Health Care Innovation Awards: Project Profile


Project Title: "CAPABLE for frail dually eligible older adults: achieving the triple aim by improving functional ability at home"
Geographic Reach: Maryland
Funding Amount: $4,093,356
Estimated 3-Year Savings: $6,800,000


The Johns Hopkins School of Nursing received an award for a Medicare/Medicaid dual eligibles program (Community Aging in Place, Advancing Better Living for Elders -"CAPABLE") that uses a care management team to improve the everyday functioning of complex, frail patients in their own homes. The program will reduce difficulty with activities of daily living and improve medication management, mobility, and health-related quality of life, based on an individualized package of interventions including home visits from occupational therapists and nurses and other services.CAPABLE will reduce nursing home admissions and hospitalizations and improve quality of life for these beneficiaries of Medicare and Medicaid. Over a three-year period, the John Hopkins School of Nursing will retrain an estimated eight occupational therapists and registered nurses and as well as engage other services.

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