maslow's hierarchy of needs, right? You almost need to find your keys before you can attend your medications. Yeah. So this is really interesting. You also obviously work with a lot of younger people in the educational setting. How do you sort of try to impart your experiences working with older people in their homes to younger people when they’re working in a hospital setting or in a classroom setting?

Dr. Szanton

Yeah, I think often younger people aren't so interested in aging, but they are interested in families and just people as people.  I think that as a whole, as a society, we tend to write off older adults when actually older adults get wiser and wiser as time goes on. Not every single older adult, but look at Dr. Tony Fauci. He's eighty-three I think, and he's been an older adult for more than fifteen years.

In terms of working with younger people, I think we'll talk about this later, but we've started a new model of care that's across the age spectrum, birth to death, you know, primary care to palliative care, that is modeled after what happens in Costa Rica, and that is also home -based, door to door, at the laundromats, at the libraries, and the schools. I think for that, it's easy to get students interested because it’s across the age spectrum.

Caleb 

Amazing. What kind of early results are you seeing with the CAPABLE program? What are some of the things that surprised you or that led you into further exploration?

Dr. Szanton

So, I wouldn't call CAPABLE early anymore because we started in 2009 and that's okay. I think it's a really important point and I'm not trying to correct you. If CAPABLE were a drug, it would be a blockbuster. It cuts disability in half and it saves seven times what it costs. So if it were something you could take every day and that the FDA could approve and then doctors and nurse practitioners could prescribe, it would be a blockbuster. But because it's

a series of services organized around somebody, there's no equivalent to the FDA for that. There's no, ta -da, here's all our data, now people should be able to prescribe it. 

In fact we've been going back and forth with the Center for Medicare and Medicaid Services because one of the trials was funded by the Innovation Center there that was set up by the Affordable Care Act so that new services can get scaled. Like, that is part of what the Innovation Center is supposed to do and it's been hard to scale it. So in some ways, CAPABLE is a big success in terms of growing. It's in twenty-three different states. It's paid for by Medicaid in some places. Medicare Advantage pays for it in some places. But in other ways, it's really early, to your point. Only about 10,000 older adults have experienced CAPABLE so far. So that's great.

In terms of research, it's not just sitting on the shelf, but by our estimates, there's about 13 million older adults who could benefit from it. And the country would benefit because it saves money and lets older adults with disabilities be able to advise small businesses, raise foster kids, volunteer in local schools, work at churches and synagogues, and all the things that older adults can do. 

I think you asked what surprised me. I think part of what surprised me is how fast it's grown and how slow that's been at the same time based on what I just said. And I think the robustness of the results have surprised me. When we had these very strong results in Baltimore from the pilot and the first trial, I worried, maybe it's just we that we have a magical occupational therapist, or that in Baltimore, it's particular to these row houses. But we've had trials in rural areas and then metropolitan and trailer parks and in all kinds of settings and the results are essentially the same.

Caleb 

Amazing. It seems like there's all the reason in the world to do more sort of preventative medicine in the ways that you described, but it's hard to sometimes quantify in the way that, you know, the larger governmental agencies require. Have you found that case any easier to make over the years? Or is it still sort of like fighting an uphill battle in terms of painting a more holistic picture of care?

Dr. Szanton

I think that it's getting easier because the healthcare systems are making the shift from paying per widget to paying per value. For example, the Medicare Advantage plans that are doing CAPABLE they -- not to get too policy wonky -- but if it was approved by Medicare generally, they could count it as the medical part of what they do. There's something called the medical loss ratio. They could count it in the medical series.

Caleb 

Mm -hmm.

Dr. Szanton

Because it's not, they count it in the administrative cost as though it's part of how they run their business, so they have to keep it small. But they're testing it out with their own money, because it makes so much sense, with the hope that over time CMS will say, okay, now this counts as part of what Medicare does.

Caleb 

Yeah. So, Osmosis actually worked with you to develop a series of videos to help onboard providers to the CAPABLE approach. 

Dr. Szanton

That's right. 

Caleb

What are your plans for scaling it further?

