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

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​CAPABLE (Community Aging in Place - Advancing Better Living for Elders) is a research study designed to help seniors live more comfortably and safely in their homes. The research findings will help to determine if services can help older adults maintain their independence longer.

The five-month program is composed of two types of in-home services - Creative Outreach and Physical Function. One type of service is randomly selected for each participant. Teams include an outreach worker or an Occupational Therapist, a Registered Nurse, and a handyman. 

The Problem

The country's medical system is unable to respond to the increasing needs of the aging population, specifically older adults' inability to perform basic self-care activities, such as bathing, dressing, and walking. This compromises the health of older adults and costs the country millions of dollars each year.

The Solution

The CAPABLE research study works to address the needs of older adults through small adjustments (e.g.: handrail install­ment) and larger investments, as needed, to help ensure each participant's needs are met. The goals of the program are to help older adults remain in their homes longer, improve health outcomes, and decrease medical costs.

Improved Patient Outcomes

Ina population of low-income older adults on Medicaid and Medicare who participated in CAPABLE:

  • 79% of participants improved their self-care over the course of five months1
  • On average, the number of self-care tasks that participants had difficulty with were halved
  • Participants experienced a decrease in depressive symptoms similar to that of anti-depressant medication

1Sarah L. Szanton, "Preliminary data from CAPABLE, a patient directed, team-based intervention to improve physical function and decrease nursing home utilization:  the first 100 completers of a CMS Innovation Project." Accepted for publishing in the Journal of the American Geriatrics Society

TEstimonial - Mrs. B's Experience with CAPABLE



Next Steps

Data gathered for the Center for Medicare and Medicaid Services Innovation Center implementation of CAPABLE is closely tracked and monitored. The rates at which CAPABLE participants and a matched group use nursing homes and hospitals will be compared to establish cost savings.


CAPABLE has been funded by the National Institutes of Health (ROl AG040100), the Center for Medicare and Medicaid Services Innovation Center (1C1CMS330970-01), the Robert Wood Johnson Foundation (69351), and by the Rita and Alex Hillman Foundation to expand the program to three cities in Michigan - Detroit, Flint, and Saginaw. The expansion is a part of Michigan Medicaid's pilot program to integrate CAPABLE into Michigan's Home and Community based services for older adults to help keep nursing home-eligible adults in the community. Proven CAPABLE's cost-effectiveness, Michigan Medicaid officials have pledged to fully integrate CAPABLE into the Michigan Medicaid waiver program (15,000 older adults). Abstract

Meet the Investigators


Capable StudyWith the number of older adults expected to double to 71 million by 2030, reducing the societal burden of age-related chronic disease is crucial. Currently, the United States spends $250 billion annually on medical care for older adults, of which the majority is spent on chronic conditions. Even though many chronic conditions lead to disability, little information exists on interventions that can delay the onset of chronic-disease related disability. Given the multi-factorial nature of many of the age-related conditions and their associated risk factors, the best interventions are likely multi-component with the components synergistically targeting multiple risks for disability. However, this is not yet known.

The Community Aging in Place –Advancing Better Living for Elders (CAPABLE) study is a client-centered home-based intervention to increase mobility, functionality, and capacity to “age in place” for low-income older adults. CAPABLE is comprised of an occupational therapist intervention (R01 AG13687, Gitlin, PI), a client-centered nurse intervention and safety and access handyman services. Each service synergistically builds on the others by increasing the participants’ bio-psycho-functional capacity to function at home. This is theorized to avert costly health utilization by increasing medication management, problem-solving ability, strength, balance, nutrition, and home safety, while decreasing isolation, depression, and fall risk.


*Szanton, S.L Leff, B.L., Wollf, J.L., Roberts, L. Gitlin, L.N Innovative home-based care model reduces disability and promotes aging in place in press at Health Affairs

Szanton, S.L. Aging in Place: Innovative Teams (2017 publication date) chapter in Nursing Research shaping Health Policy: Springer Publishers.  Edited by Patricia Grady and Ada Sue Hinshaw

*Szanton, S.L. Thorpe, R.J., Boyd, C., Tanner, E.K., Leff, B., Agree, E., Xue, Q.L., Allen, J.K., Weiss, C., Seplaki, C.L., Guralnik, J.M., Gitlin, L.N.  (2011). CAPABLE: A bio-behavioral-environmental intervention to improve function and health-related quality of life of disabled, older adults.  Journal of the American Geriatrics Society, 59(12): 2314-2320.  PMCID: PMC3245364

