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Community Aging in Place—Advancing Better Living for Elders (CAPABLE)

Overview of the CAPABLE Program

Community Aging in Place--Advancing Better Living for Elders (CAPABLE) addresses both function and cost. CAPABLE is a program developed at the Johns Hopkins School of Nursing for low-income seniors to safely age in place. The approach teams a nurse, an occupational therapist and a handyman to address both the home environment and uses the strengths of the older adults themselves to improve safety and independence.

CAPABLE Improves Health Outcomes and Lowers Costs1

More Than 6X Return on Investment

Roughly $3,000 in program costs yielded more than $30,000 in savings in medical costs driven by reductions in both inpatient and outpatient expenditures.

Source: Ruiz, S., Snyder, L. P., Rotondo, C., Cross-Barnet, C., Colligan, E. M., & Giuriceo, K. (2017). Innovative Home Visit Models Associated With Reductions In Costs, Hospitalizations, And Emergency Department Use. Health Affairs,36(3), 425-432. doi:10.1377/hlthaff.2016.1305

Halved Difficulties in Function

Participants had difficulty with an average of 3.9 out of 8.0 Activities of Daily Living (ADLs) at baseline, compared to 2.0 after five months.

Reduced Symptoms of Depression

Symptoms of depression, as well as the ability to grocery shop and manage medications also improved.

Improved Motivation

The change in physical environment further motivates the participant. Addressing both the people and the environment in which they live allows the person to thrive.

1 In the period 2012–15, a demonstration project enrolled 281 adults ages sixty- five and older who were dually eligible for Medicare and Medicaid and who had difficulty performing ADLs. ADLs include eating, bathing, dressing, moving around, transferring and toileting.

Learn More About CAPABLE

CAPABLE Testimonial

  • Overview of the Training

    The on-line training and home visit simulations taught by JHU professors and clinicians is available so that your organization can provide the CAPABLE program. Two different tracks are offered: one for nurses, the other for Occupational Therapists. The training is supported by additional webinars, office hours, a peer user group, and review of up to 3 work orders.

    The target audiences of CAPABLE training include health care systems, accountable care organizations, insurance companies, state/county/city Department of Aging, skilled nursing facilities, nursing homes, home healthcare agencies and non-profits in the healthcare and housing sectors.


  • Who We Are


    Sarah L. Szanton, PhD, ANP, FAANSarah L. Szanton, PhD., A.N.P.

    While making house calls as a nurse practitioner to homebound, low-income older adults in West Baltimore, Sarah noticed that their environmental challenges were often as pressing as their health challenges. This inspired her to explore ways to make it possible for low-income older adults to live in their own homes for a longer period of time. Her “aha” moment came when she realized the potential impact home maintenance could have on health. Sarah has since developed a program of research, The Community Aging in Place—Advancing Better Living for Elders (CAPABLE) that combines handyman services with nursing and occupational therapy to improve mobility, reduce stress, and decrease health care costs. When she’s not investigating ways to help older adults “age in place”, Sarah mentors and teaches future nurse researchers as a Professor and the Director of the PhD program at the Johns Hopkins School of Nursing.


    Meet the Investigators

  • Topics Covered

    Here are some of the key topics covered in our learning modules

    Module O (for both the OT and the RN):

    • Background of CAPABLE
    • Importance of Physical Function and Home Environment
    • Aging with functional Limitations
    • Motivational Interviewing

    OT Module 1:

    • Procedures and Documentation for the first visit
    • Building rapport
    • Assisting in selection of goals
    • Determining readiness

    OT Module 2:

    • Administration of home visit 2, which includes:
    • Review of first visit
    • Conducting a home tour
    • Discussion of fall prevention and recovery strategies
    • Determine which repairs need to be made
    • Identification of modifications, assistive equipment and devices needed

    OT Module 3:

    • Conducting 3rd, 4th and 5th home visit, which includes:
    • Developing, delivering and modifying the action plan
    • Demonstrate and practice strategies

    OT Module 4:

    • Delivering the final visit, which includes:
    • Reviewing goals met/partially met/not met
    • Determining a final readiness-to-change scale score

    RN Module 1:

    • Procedures and Documentation for the first visit
    • Building rapport
    • Assessing function
    • Assisting in selecting goals
    • Assess readiness to change score

    RN Module 2:

    • Administration of home visit 2, which includes:
    • Review medication list
    • Demonstrate CAPABLE exercises
    • Brainstorm and problem solving for target areas

    RN Module 3:

    • Completing Home Visit 3, which includes:
    • Brainstorm strategies
    • Action planning
    • Evaluate communication between participant and their health care provider

    RN Module 4:

    • Conducting Home Visit 4
    • Complete action plans
    • Review accomplishments of program
    • Assess readiness to change score

    View a sample of a section of an online module


- Self-paced, Online Learning Modules and Simulations

If you have any issues accessing the modules and simulations contact us at

Register Here 

Online Access Instructions

Contact Information

Price for Health Care Organizations

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