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Disability in the home: Podcast with Sarah Szanton and Kenny Lam

 


We know from study after study that most older adults would prefer to age in place, in their homes, with their families and embedded in their communities. But our health system is in many ways not particularly well set up to help people age in place. Medicare does not routinely require measurement or tracking of disability that leads many people to move out of their homes, and many interventions that support people to age in place are unfunded, underfunded, or funded by philanthropy rather than the government.

Today we talk with Sarah Szanton, who created the CAPABLE multi-disciplinary model to help older adults stay at home, and Kenny Lam, who used a national study to examine the need for home-modification devices.  And we preview another of the AGS songs for the literature update - this one to the tune of “My Get up and Go” by Pete Seeger.

Enjoy!

-@AlexSmithMD


  


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TRANSCRIPT

Eric: Welcome to the GeriPal Podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, we have some very special guests with us today -- who do we have?

Alex: Some very special guests. We have Sarah Szanten, who is the Health Equity and Social Justice Endowed Chair and Professor at the Johns Hopkins School of Nursing with a joint appointment in the school of public health. Welcome to the GeriPal Podcast Sarah.

Sarah: I'm so happy to be here with you.

Eric: And we have Kenny Lamb, who is from UCSF and the San Francisco VA Quality Scholars, he's a geriatrician researcher. Welcome to the GeriPal podcast Kenny.

Kenny: I feel very honored to be here.

Alex: We are honored to have you both.

Eric: So I'm really excited. We're going to be talking about actually two, I think JAMA IM, was it two JAMA IM papers about this subject. One that Sarah did on the CAPABLE Study and one that Kenny did on Need for Home Modifications.

Eric: We talk about both of those and this general concepts of disability and what we can do about it in older adults. But before we do that, we thought, you know what? The AGS Annual Meeting is coming up, we usually ask our guests, so I apologize our guests, but I thought maybe Alex since we're going to do CAPABLE at the AGS Annual Meeting, do you want to give our listeners a tease, as far as your geriatrics, super fun time, happy fun times sing along...

Alex: ...parody songs. So this one is one we actually have done before on the GeriPal Podcast. I think Muriel Gillick requested this three or four years ago. It's called My Get Up and Go by one of the Seegers.

Sarah: Pete Seeger.

Alex: Pete Seeger. And we are doing a little parody and Kenny actually helped refine some of the parody lyrics, so thank you to Kenny. So here's just a taste of it at the beginning.

Alex: (singing).

Eric: Do you have like 30 people behind you Alex?

Alex: It did sound, as Kenny was saying in our earlier warmup, like there were a bunch of Mermen behind me or something underwater. Well, good. All right, good to know. [laughter]

Eric: That was actually our second parody song. We had one published on amyloids and Aducanamab that Alex previewed.

Eric: So let's get into this topic of disability and what we can do about it. I'm going to start off with Sarah, because I absolutely adored the CAPABLE Study published in JAMA IM last year, about home-based multi-factorial interventions that you developed. How did you get interested in creating CAPABLE and around things like disability?

Sarah: Well, thank you. And to be clear, everything in science is with a team and there's no "I did this." But I am a nurse practitioner and my first nursing job was with migrant farm workers, and then my second nursing job was with adults experiencing homelessness. And then my third one was with home-bound older adults. And I've always been interested in housing and health and people's environment and how it affects them. And with the older adults who are home-bound, a number of them would drop their keys to me from their second floor that I'd have to find in the grass because they couldn't get down the stairs to let me in. I had a few who answered the door on their hands and knees, because they couldn't walk and didn't have a wheelchair.

