CAPABLE (Community Aging in Place—Advancing Better Living for Elders)
- Need: To help older adults age in place.
- Intervention: For five months, CAPABLE participants receive home visits from a registered nurse, occupational therapist, and home repair services.
- Results: There are currently 34 CAPABLE sites across the country, 9 of which are located in rural communities.
CAPABLE (Community Aging in Place—Advancing Better
Living for Elders) is a five-month home visit program
that helps low-income seniors age in place.
This program was developed by the Johns Hopkins School of
Nursing. There are currently 34 CAPABLE sites across the
country, 9 of which are in rural communities.
Massachusetts offers the CAPABLE program through its
Medicaid program, and four other states are considering
or starting up similar statewide programs.
The rural sites are located in the following states:
- New York
For five months, each CAPABLE participant works with:
- A registered nurse (RN), who visits 3 to 4 times
- An occupational therapist (OT), who visits 4 to 6
- Home repair services, which has
a budget of $1,300 to make repairs and install safety
These visits are client-driven. Instead of the CAPABLE
staff deciding what the client needs to do, they use
motivational interviewing to help participants set their
own goals. For example, if the participant wants to bathe
safely, the RN might partner with the client to identify
issues that affect balance, like overmedication; the OT
could teach strengthening exercises and ways to
enter/exit the tub safely; and home repair technicians
could install safety features like handrails and nonslip
treads. Through this brainstorming process, participants
also develop self-efficacy skills to face any challenges
that arise after CAPABLE program visits have ended.
national CAPABLE model reports a return on investment
of over 6 to 1, with over $30,000 in medical costs saved
for every $3,000 invested in the program. Participants
nationwide have shown reduced symptoms of depression and
improved functionality. There are
publications about CAPABLE, but there have not been
any rural-focused studies published.
For more information about how CAPABLE worked in rural
Hawaii and Maine, please read the 2019 Rural Monitor
National Program Helps Older Adults in Rural Maine and
Hawaii Feel More CAPABLE.
A review of six CAPABLE studies was published in the
Journal of the American Geriatrics Society. Some
sites featured in the studies served rural clients:
Szanton, S.L., Leff, B., Li, Q., Breysse, J., Spoelstra,
S., Kell, J., ... & Gitlin, L.N. (2021). CAPABLE Program
Improves Disability in Multiple Randomized Trials.
Journal of the American Geriatrics Society,
69(12), 3631-3640. Article
Finding funding sources and sustaining a program after a
grant has ended can be difficult for rural sites. RHIhub
offers a list of funding
opportunities, which can be narrowed down by topic
and state, as well as a Rural
Philanthropy Toolkit, which provides advice to help
rural organizations build relationships with
While aspects like the OT and RN are needed to count as a
CAPABLE program, national model coordinators can work
with rural sites to help them adapt the program to fit
their community and clients. For example, the site that
used to be in Bath, Maine, used a different grading
scale, the Patient-Specific Functional Scale, to help
clients rate their goals throughout the five months of
the program. In addition, this site also offers safety
checks like testing or replacing smoke alarms.
The RN and OT each complete five 60-minute online
learning modules, up to 8 hours of live online training,
and five webinars or coaching calls. The
CAPABLE FAQs section has more information about
training, costs, and program support.
Aging and aging-related services
Home and community-based services
National/Multi-State, Alaska, Hawaii, Maine, Minnesota, Pennsylvania, Texas
July 11, 2019
Date updated or reviewed
July 11, 2022
Suggested citation: Rural Health Information Hub,
CAPABLE (Community Aging in Place—Advancing Better Living for Elders) [online]. Rural Health Information Hub. Available at:
[Accessed 28 September 2022]
Please contact the models and innovations contact directly for the most complete and current information
about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The
programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural
community should consider whether a particular project or approach is a good match for their community’s
needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep
in mind that changes to the program design may impact results.