Actively Recruiting
CAPABLE Care + Connect: Pilot Feasibility of Implementing CAPABLE Into Homebased Primary Care
Led by Johns Hopkins University · Updated on 2026-06-02
450
Participants Needed
1
Research Sites
N/A
Total Duration
On this page
Sponsors
J
Johns Hopkins University
Lead Sponsor
N
National Institute on Disability, Independent Living, and Rehabilitation Research
Collaborating Sponsor
AI-Summary
What this Trial Is About
Researchers are evaluating the CAPABLE Care + Connect program, a home-based, interdisciplinary, and goal-directed approach designed to reduce physical disability and improve quality of life for homebound older adults who may experience social isolation and loneliness. This mixed methods study aims to adapt and test CAPABLE within home-based primary care settings, exploring how combining CAPABLE with Johns Hopkins Home-Based Medicine (JHOME) might enhance health, function, and social connections for people living with disabilities and their caregivers. The CAPABLE Care + Connect intervention involves a tailored package of services delivered over four months by an occupational therapist, a registered nurse, and a handy worker. Participants receive approximately six home visits from the occupational therapist, four from the nurse, and visits from the handy worker, each lasting up to one hour. The study includes an open-label pilot phase and a pilot intervention phase, recruiting caregiver-patient pairs and individuals without caregivers. A comparison group consists of JHOME patients receiving standard care to evaluate the intervention's effects. Participants will engage in baseline and 16-week assessments measuring changes in activities of daily living, pain, depression, social connection, and caregiver burden using various standardized scales. Health system effects such as urgent visits, emergency room visits, nursing home placement, and medication use are also tracked. The study involves virtual or in-person meetings lasting 45 to 60 minutes and monitors outcomes over 16 weeks, with a total sample size including both intervention and standard care participants of up to 450 individuals.
CONDITIONS
Brief Title
CAPABLE Care + Connect
Who Can Participate
Eligibility Criteria
You may qualify if you...
- Any patient currently in the Johns Hopkins Home-Based Medicine program (JHOME)
- At risk for or experiencing social isolation with Lubben Social Network Scale score ≤12 or loneliness with UCLA Loneliness Scale score 6 to 9
- Montreal Cognitive Assessment (MOCA) score greater than 23
- English speaking
- Able to participate in a 45-60 minute virtual or in-person meeting
- Eligible for CAPABLE program
- 50 years or older
- Not hospitalized overnight more than 4 times in the last 12 months
- Have some difficulty with any activities of daily living (ADL)
- Cognitively intact
- Live in Baltimore County or Baltimore City
- Not receiving active cancer treatment
- Interested in participating in CAPABLE
- Care partners providing more than 10 hours of care per week may be included
You will not qualify if you...
- Terminally ill
- Living in a long-term care setting
- Receiving active cancer treatment
- Patients in JHOME who did not receive the CAPABLE intervention and declined record review are excluded from the study
AI-Screening
AI-Powered Screening
Complete this quick 3-step screening to check your eligibility
Your Study Journey
Duration - 2 to 4 weeks
Participants are screened for eligibility to participate in the trial.
1 visit (virtual or in-person)
Duration - 4 months
Participants receive the CAPABLE Care + Connect intervention, which includes an individually tailored package of services delivered over 4 months by an occupational therapist, a registered nurse, and a handy worker through multiple home visits.
Approximately 6 home visits with an occupational therapist, 4 home visits with a registered nurse, and visits by a handy worker
Duration - Up to 16 weeks after baseline
Participants are assessed for changes in function, pain, depression, social connection, and caregiver burden at the end of the intervention period.
1 visit at 16 weeks
Trial Site Locations
Total: 1 location
1
Johns Hopkins School of Nursing
Baltimore, Maryland, United States, 21205
Actively Recruiting
Research Team
C
Chloe Wynn, MS
How is the study designed?
Study Type
INTERVENTIONAL
Masking
NONE
Allocation
NON_RANDOMIZED
Model
PARALLEL
Primary Purpose
PREVENTION
Number of Arms
3
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