Sarah: I had people who were stuck on the second floor for years and couldn't come down and had people who were literally bedbound and maybe they would have a schizophrenic son who would go off to a daycare center during the day and would have made his mother a smoothie for her to drink during the day while he was gone. And just all these experiences that are so different that you see during house calls, that you don't see just if you're walking around a neighborhood, you don't know what goes on inside people's homes. And coming in as a nurse practitioner, what I thought I was supposed to focus on was their blood pressure and their cholesterol and I wasn't trained in any gerontology specifically. So I just had a very regular old primary care mindset. But to be there with someone who had gotten around on their hands and knees, you cannot only focus on their diabetes or if they are eating enough fiber. And so really got me to thinking about what can we do besides just focusing on the medical.

Sarah: And while I was thinking about that, we had one, 101 year old, who had to get on our hands and knees to crawl into the kitchen to eat because she could get around the rest of her apartment, but she couldn't get into the kitchen on her wheelchair. And there were other distressing things about where she lived and when we got her moved, it wasn't my doing, into a beautiful revamped school building with beautiful big windows, and some of the people were 50 years younger than her because it was senior housing, but she was 101. And they looked in on her and took care of her and it was clean. And I was able to take her off of two of her blood pressure medicines and two of her diabetes medicines.

Sarah: And that was such an aha moment for me of, "My goodness, this woman is the same 101 year old. She's got the same biology, she's had the same racial discrimination through her life, the same opportunities and challenges and yet biologically she's now different." And so I think that we'll talk later about what we can do about disability, but that was just the biggest moment for me of, "Wow, we really need to do something about people's environment while we're trying to help them live their best lives possible."

Eric: And Kenny, how did you get interested?

Kenny: I actually think I came to the same conclusion, but from the inpatient side. I trained in medicine, I was seeing patients come in and I tell this story where I remember my first night on call as a senior, I admitted like 13 people, four of them were older people who had just failed at home. I remember going through the whole differential trying to figure out what was the cause of this bicarb of 19, that was the only lab finding I could figure out was abnormal. And I was just thinking, "Wow, a full 20, 25% of the people I'm admitting the first night on my medicine." I don't have an answer for it. They're going through an emergency and I can't figure out what's going on, that led me to geriatrics where I said, "I didn't want to just know what happened to people when they were admitted to the hospital, I wanted to follow them out and see what happened afterwards."

Kenny: And then when I started to do my own home visits, I can tell similar stories where I remember I saw someone who was blind, wheelchair bound. And he opened the door for us, and I remember looking at the walls and just seeing he had pockmarked the walls all the way there because he can't see as he tries to make his way to the front door to open, so his wheelchair just runs into the wall all the time. And the way they kept him at home was that they kept a box of cookies on the counter because he couldn't prepare food because of his visual impairment, but at least then he could get food throughout the day. And so I was seeing all these strategies being employed in people's homes that had nothing to do with whether or not we were giving them perindopril or lisinopril or ramipril.

Kenny: And here on the inpatient side, I was like, "We're having debates about stuff that I was like, 'Is this really the only thing that matters?" Sometimes it matters. Obviously it's important to be able to do the medicine and to know lisinopril. Perindopril is the drug used in stroke trials, lisinopril is the one that has urea reducing effect. That's all important, I suppose, but at some point the disability becomes far greater than the medical condition. And I felt like we were just missing that in our overall paradigm. So, I mean, I resonate really strongly with Sarah in saying that I see the same problem. I think it actually plays a big role in how aging causes problems. We just haven't figured out yet how to measure it and show it, that's why I really love Sarah's work because I think already getting all the way into the future and just showing that you can actually make a difference with it, is really important to sustain, I think, morale in this field.

Sarah: Wow. Thank you.

Eric: And when we think about disability, wait first, how should I think about or define disability? And second, how common is it? So I'm going to turn to Sarah for the first one and maybe Kenny, you can take the second one.

Sarah: So, Kenny feel free to jump in on me too.

Kenny: Sure, this is a controversial topic.