Dr. Szanton

Yeah, so as I mentioned, it's in almost half the states in small ways and big ways and it's in Nova Scotia and Australia as well. Osmosis was really helpful with the training videos. Just a brief note on that, because the older adult is in charge, it really takes nurses and occupational therapists some training to really listen and have the other person in charge. It's not primary care and it's not a traditional visit. So the trainings have been really important because it's really a relearning for clinicians, not just to jump in and brainstorm with someone and give them solutions, but to really help the older adult elicit what might be causing issues and what they might be able to do to solve it.

But in terms of your question about scaling it, it was spun out of Johns Hopkins two years ago. Now have the CAPABLE national program office in Denver at a group called Care Synergy that is a nonprofit. We had a national request for proposals and various organizations applied and they won in terms of getting it and so they're now in charge of scaling it because universities are great places for some things but are not necessarily great places for a startup.

Caleb 

Great. And now sort of transitioning a bit more into the wider work you do at the at the School of Nursing, it'd be great to get an overview of the Johns Hopkins School of Nursing and what you think its particular strengths are.

Dr. Szanton

Sure, well that's easy. So we're ranked the number one school of nursing in the country. Our niche is students who have already done something else before they become nurses.  I mentioned I was a lobbyist on Capitol Hill before I went to nursing school. I came here in 1992, a long time ago. And we have similar stories from other people. People get a bachelor's degree in something else. Mine was in African American studies, but other people are, you know, history or anthropology, or many of them have gone to the Peace Corps and then decide they want to go into nursing. Some people are social workers first, some people are lawyers first. We've had people at the State Department, circus performers, wine sommeliers, architects...all kinds of people who later in their 20s or 30s, sometimes 40s, think there's something missing or they want to do something with particular purpose and they turn to nursing. So, that's our niche. 

And so we develop leaders. They get a master's degree as their entry to practice and then of course we've got a DNP to train people to become nurse practitioners and we have executive programs with our sister schools and have an MBA. Of course, we have a PhD being a research university where people are expanding the scientific knowledge base of humans. I got my PhD here and we've got about twelve hundred students a year across those programs that I mentioned. 

In November, we started an Institute for Policy Solutions in Washington, D .C. that is just steps from the Capitol. It's run by Vincent Guilamo-Ramos, who used to be the dean at the Duke School of Nursing, which is a great school. He stepped down to lead that institute. The idea of the institute is that nurses have a lot of answers. We're problem solvers. We're innovators. But we don't necessarily think of taking that all the way through towards policy.

change and so we're trying to change that, not just for our students and faculty, but also for nurses across the country.

Caleb 

Given the diversity of the students that you guys enroll and look for, what are some of your challenges around getting them all up to speed given the variousness of their backgrounds? Is that a particular challenge, or do you feel like that comes in due course?

Dr. Szanton

So, they take prerequisites. It doesn't matter if they're an English major, a history major, or if they worked on the Hill. You know, for me, I had to take anatomy and physiology and all those kind prerequisites that we'd have for the entry to practice degree. And then all the professions, I believe, are moving towards more of focusing on competencies than content. 

Caleb Furnas 

Yeah.

Dr. Szanton

So there’s a little less memorization and a little bit more how to think through issues, and how does the kidney affect the heart, and how would you have a critical conversation with someone on your team or how do you give a difficult diagnosis...those kinds of things more than ‘memorize this medication.’ And so I think competency -based training really is important and useful for people who come at nursing education with all different kinds of backgrounds.

Caleb 

Great. I know the school has made significant investments in digital and immersive learning opportunities for students, including virtual reality simulations, online classes, and the creation of the Center for Immersive Learning and Digital Innovation. What's your perspective on some of those technologies and how do you see them as being a tool in your toolbox for this larger project that you're undertaking at the school?

Dr. Szanton

So that's a great question. If you think about the kinds of training that we imagine in our heads of nurses going on hospital units to shadow nurses and learn eight hours at a time, perhaps, that's important, but you never know what the students are going to see. So, for example, if you have students on a pediatric ward in the evening shift, a lot of the patients are asleep. Or if people are in labor and delivery, someone may never see a birth.

