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 over 35 CAPABLE sites across the country, 11 of which are located in rural communities.
(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 over 35
CAPABLE sites across the country, 11 of which are in
rural communities. Massachusetts offers the CAPABLE
program through its Medicaid program. Colorado is
conducting a pilot (to be completed 2024) for Medicaid
members, and Connecticut is in the process of rolling out
CAPABLE under Medicaid.
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 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 Center 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
A nursing shortage may be a challenge in some locations.
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, California, Colorado, Iowa, Maine, Maryland, New York, Pennsylvania, Texas, Washington
July 11, 2019
Date updated or reviewed
July 7, 2023
Suggested citation: Rural Health Information Hub,
CAPABLE (Community Aging in Place—Advancing Better Living for Elders) [online]. Rural Health Information Hub. Available at:
[Accessed 2 October 2023]
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.