Sarah: People and whether you call it functional limitations or disability, and how much does it have to do with being able to participate in activities you want to be able to do versus how much is it literally just what people would call activities of daily living like bathing or dressing or grooming. And we came down on for CAPABLE to address, to screen on and target activities of daily living, like bathing and dressing and grooming, but then we intervene on those and whatever else matters to them also. So it might be gardening or going to church or something else that gets to the social participation. So I guess I would prefer a more expansive definition, but I think a lot of people focus on activities of daily living for disability.

Eric: Well, how do you think about it Kenny?

Kenny: I'm aware of all of the differences of opinions. I am using an older model that was proposed by Verbrugge, and the older model says, "Well, your body develops impairments." Those impairments are specific things, like you can't bend your arm or you can't bend over. Those lead to functional limitations where there are certain things that you can't do, and it really becomes disability based on how it interacts with your environment. So if you can't bend over and say you can't cook a meal, because of a variety of reasons, you are blind, you have great difficulty standing up just to stay at your stove. It only becomes a disability and so far as the environment is not set up for you to make meals, if you adjusted the stove so that you could put a wheelchair underneath it and you set things up in a very clear way so the person knows how to reach for the objects that they need to, or you shifted and made adaptations and went to microwave meals, then all of a sudden the limitations that you have and still have, like someone who's blind won't be able to suddenly see, it doesn't become a disability because they can still prepare their meals and they can still do the things that they want to do.

Kenny: I think, as Sarah mentioned, where that boundary lies, it really hinges on whether or not you think about activity as just things your body can do, like bend your arm see things or as activity all the way to participate in meaningful things in your life. And I think people shift back and forth with regards to where that is and the definition shifts accordingly. But that's how I think about it. I think about it as, let's separate the impairments that people have, which someone would carry with them no matter what environment they were in, from the disability that it produces, which is completely an interaction with the environment that they're in.

Sarah: Yeah. And one of the ways that I haven't talked about that is if you think about someone who is so paralyzed, all they can move is their eyes. There are people who can manipulate the environment with their eyes, they can type with it and so in some ways they're less disabled than someone who just has a shaky banister or other things, it's a gap between what someone can do in their environment, and the more supportive the environment is, the less disabled they are in a way, which is why it's important to address both the person and the environment. And a lot of times programs either just address a person or their home, like provide grab bars or something, but we've found that doing both is really important.

Eric: So sorry, I was on mute. We got this mismatch between somebody's abilities in the environment. So I'm going to go to the Kenny, particularly in Kenny's paper. How common do we have this mismatch? How common is disability in like, "I've fixed it all the time as a doctor. I tell them do things, like grab bars and other stuff like that."

Kenny: So that's the basis of the study that we completed where we really tried. The big picture is there's probably a mismatch in about 40% of older adults who need it. So the development means that we needed to do to come up with our paper, was actually first defining people who might need equipment. And I had done a literature search, there really aren't any objective criteria so we had to come up with our own, just rough back of the envelope. These are people where we would think, "Well, they would probably benefit from equipment." And then once that was established, we were able to measure how often we were falling short of that goal. And so our estimates came out, there are about 40 million people over the age of 65 in the US, we estimate that about 12 million lack, sorry, need equipment, and five million of those people lack it. So it comes out to about 40%. That's a five million out of the 12 million.

Eric: So there's a lot of need. Why do you think there is? I mean, a grab bar is not very expensive, right? Why do you think we have this gap?

Kenny: I'm curious to actually know Sarah's opinion on this. Somebody has definitely been on the cold face and trying to intervene on it. I have my theories having been in people's homes as well, but I'd love to hear her take.

Sarah: Well, I think there's layers of reasons. So not in particular theoretical order, but first is, a lot of people don't know what does exist. So for example, we had someone who wanted to be able to shave standing up, that was one of his goals. It didn't occur to him that he could have grab bars around his sink for example. You think of them as like in your shower. So first of all, it's what people might not know. Second is they might not know how to install it or how to get it. Third is about how to use it, and then fourth, you already mentioned, expense. And fifth I would say fear.