With immersive learning and virtual reality and simulation, you have a lot more control over what people are experiencing. People can try things, difficult things, on each other or with a standardized patient or with a mannequin -- or in the middle of the air, if you're talking about virtual reality -- and then debrief about it. How did it go? What did they think? What did they wish they'd done? It's very different than doing something for the first time with an actual human who has not been hired to help you learn. 

I think people often think about mannequins when they think about simulation, but we have simulation that runs the gamut. We do have mannequins, you can also walk into a room in the School of Nursing and see four or five different actors in hospital beds who can have simultaneous needs and things that are going on with them that one nursing student needs to attend to as though they are a nurse on a hospital floor. We also have a very strong emphasis at Johns Hopkins School of Nursing on community -based nursing. So we have simulations that take place in people's homes and in schools. We have a kind of a mass casualty simulation. We have simulations just of difficult conversations that one might have. 

We also are very excited about simulation we're launching where you can be the patient. It's a virtual reality thing. You can be the patient, you can suddenly be the nurse, you can suddenly be the doctor, you can suddenly be the anesthesiologist, and as you switch you're getting more empathy for each of these roles, including the patient. So, we think that there's all kinds of potential with simulation if you think carefully about the role it can play and where it fits amongst all the other tools.

Caleb 

Cool. You mentioned that you had a background in policy. My own mother became a registered nurse here in Philadelphia and sort of had a similar trajectory. It got her into public health and health literacy. One of the things that's always really been interesting to us at Osmosis is that there's such a great potential for job creation in the nursing profession. I wondered if you could sort of just speak broadly about how you see yourself fitting into that larger project of putting people on a path to a wide range of viable professional careers.

Dr. Szanton

Yeah, thank you. That gives me a chance to talk about our neighborhood nursing work that we're doing. I think that we're the most trusted profession. We have been for twenty-three years, and that's great, your mom has been a nurse. We are not the most respected profession, and it's always in the news that doctors and nurses are feeling burnt out. Burnout is a very individual term, and it sort of takes away the responsibility of the system, I think. It's important to think about what supports people. But we have enough nurses if you think about if we had a better health care system. There's one nurse for every eighty-three Americans, which is probably enough. Like when people talk about the nursing crisis to me it's much more that we have a health system crisis. 

If you transfer it to thinking about fire and fire prevention and firefighters, if five percent of houses were on fire we would say my goodness we don't have enough firefighters but we have enough firefighters because our houses aren't on fire. It's a little bit equivalent. We have so many people where their diabetes, their high blood pressure, their cholesterol, their kidney disease...you know we don't really give people real access to care even if they have insurance often. It's not real access until something happens that we react to such as they break a hip or they need a kidney replacement and then Medicaid or Medicare can pay for it and then they're in the hospital. 

In the hospital, you have one nurse for every two or three or eight people depending on where they are. And in the community, you would only need one for every 500, for example. So, your question was about the job market and creating jobs for nurses, but I think it's all related to into what system and what are we doing here as a country about health.

We are trying to import the model that Costa Rica has that thinks about whole zones where you're what is called geographically impaneled, meaning everybody on the same block has the same nurse and community health worker. We're standing up this door -to -door model and that will create good jobs, jobs people want. People want jobs in the hospital too. That's important as well. But I think that for a lot of people it’s about enjoying nursing as a career because there's a lot of meaning and purpose and there's so many kinds of settings one can do including policy and leadership and teaching and research and clinical care.

Caleb 

Yeah. I'm not very familiar with what they're doing in Costa Rica, but why is it that you think they have a more sort of holistic, if not preventative, approach to care? And do you think that that's really adoptable here? I confess, I sometimes fall into sort of a bit of fatalism around this kind of thing, but I wanna be encouraged, so we'll have to hear more.

Dr. Szanton

Right. Well, I'm definitely a glass half full person.  Costa Rica is really interesting to read about. There was a great New Yorker article by Atul Gawande from a few years ago saying Costa Ricans live longer and he's also done more scholarly work as well. But starting in the 70s, Costa Rica started to try to have a more preventive health approach. And then in the 90s, they created these zones that I mentioned with the idea that everybody should get a visit at least once a year. 

