New CAPABLE Program Promotes Aging in Place

Aging and Disability Services—the Area Agency on Aging for King County—is partnering with Habitat for Humanity Seattle-King County (Habitat SKC) to bring an innovative program to Washington state that promotes aging in place.

CAPABLE stands for Community Aging in Place—Advancing Better Living for Elders. It’s a person-directed, home-based program developed by Johns Hopkins University (JHU) School of Nursing that assists eligible homeowners with wrap-around services and connects them to health care and home modification services they need to continue to thrive safely in their homes.

CAPABLE addresses both function and healthcare expenses. The program integrates services from an occupational therapist (OT), a registered nurse (RN), and a handy worker over the course of four to five months. They work as a team and use Motivational Interviewing, active listening, and coaching to help participants prioritize activities and achieve goals.

Key program components are helping participants set personal goals and addressing behaviors to improve health, independence, and safety. People who participate in the program develop skills and learn how to work with additional tools, equipment, and home modifications to improve function and safety. The program focuses on prevention and problem-solving, and participants build skills they can use in the future.

Initially, two Aging and Disability Services case management teams—one in our Seattle office and one in our Renton office—will pilot CAPABLE, in collaboration with Habitat for Humanity Seattle-King County. The case manager will determine whether the client meets program criteria and then provide program information. If the client agrees, the case manager will send a referral to Habitat SKC.

Once Habitat receives the referral, they will screen participants by telephone. The screener will ask about the person’s readiness to change, as well as their willingness to set goals and work with CAPABLE clinicians to achieve those goals. The CAPABLE team member assesses cognitive ability, identifies challenges with at least one Activity of Daily Living, and ensures the participant can schedule home visits over five months.

Activities of Daily Living

Activities of Daily Living (sometimes referred to as ADLs), are the skills required to manage one’s basic physical needs. These include:

• Bathing, toileting and/or other personal hygiene
• Dressing
• Food preparation and/or eating
• Indoor and outdoor mobility
• Medication management
• Transfer between surfaces (e.g., to/from bed or chair)

The CAPABLE program’s OT will address tasks such as strategies for dressing, bathing, cooking, grooming, and moving around the home, while the RN works on medical issues such as pain, mood, medications, and falls prevention. Minor home repair and modifications from a handy worker could include adding a grab bar in the shower, or a handrail to front porch steps.

Johns Hopkins University School of Nursing provides comprehensive online training for OT and RN staff. Trainings include videos, home visit simulation, and tools to help staff complete assessments and documentation.

CAPABLE benefits

Johns Hopkins University research indicates that CAPABLE program participation can result in:

• Improved independence, safety, and health
• Lower healthcare costs
• Enhanced motivation, self-confidence, and self-efficacy
• Reduced health disparities

CAPABLE is a free program for older homeowners who qualify—currently low-income (below 80 percent of Area Median Income) homeowners in South Seattle, White Center, Southeast Renton, Federal Way, Glendale, and Skyway. Other areas may be added in the future. Aging and Disability Services case management program clients can ask their case manager about the CAPABLE program. Non-clients can inquire about case management program eligibility by calling Community Living Connections at (toll-free) 844-348-5464.

Learn more about the implementation of CAPABLE on the JHU School of Nursing website.

Contributor Mary Pat O’Leary, RN, BSN is a senior planner at Aging and Disability Services, Seattle Human Services Department. She thanks Kristina Copley, Mia Walterson, and Kaylen O’Hara at Habitat SKC for collaborating on this article.