Sarah: We had someone recently in CAPABLE, who actually had been given by someone before us grab bars, a tub bench and a long-handled sponge and she was still taking a hand bath by the sink, a bird bath. A bathroom is a scary place, it's porcelain, it's slippery and in CAPABLE, part of what we do is increase people's self efficacy and confidence by tiny little small goals along the way, and during the course of CAPABLE she was able to use this equipment that she'd already had. Now that's a different question because you are talking about if people don't have it at all. But I think there's also beyond having it, there's knowing how to use it and was it put together right? And do you know how to adjust it to fit you?

Eric: I really like this point that you make about incremental steps because it's one of these funny things. One of my hobbies is that I rock climb. And as a geriatrician who rock climbs, I always think, "Wow, the bathroom must feel like this outdoor environment." And it's actually very nerve wracking. The thought of falling... but we know with aging there's equivalent risk and you have to go through grades before you become more comfortable with more intense scenarios. It's a very real fear. So I'm very sympathetic, I think that's what I'm trying to communicate, that I'm very sympathetic to how tricky changes might be. Yeah.

Alex: So we should talk about CAPABLE and what it is, and you've already hinted at on some parts of it. And in our correspondence before, of course, as you pointed out, it's so much more than home modifications, as you talked about now. It's helping people understand how to use these modifications and other components, which we'll talk about in a moment. I just want to do one more setup for the CAPABLE trial. Remember Rebecca Brown, who used to be at UCSF, now she's at Penn she's geriatrician researcher. I mean, I don't think she'd met you, but earlier on, she was like, "Sarah Szanten is my hero. I want to be Sarah Szanten." This is the kind of work that actually helps people in real ways, practical. It just makes a ton of sense. So I'd love to hear more about CAPABLE, what it is and what you found in your JAMA Internal Medicine study, as well as other studies because I know you have a whole body of literature about this. But what's the top level view for our listeners about what CAPABLE is?

Sarah: Well, thank you for those are really kind words, and I was a lobbyist before I was a nurse. So everything I do, I try to make it understandable to a congress person or a staffer because that's my view. So common sense is my wheelhouse. So CAPABLE is a time-limited, it's four months long intervention for people who have at least one area of difficulty with an activity of daily living, like bathing, for example. And they receive four nurse visits, six occupational therapy visits, and currently up to about $1,300 of home modifications, home repair assisted devices or everyday items. So $1,300 for things for the home environment as like we were talking about. And the occupational therapist assess these and helps them come up with goals about their ADLs, their instrumental activities of daily living, like finances and medications and meaningful activities.

Sarah: And the nurse focuses on, in terms of assessment, but then it's the older adults goals, pain, depression, strength, balance, primary care provider, communication and medications is it too much, too little, do they understand it? But really importantly, and I think this gets undersold or under talked about, it's really a self-efficacy intervention underneath all of it. And so all of it is about what the older adult wants to do. We are not primary care, we're not telling them to take medication or stop smoking or anything, that's other people's jobs. In CAPABLE, it's only an assessment about what matters to them, what they would like to be able to do in their home or community. And then the nurse and the OT and the handy worker part is completely wrapped around those goals and those goals only. So if somebody wanted to be able to get out there, back stooped to listen to the birds, we don't say, "Yeah, maybe you should quit smoking first or why don't you deal with these roaches first?" We go with exactly what they want to do, and as they have successes, then they think of the next thing that they want to do past CAPABLE.

Eric: So let's say they have a really difficult time getting into the bathroom at night. Do you think about all these interventions? Maybe some of it could be their physician prescribed them BID Lasix. How does CAPABLE work with the rest of the healthcare system once you find something on the assessment that needs to be addressed?

