CAPABLE Care + Connect
CAPABLE Care + Connect: Pilot Feasibility of Implementing CAPABLE Into Homebased Primary Care
Johns Hopkins University
450 participants
Aug 14, 2025
INTERVENTIONAL
Conditions
Summary
In this evaluation scale-up research project, the investigators seek to test an implementation of CAPABLE on the infrastructure of home-based primary care for individuals who may experience social isolation and/or loneliness. These two home-based care programs may improve each other and provide opportunity to further improve quality of life for people living with disabilities and the caregivers. The purpose of this mixed methods study is to adapt and test CAPABLE, an existing evidence-based program, to a new target population with the scalable infrastructure of home-based primary care.
Eligibility
Inclusion Criteria13
- Any patient currently in JHOME
- At risk for or experiencing social isolation as defined by the Lubben Social Network Scale 6 item score less than or equal 12 points or loneliness as defined by the UCLA Loneliness Scale 3 item score of 6 to 9 points
- English speaking (measures are standardized in English)
- Ability to participate in an approximately 45-60 min virtual or in person meeting
- Eligible for CAPABLE
- years or older
- Not hospitalized over night more than 4 times in the last 12 months
- Have some difficulty with any ADL
- Cognitively intact
- Live in Baltimore County or Baltimore City
- Not receiving active cancer treatment
- Interested in participating in CAPABLE Care partners will be included if the care partners provide \> 10 hours of care/week
- • Any patient currently in JHOME who did not receive the CAPABLE intervention
Exclusion Criteria3
- Terminally ill
- live in long term care setting
- receiving active cancer treatment
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Interventions
As in CAPABLE, the delivery characteristics of CAPABLE Care + Connect consist of an assessment-driven, individually tailored package of interventions delivered over the course of 4 months by an occupational therapist (OT) (\~6 home visits for ≤ 1hour), a registered nurse (RN) (\~4 home visits for ≤ 1hour) and a handy worker (HW). Adaptations targeting those in JHOME will be made on a per-client basis as part of the open-label pilot. The investigators will further refine and develop the intervention by receiving feedback from the open label pilot participants and CAPABLE clinicians who implemented the pilot to gain those perspectives of the acceptability and feasibility of implementing the CAPABLE Care + Connect intervention. Based on this feedback, the study team will have developed an adapted iteration of the prototype.
As in CAPABLE, the delivery characteristics of CAPABLE Care + Connect consist of an assessment-driven, individually tailored package of interventions delivered over the course of 4 months by an occupational therapist (OT) (\~6 home visits for ≤ 1hour), a registered nurse (RN) (\~4 home visits for ≤ 1hour) and a handy worker (HW). Refinements based on the open label pilot results will be included.
Locations(1)
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NCT07123298