Pho, A. Tanner. E.K., Roth, J., Greeley, M., Dorsey, C., Szanton, S.L. (2012) Nursing Strategies for Promoting and Maintaining Function among Community-Living Older Adults: The CAPABLE Intervention. Geriatric Nursing. Nov-Dec; 33(6)439-45 (with Master’s student)

Gitlin, L.N., Szanton, S.L.,  Hodgson, N. (2014) It’s Complicated – But Doable: The Right Supports Can Enable Elders With Complex Conditions To Successfully Age In Community.  Generations.37 (4): 51-61

Szanton, S.L. Klimmek, R. Roth, J., Savage, J., Nkimbeng, M. (2014)  Improving  unsafe environments to support aging independence with limited resources. Invited manuscript for Nursing Clinics of North America issue: Facilitating Aging in Place: Safe, Sound, and Socially Secure.49 (2) 133-145 PMCID: PMC4074077

Szanton, S.L., Wolff, J.W., Leff, B.L., Thorpe, R.J., Tanner, E.K., Boyd, C., Xue, Q., Guralnik, J. Bishai, D.  Gitlin, L.N., (2014)  CAPABLE trial:  a randomized controlled trial of nurse, occupational therapist and handyman to reduce disability among older adults: rationale and design.  Contemporary Clinical Trials 38(1):102-112. PMCID: PMC4074085.

*Szanton, S.L., Wolff, J.W., Roberts, L. Leff, B.L., Thorpe, R.J., Tanner, E.K., Boyd, C., Xue, Q., Guralnik, J. Bishai, D.  Gitlin, L.N. (2015) Preliminary data from CAPABLE, a patient directed, team-based intervention to improve physical function and decrease nursing home utilization: the first 100 completers of a CMS Innovations Project Journal of the American Geriatrics Society 63(2):371-374. PMCID: PMC4498670

*Smith, P.D., Boyd, C., Bellantoni, J., Roth, J., Becker, K., Savage, J., Nkimbeng, M. Szanton, S.L., (2016) Communication between primary care providers and nurses within the home: an analysis of process data from CAPABLE  Journal of Clinical Nursing (with a doctoral student)25(3-4)  454-462. PMCID: PMC4738578

Szanton, S.L., Gitlin, L.N., Meeting the demographic and health care financing imperatives through focusing on function: the CAPABLE studies Public Policy and Aging Report 6.16

Gitlin, L.N., Szanton, S.L., DuGoff,  E.H. (2011). Supporting Individuals with Disability Across the Lifespan at Home: Social Services, Technologies, and the Built Environment. “White paper” commissioned by the SCAN Foundation.

Bridges, A., Szanton, S.L., Evelyn-Gustave, A., Smith, F. Gitlin, L. Home Sweet Home: Interprofessional Team Helps Older Adults Age in Place Safely.  OT Practice 9.9.13

*Gleason, K. Tanner, EK, Boyd, C.M., Saczynski, J.S., Szanton, S.L.  (2016) Factors Associated with Patient Activation in an Older Adult Population with Functional Limitations  online  ahead of print at Patient Education and Counseling (with PhD student) PMCID: 772754

Smith, P.D., Becker, K.L., Roberts, L., Walker, J.L., Szanton, S.L. Associations among pain, depression, and functional limitation in low-income, home-dwelling older adults: an analysis of baseline data from CAPABLE. in press at Geriatric Nursing (with nursing student and post-doc)


Additional Resources

In the News

View News and Podcasts for the CAPABLE program.


2016    Health Equity Leadership Award, given by Baltimore City
2016    National Influencer in Aging, awarded by Next Avenue
2016     American Public Health Association and Archstone Foundation
2016     Excellence in Program  innovation honorable mention (being presented November, 2016)
2015     Baltimore Business Journal Health Care Innovator award


Center for Medicare and Medicaid Services: CAPABLE for frail dually eligible older adults:  achieving the triple aim by improving functional ability at home 1C1CMS330970-01  $3,843,715

National Institutes of Health: Reducing disability via a bundled bio-behavioral-environmental approach R01 AG040100 $2,405,495

Robert Wood Johnson Foundation: Bio-behavioral mediators of enhanced daily function in disabled low income older adults  $350,000

Learn More

For more information on the project, contact:

Sarah Szanton, PhD, ANP, FAAN
Associate Professor, Johns Hopkins School of Nursing