Sarah: Right. Well, that's a really good ad for one of our current research projects. And I didn't get to any of the results or the papers that you asked me to talk about. So we've had some inner people who it turns out they're on three blood thinners or they're on a Lasix that they're taking at night and then they're racing to the bathroom and they fall or they're afraid they're going to fall. We started off as a research and this is what we're talking about today, but it's now in 33 places across the country. And every program does the feedback to the primary care or the geriatrician a little differently. Some people call, some people do letters. We are currently working on a new project called GOALS, where we're specifically talking with primary care providers. But how do they want to know? People are sick of alerts and primary care providers don't change their behavior necessarily by alerts, but they don't necessarily want a whole lot of other communications. That still is a work in progress.

Sarah: But again, it's all based on... to the extent that we do worry about the medications it has to do with, if it affects their function, as you were talking about. But in the example of going to the bathroom in the night and being afraid to fall, the occupational therapist will brainstorm with the older adult about what are the parts, pulling apart the task, what is involved in going to the bathroom in the middle of the night? And all the way down to, like you sit up, you turn to the side, you try not to get up too quickly, maybe you have grab bar, put in a chair rail or do a bed rail that goes in between mattress in the back spring. When they see that they remember, "Oh yeah, I'm supposed to sit for a minute on the side of the bed, then I'm going to go."

Sarah: And so taking away the Lasix would be great or modifying it, but there's also a lot of environmental things and importantly, those environmental changes act as behavioral cues. You see them and you say, "Oh yeah, I was going to do this a little differently." And part of the reason CAPABLE works so well is those behavioral cues, environmental cues last. They're there, that chair rail is there or the crackpot that we buy you because you don't have teeth and you want to be able to cook really soft things. That stays there. And it helps you remember, "Oh yeah, I was going to do this a little differently."

Kenny: I'll echo back that at least, I think in my clinical practice, the thing that's so challenging, I think, for doctors is we might think, "Well, we've tried Lasix once daily, and the heart failure requires Lasix twice daily." And those were the cases that I felt like were the ones where I would really just try and really dig deep into. And that's why I got interested so much in home environments and what services were available, because in some ways I see it as the infrastructure necessary for people to execute the medical care that they need. And if that infrastructure is not there, then you're stuck, you're really stuck.

Kenny: I think the case example that really brought this home for me was, I had a patient with Parkinson's disease lived at home with her sister and I remember asking her one day, she came into my office and she was like, "Oh, it's 1:00 PM, I need to take my levodopa." And I just watched her try and pull it out of the container and her tremor didn't let her take her own medication that she needed for the same disease. And I just thought, "This is ridiculous." You have a disease that is characterized by tremor and then you ask them to take medications, and they will inevitably run into a situation where the disability caused by the disease that you can diagnose and anticipate leads to a condition where they can't interact with their environment. It was mind boggling to me just how poorly designed our services are. We have the power of these clinical diagnoses, where you can make predictions for how things will unfold for people and yet nothing to provide people with the inevitable consequences of chronic illness.

Kenny: So everyone has to get involved. Yeah. I'll also share that actually, even before I finished this study, I called Laura Gatlin, actually, to ask her for her opinion. She's your mentor, I think, on the CAPABLE project, because I saw she had been working on this from her end for a while and I just asked her for advice. I was like, "I don't want to reinvent the wheel, help me understand what you've learned from your years of experience trying to work in this arena." And one of the things she said was, it's the payment structures, one. And then two also that doctors or MDs aren't entirely on board.

Kenny: So I tried to think of a study, like how do doctors think about things? I think about things in terms of criteria and intervention and so that's why I was really trying to paint this picture. I know there's more to it than just home modification, but home modification is a clear intervention. And I was trying to develop what are the criteria, if you're in primary care, that you need to look for so that you can say, "Oh, this is a place where I'm not doing well enough," because that's how doctors think. And I was just trying to translate all of that in the study, like that's what goes underneath it.

Eric: Well, since I am a doctor, I have a criteria from the CAPABLE Study which is people with at least one ADL or at least two IADL deficiencies. I have an intervention which is CAPABLE, I don't know yet if it works. So does it do anything Sarah?

