Expanding and Sustaining
the CAPABLE Aging in Place Program
SECTOR
Healthcare
TIMELINE
14 Weeks
TEAM
Anushree Joshi, Ashlyn, Akshay Pagar, Samantha Chandra, Daniela Velez,
June Pruk, Kristin John, Yanting Wang
FACULTY AND PARTNER
Tomoko Ichikawa (Institute of Design)
Andre Nogueria (Johns Hopkins School of Nursing)
ABOUT PROJECT
As part of a collaborative team with Johns Hopkins School of Nursing, this project applies communication design principles to visualize pathways for CAPABLE—a national non-profit program helping elderly individuals age safely in their homes to scale in a sustainable manner.
KEY HIGHLIGHTS
Conducted research through 12+ stakeholder interviews across 4 implementation sites to identify scaling barriers and growth opportunities.
Co-created ecosystem maps and visual models to illustrate complex funding pathways and dependencies between federal, state, and local healthcare stakeholders.
Synthesized research findings into 8 strategic opportunity areas, 6 design principles, and co-developed 4 concepts to guide and inform CAPABLE’s national expansion and sustainability efforts.
Create a comprehensive design document to share with stakeholders.
Context
CAPABLE, developed by Johns Hopkins School of Nursing, is an evidence-based program that helps older adults age in place with dignity and safety. Despite proven effectiveness in improving quality of life and reducing healthcare costs, the program faces significant barriers such as
national expansion,
complex funding pathways,
operational friction, and
workforce constraints.
How CAPABLE functions
CAPABLE is a participant directed, home-based model delivered over 10 visits in 4 to 5 months. The program centers around an interprofessional team including an occupational therapist, a registered nurse, and a handy worker, who work with older adults to identify and achieve self-prioritized goals that enhance mobility, function, and quality of life.
Current situation
3600 participants across more than 65 implementation sites
As of 2025, CAPABLE has served over 3,600 participants across more than 65 implementation sites and has been piloted in diverse contexts, from state Medicaid innovation initiatives to community-based housing partnerships. However, the path to national adoption still faces critical challenges (CAPABLE, n.d.).
Why scaling matters now
10000 people will be turning 65 each day for next 15 years
Aging in place is no longer just a personal preference. It is becoming a demographic, economic, and systemic trajectory. With 10,000 people turning 65 each day for the next 15 years and 74% of people over 85 experiencing functional limitations, the U.S. faces mounting healthcare costs and infrastructure gaps. Scaling CAPABLE now is both urgent and strategic..
Visual modeling as analysis
Throughout our research and analysis, we developed over 50 visual models to synthesize insights and communicate complexity. These included funding pathway diagrams, mind maps to distill expert interviews, ecosystem maps to frame the broader system, as well as value webs, opportunity models, and concept maps.
Modeling the Ecosystem
The CAPABLE Ecosystem Map illustrates two primary streams: clinical care and home modifications. Within these streams, we identified and mapped the involved organizations and funding sources across federal, state, and local levels, including both public and private sources.
This map helped us grasp the complexities of funding and service delivery by providing a high-level view of the key players, relationships, and components that shape the CAPABLE ecosystem.
Some of our takeaways include:
CAPABLE is launched by initiators from multiple levels
The motivations behind launching CAPABLE are varied
Funding pathways are decentralized and opaque
Everyone interfaces with everyone
The Local Ecosystems
CAPABLE’s implementation varies significantly across locations. To better understand these variations, we studied four CAPABLE sites in the U.S.: Kentucky, Chicago, Boston, and Colorado, mapping their local ecosystems to uncoversite and stage-specific insights.
Kentucky emphasized pre-implementation,
Chicago provided lessons on evaluation and adoption,
Boston and Colorado offered perspectives on implementation and long-term sustainability.
Throughout our research, we identified key factors that contributed to CAPABLE’s growth, factors that can get in the way of progress, and the elements in the system that depend on one another.
Dependencies
Within every system, interconnections exist among various elements (such as objects, people, and ideas). While these relationships aren’t necessarily comprehensive, we’ve mapped the key dependencies and identified critical hotspots within the CAPABLE system.