If you think about in this country, when we talk about primary care and advanced primary care and great primary care, all we're thinking about is the people who come into a clinic. We're never thinking about the people who are homebound or homeless or too anxious to come in, even if they have insurance. And so if you start with the people who are willing to take visits and to see you out in the community, then that starts to grow. We've been doing that starting since January in one community in Baltimore and moving on to other communities in Baltimore and the suburbs and rural areas.

I do think it's possible to change. The trick is getting all of the payers to pay into it because if you imagine a block down a street, you know, someone would be covered by a Blue Cross, someone would be covered by Humana, someone would be covered by Aetna. How do you pay that nurse and who's paying that nurse? But in Maryland, we have a tradition since the 1980s of paying for healthcare, for hospitalizations altogether as insurers. We have a cost setting commission that covers the uninsured for hospitalization and the insured and details how the insurers should pay together.  

So then I'm banging on and trying to get it to the next phase of that which is a population health version of that, that the insurers pay into it and we're getting a lot of great traction. There was just an NPR story two weeks ago about it and it just makes a lot of common sense. When we explain it to people, they're like, wow, that makes sense. We just have to figure out how to get it done. But if enough people think it makes sense, it seems to me we could do it.

Caleb 
Sure. And it would seem to be something that both sides of the aisle could get behind because we all have family who could benefit from care in the house.

Dr. Szanton

Exactly. Exactly. And I just want to sort of transition back for a second. I didn't really answer your question about Costa Rica. Let me just say a little bit more. It's been shown that their life expectancy has grown since they've had this model, including the richest quintile. And I think it's important to say that our country, we have, you know, the worst health outcomes of any industrialized country, even though we spend almost twice as much as the closest country, which is Germany. We have worse health expectancy, even for our very rich people. So a model like this where you can imagine the anxious teenager, the new mom, the new widower, the kids at school...if everyone had someone they knew to reach out to, and not just the people who have a doctor or nurse in their family, that could go a long way towards more health.

Caleb Furnas 

Not to mention it would be far more equitable. I'm often taken aback by the amount of informal healthcare I get in my family, right?  

Dr. Szanton

Yes. Exactly. Right. And actually there's a study from Stanford showing that families with doctors or nurses in them live longer. I mean, that could be cause and effect, who knows. But part of poverty is social isolation in a way, or network isolation. The network isn't as big. And you're less likely to have clinicians or other folks who can access clinical care in your family. So this is kind of part of the reason to change that.

Caleb 

Right, right. It sounds amazing. There's no other way to put it. Great. 

We have many students and early career health professionals in our audience. What's your advice to them about meeting the challenges of this moment and approaching their career in healthcare, maybe with regard to some of the contextual things that we've talked about?

Dr. Szanton

I think health professionals have great careers. It's important. There's so many different ways to serve people as doctors or nurses or occupational therapists or physical therapists or pharmacists or anyone that's thinking along these lines. The trick is to find the people you like and the setting you like and that gives you joy.

So for example, for me, I was never a full -time clinician. I was always, you know, like half

lobbyist, half a clinician. For me, it's too extroverted to see patients all day every day. I figured that out early and I was always happy and I loved house calls. I loved all the different kinds of things that I did. Teaching is a wonderful balance.

I would say to anyone listening both too much teaching with too many students and too much clinical care with too many patients...both of those can be hard but if you combine them both where you have some teaching and some clinical care, that can be just a fantastic career.

So is research, you know, getting to the bottom of why things happen and what can be changed. And just bringing it back to CAPABLE for a minute, I co -developed it with others who already had others' experiences and had done important things, but in terms of my part of it, it was from my clinical insights, from what I'd done in seeing people's homes and then I got a research degree, a PhD, and then developed it. Now, 10 ,000 people have benefited from it. If I die tomorrow, hopefully I won't, I feel like I've done something in this life. I think we sometimes neglect the power of research to change things that are bigger than the people we can see in a day or a lifetime.

Caleb 

Sure. Well, Dr. Szanton, thank you so much. I've really enjoyed our conversation and  learning a bit about some of these initiatives that you've worked on. 

Dr. Szanton

Thank you so much.

Caleb

And with that, I'm Caleb Furnas. Thanks for checking out today's show. Remember to do your part to raise the line and strengthen the health care system. We are all in this together.