Sarah: Yes. And I'd also like to talk about payment and to add more to what Kenny was saying. But yes. So CAPABLE I think we've made about 25 papers at this point, it works in a lot of good ways. I think 75% of people on average in a sample improve and another 12 to 13% stay the same in terms of their ADLs. And of those 75%, the average change is they lose difficulty in about two or four ADL areas. And that's really an undercount because in that study, we measured just any difficulty. So you could have this really hard duty to take a bath. Yeah, it's a little difficult and that would have showed no change. So needless to say, we measure that differently now so that we can get a better assessment of that.

Sarah: In the JAMA IM paper that you were highlighting today, we had a control group who had the same time visits, also goal directed based around what they wanted to be able to do, but they were social kinds of goals or sedentary goals. So learning to use the internet or putting together a photo album or storytelling, listening to music together. And as we know from COVID and all those social isolation, that's actually a pretty potent intervention and that control group improved too, which we were happy about. They didn't improve on their ADLs as much, which is what we had hypothesized. But back to the point about what do we need to do. Part of it is that in Medicare and insurers and a need to focus on disability and function, and that's partly morally based on what we're all talking about, but also chronic conditions are not what is costly.

Sarah: Chronic conditions by themselves are not what generates so much avoidable hospitalization and nursing home admission. It's really when you have chronic conditions and functional limitations that you're much more likely to be what economists call a high cost spender or someone in the top 5% of spending. And so CMS is really moving towards readjusting for function and having claims a diagnosed function. And once that happens and once the insurers are on the hook or can make more money from addressing function, I think we'll be in a very different place in terms of home modifications and other things like CAPABLE of that can make a difference in people's lives.

Alex: That would be Incredible. Can you say more, I mean, that would require that CMS mandate some assessment or functioning, which would be tremendous change, a sea change...

Sarah: Yeah, currently, in the annual wellness visit, people are supposed to ask about ADL and IADL. I think those annual wellness business visits should be offered in the home at least every other year. Currently they're usually in an office and it's under utilized. I think it's about 20% now people get them. I think it should be at the home, ideally, with an occupational therapist where you can see, "Okay, how are you? Are you grabbing onto the soap dish as you get into the tub?" But often in the annual wellness visit, it is done and then not. There's no loop from that into what should happen next. It's just, "Oh, we did that visit." And same with a health risk assessment that Medicare Advantage Plan does often, that's just used for coding but it doesn't loop back to anything about payment or interventions. And so that is a big part of what we all need to do, is to get those looped together and have there be risk adjustment for a function. And then we'll have a real estate change.

Alex: I'd love to hear, well, a couple of questions. Okay, I'll do one at a time. But while we're on this topic, how is CAPABLE paid for, does Medicare pay for it? What do they pay for? What don't they pay for?

Sarah: Well, that is a great question. So currently most CAPABLE sites are from philanthropy and there are some that Medicare Advantage can pay for it through their supplemental benefits. They do have to alert CMS in June of the year before they're going to start it. Massachusetts covers it through the Medicaid system and we're hoping that other states will do that. It makes sense for a Medicaid program to pay for it because people will end up in a nursing home that's paid for by the same Medicaid program. You're always trying to work on this so-called wrong pocket problem that if an Area Agency on Aging pays for CAPABLE, they don't get the money back if someone doesn't have to be in a nursing home, but Medicaid program does, so would a Medicare Advantage program.

Sarah: They are also in Maryland, we have an unusual payment system for hospitals where prevention is really prioritized. And so for example, the Johns Hopkins Hospital pays for people in the community to get CAPABLE, both to be a good community partner and because it will avert hospitalization, so it'll make their bottom line better, but there's a number of ways it's being paid for. Now we are working to try to get to be part of fee-for-service Medicare. So Medicare Advantage covers about a third of Medicare beneficiaries and fee-for-service traditional covers two-thirds and so that's a really big number of people who need it. So far it's not paid for, but I'm thinking within the next three or four years it will be.

