Aging Gracefully in Place

Project Funder: Archstone Foundation, the Harry and Jeanette Weinberg Foundation, the U.S. Department of Housing and Urban Development.

Project Partners: Community Housing Solutions of Guilford, Inc., Catholic Social Services of the Diocese of Scranton, Cathedral Square Corporation, Inc., and the Family Health Centers of San Diego. 

Project Contact: Jill Breysse,

Project Description: By the year 2030, it is estimated that the older U.S. adult population (age 65-plus) U.S. will double to more than 70 million individuals. Policymakers and practitioners are grappling with the need for safe and healthy housing that matches this important demographic, which will constitute approximately 20% of the U.S. population. NCHH is collaborating with Johns Hopkins University (JHU) and organizations in four communities around the country to conduct the Aging Gracefully in Place ("Aging Gracefully") project. This project is evaluating the replicability of JHU’s "Community Aging in Place, Advancing Better Living for Elders" (CAPABLE) intervention model. JHU’s CAPABLE program is a client-centered, home-based, unified set of interventions utilizing an occupational therapist (OT), a registered nurse (RN), and a home improvement professional to increase older adults’ mobility and physical function and improve their homes so they can more safely age in place and move more independently and safely both inside and outside their homes. 

The Archstone Foundation and the Harry and Jeanette Weinberg Foundation are co-funding the CAPABLE interventions, and the U.S. Department of Housing and Urban Development’s (HUD) Office of Policy Development and Research (PD&R) is funding an evaluation to determine whether the JHU’s CAPABLE program improves low-income elders’ physical function and decreases home safety hazards both immediately after CAPABLE interventions are completed and one year after they began.
Through this formative evaluation, Aging Gracefully is also fostering a learning community among the following four diverse partners to see if JHU’s CAPABLE model can be replicated in their communities and to document vital information needed to scale up and sustain the CAPABLE model across the country: 

These four community partners are implementing the JHU CAPABLE program using different organizational structures, different housing stocks, and different client bases. Staff from the JHU School of Nursing are providing training and technical support to the partners on the CAPABLE program. 

Summary of CAPABLE© Program Services Provided in the Aging Gracefully Project (adapted from Szanton et al., 2014[1])



Content of Visit

Eval staff #1

In-home eligibility check. If eligible, review and obtain informed consent and conduct evaluation interview and home safety checklist.

OT #1

OT conducts function-focused OT assessment, works w/client to identify three functional goals, conducts physical therapy screen.

OT #2

OT conducts fall education and home safety assessment, works with client to prepare SOW for HRP, identifying priority home repairs, home modifications, DME, and AE needed to help meet client’s three functional goals.


OTs order DME and AE. HRP visits home to assess materials needed for home modifications and repairs, then conducts a second visit to complete SOW based on client’s goal-prioritized SOW.

RN #1

RN introduces client to RN portion of CAPABLE and conducts function-focused RN assessment including pain, mood, strength, balance, medication information, and need for healthcare provider (PCP) advocacy/communication.

OT #3

OT and client brainstorm and develop action plan for client’s first functional goal (e.g., safely bathing).

RN #2

RN and client identify RN-related goals and brainstorm how to meet first RN-related goal (e.g., pain in standing). RN demonstrates CAPABLE exercises, reviews CAPABLE medication calendar, and discusses client’s communication/relationship with his/her primary care physician.

OT #4

OT and client review action plan for goal 1, then brainstorm and develop an action plan for client-identified goal 2. The OT trains client in safe use of DME, AE, and home modifications.

RN #3

RN & client complete problem-solving process for RN-related goals and finish action plans for identified goals. If available, they assess primary care physician’s response to communication of client needs. RN reviews, assesses, and troubleshoots client’s exercise regimen.

OT #5

OT and client review the action plan for the third functional goal and brainstorm and develop an action plan for client-identified goal 3.

RN #4

RN reviews client’s progress and use of strategies for all goal areas and evaluates client’s achievements and readiness-to-change scale. RN helps client brainstorm how to address future health issues, and answers any final questions.

OT #6

OT helps client generalize solutions for future problems and problem-solving techniques, evaluates client’s achievements with the three functional goals and their readiness to change, and answers any final questions.

HRP=home repair professional; OT=occupational therapist; RN=registered nurse; DME=durable medical equipment; AE=assistive equipment

© 2015 Johns Hopkins University. All rights reserved.

[1] Szanton, S. L., Wolff, J. W., Leff, b., 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, 102-112.

Last updated July 25, 2017.

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