Having identified the system’s key levers, we’re positioned to take decisive steps that will unlock opportunities in scaling and sustaining the CAPABLE program.
Design Principles for Growth
Based on findings and insights from our research process, we defined a set of design principles that can guide future work for scaling and sustaining CAPABLE initiatives.
The six principles were derived through a synthesis of our primary and secondary research. This process involved examining key barriers and facilitators to growth, revisiting critical dependencies, unpacking insights from our design explorations, and distilling the most impactful factors to guide future decision-making.
We prioritize collecting data of the system, not just about client results
We offload work from the center to the center
We prioritize collecting data of the system, not just about client results
We are loud about showing
our impact
We make knowledge sharing across the system easier
We building strong alliances with people who share our values
CAPABLE Opportunity Area Model
This model maps a comprehensive set of 8 opportunity areas for scalability and sustainability, each shaped by insights from our research. These areas highlight where design has the potential to create a meaningful impact and invite solution exploration.
Translating insights into concepts
We proposed four concepts to support CAPABLE’s growth, each addressing the challenge from a different systemic angle. These concepts were developed with the opportunity areas and design principles in mind. They are intended to frame potential areas for future research, help the CAPABLE National Center envision future scenarios, and imagine actionable steps toward them.
In an internal workshop, our class generated 15 opportunity areas, which formed the foundation for over 100 initial ideas. From there, teams developed the most promising ideas into 12 concept sketches. We then clustered similar concepts, built on them, and refined them through insightdriven iteration to ultimately arrive at these four concepts.
1. CAPABLE Compass
A tool that transforms the established JHSON “Initial Implementation Readiness Self-Assessment" into a digital platform that enhances the implementation journey for the CAPABLE sites.
3. Data Story Engine
A framework, process, and set of tools that help the CAPABLE National Center with evidence-based storytelling, transforming complex program data into accessible, targeted, and compelling narratives that demonstrate value to different key stakeholders.
2. CAPABLE InsightHub
An internal system that connects sites with one another and connects teams within each site, serving as a mechanism to streamline administrative tasks, communication,and data processing.
4. CAPABLE Commons
An alternative implementation model in which CAPABLE partners with senior housing developers to offer CAPABLE as a differentiating on-site service, supporting residents to age in place and avoid hospital visits or transitions to nursing facilities.
CAPABLE Compass
Activating readiness through contextualized guidance
CAPABLE Compass, a digital assessment and recommendation tool builds on this foundation by transforming the existing self-assessment into an interactive platform that delivers real-time feedback, data-informed insights, and tailored implementation support.
CAPABLE InsightHub
Developing cohesive team connection and data practices
The CAPABLE InsightHub is a centralized internal dashboard and data system that connects sites, streamlines administrative tasks, and improves communication within site teams. By simplifying data practices and enabling access to shared operational insights, this system fosters smoother day-to-day operations and strengthens CAPABLE’s ability to scale effectively.
Data Story Engine
Building support by linking goals and data through engaging narratives
The Data Story Engine is a set of frameworks, tools, and processes that enable evidence-based storytelling by combining quantitative outcomes with qualitative experiences. It aligns CAPABLE’s program data with the priorities of key stakeholders, ensuring that messaging is tailored to different audiences. Additionally, it incorporates visual tools that make complex data more accessible and actionable for stakeholders within the CAPABLE ecosystem.
CAPABLE Commons
Bringing aging-in-place services to senior housing
This new model repositions CAPABLE as a premium, revenue-generating service by partnering with senior housing developers and property managers to offer it as an on-site amenity. By helping residents age in place and avoid hospitalizations or nursing home placements, this approach not only enhances quality of life but also reduces costs. It also opens up new funding opportunities, from being financed directly by housing providers to being supported through community-based funding platforms.
These concepts serve as catalysts for ideation designed to stimulate fresh perspectives on how CAPABLE might expand while preserving its core values. They invite stakeholders to envision new possibilities for growth.
As the aging population grows, the importance of programs like CAPABLE becomes increasingly critical. To conclude this project we designed a report that contributes to a broader movement reframing aging not as a decline to be managed, but as a stage of life supported through care, community, and creative systems thinking.