Alex: Oh, that would be so exciting. That'd be tremendous at so many levels. Assessing function routinely, payment for services that are common sense services that will help older adults age in place, cohesion of payment and alignment with what people's goals are. I could think of so many different outcomes from studies like this, from cost reduction, from decreased acute care visits to avoidance of hospitalizations and ED visits, to improved physical function and mobility, to decrease disability as we've already talked about, which is the interaction between a person's physical capabilities and their environment. And then of course, quality of life which is one of the main things that we're focused on. Then ultimately what we're talking about with Sarah, you and Kenny today is helping older adults age in place.

Sarah: Well, and I would say even more ultimately having them be part of their families and communities in ways that are meaningful to them. There's a gentleman who hadn't taken a bath in a year when we got to him, and couldn't stand up off of his couch and a number of other things and he had several goals. But in terms of those two, he achieved them really well. And we were just in touch with him this week and he has been the main person helping his grandson with his online education during the pandemic. So it's not just that we want people to be able to age and we're thinking about what they want to do. It's also when you can get dressed and get around and take your medication and do what you want to do, you could be advising small businesses or taking care of grandchildren or doing all the other things that we know that the wisdom of older adults can make a difference too. So there's a bigger feedback loop than just the aging in community.

Alex: Right. It's keeping community intergenerational communities together. Kenny, if you could wave a magic wand and make one change to policy or practice, what would it be?

Kenny: I mean, if I could really had a magic wand, then I would just get rid of all of the disability all at once. This is what I think about it, like the Avengers movie when Thanos needs to kill half of the world's people. I was like, "Why didn't he just double all the supply?" But beyond that, I think I would try, I would probably wave a magic wand and put functional assessments into the medical system. I think at day's end that's ultimately what patients want, when patients think about the diseases that they're dealing with, they interpret it in the lengths of what does it let me do, or what does it not let me do? And so I think that's the bridge that we need when it comes to translating all of the science of medicine into something that really matters for patients.

Sarah: That's a great answer.

Eric: And Sarah, your magic wand, you got one thing.

Sarah: Well, I'll loop on to Kenny's and say not just the assessment, but the paying for good interventions with good outcomes to either decrease the functional limitations or allow for more adaptation to them.

Eric: Do you think we're going to get there.

Sarah: Yeah, I'm sure we are.

Alex: I love the optimism. Actually this has been really uplifting, because usually in our podcast we talk about all the things that are wrong and it seems like there's no hope and our system is so fundamentally deeply flawed. So it's great to hear that you're optimistic that change will be on the way and positive change on all of these fronts.

Eric: And also it's very timely as we talk about what is and what is not infrastructure.

Kenny: I use the word strategically.

Eric: Yeah. Infrastructure is not just about a car getting you from home to work, you can think of infrastructure as a lot of things and potentially infrastructure of getting you to the kitchen or to the bathroom.

Sarah: And it helps other people work, right? Even if you're only limiting infrastructure to be, "How do we make commerce flow?" And that's roads and bridges, it's also that then family members can focus at work and get to work and do what they need to do.

Eric: Well. I want to thank both of you Sarah and Kenny for joining us at this podcast. But before we end, Alex, are you going to give us a little bit more of the preview?

Alex: A little bit more preview here? We'll do the uplifting part which includes some lyrics about CAPABLE.

Alex: (singing).

Eric: Sarah and Kenny, thank you for joining us on this GeriPal Podcast.

Alex: Thank you so much.

Kenny: Thank you.

Sarah: Thank you, it's been a pleasure.

Eric: And a big thank you to Archstone Foundation for their continued support and to all of our listeners. Please share this podcast to at least one social networking site, tweet about it, Facebook about it. Thanks everybody. Have a good night.

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