Reducing Disability Following Hospital Discharge in Vulnerable Older Adults: The CAPABLE Intervention

NCT03456128 | Completed

• 2 other identifiers: IRB001419681R01AG056607-01
• Study Type: interventional
• Target: 268
• Locations: 1 country
• Sites: 1

Brief Summary

This study evaluates whether the utilization of integrated health services such as help with medications, muscle strengthening, balance training, pain management and home modification interventions can help improve older adults' ability to sleep, balance, walk, and take care of themselves after hospitalization.

Conditions

Disability Physical

Keywords

Older Adult; Rehospitalization; Physical function

Outcome Measures

Primary Outcomes (1)

• Mean ADL Difficulty Score

  Change in ADL- the range is 0 - 16, with higher scores indicating that the participant needs a lot of help with performing many ADLs (is more disabled) and lower scores indicating that the participant is not disabled

  20-week follow-up period

Study Arms (2)

Intervention

EXPERIMENTAL

The experimental group will receive CAPABLE services. These include ≤10 sessions: ≤ 6 with an Occupational Therapist (OT) and ≤ 4 sessions with a Registered Nurse (RN) and up to ≤ $1,500 of home safety and home modifications from a licensed handyman who is guided by the OT. The OT and RN sessions will target participants' self-identified functional goals (e.g., getting safely into the tub, getting upstairs to sleep in own bed).

Other: CAPABLE

Usual Care

NO INTERVENTION

Participants in the usual care group will not receive visit from study clinicians and will continue to receive their usual VNSNY CHOICE benefits and healthcare.

Interventions

CAPABLE OTHER

It involves up to 10 in-home tailored interventions of approximately 60 minutes duration each over a 5-month period. The assessment driven interventions are delivered by an Occupational Therapist (OT) (≤ 6 home visits for ≤ 1hour), a Registered Nurse (RN) (≤ 4 home visits for ≤ 1hour), and a handyman (HM) team.

Intervention

Eligibility Criteria

• Age: 65 Years+
• Sex: all
• Healthy Volunteers: Yes
• Age Groups: Older Adult (65+)

You may qualify if:

• Aged ≥ 65 years old;
• Are 60 days post-hospitalization in an acute care setting and have had a Visiting Nurse Service of New York (VNSNY) visit;
• Have difficulty with at least one activity of daily living (ADL);
• Are a member of the VNSNY CHOICE Medicare Advantage Health Plan;
• Are able to stand with or without assistance; and
• Are available during the intervention period

You may not qualify if:

• Have significant cognitive impairment identified by the Callahan screening tool;
• Do not speak English or Spanish;
• Have had more than 3 hospitalizations within the past 12 months;
• Are actively receiving radiation or chemotherapy;
• Have plans to relocate in less than one year;
• Have diagnoses of the following: Dementia, Alzheimer's, Other Cerebral Degeneration, and serious cognitive impairment or OASIS assessment level 3 response on M1034 "serious progressive conditions that could lead to death within a year"

Sponsors & Collaborators

• Johns Hopkins University: lead
• National Institute on Aging (NIA): collaborator

Study Sites (1)

Visiting Nurse Service of New York

New York, New York, 10001, United States

Location

MeSH Terms

Interventions

CAPABLE protocol

Study Officials

• Sarah L. Szanton, PhD, RN

  Johns Hopkins University

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: SINGLE
• Who Masked: OUTCOMES ASSESSOR
• Masking Details: 1: 1. The outcome assessor will be unaware of which groups the older adults are assigned to.
• Purpose: TREATMENT
• Intervention Model: SINGLE GROUP
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Model Details: The study is a single-masked, two-group, randomized trial to test the effectiveness of CAPABLE in reducing ADL difficulties compared to those randomized to usual care.

Study Record Dates

• First Submitted: January 3, 2018
• First Posted: March 7, 2018
• Study Start: August 25, 2018
• Primary Completion: September 11, 2023
• Study Completion: September 30, 2025
• Last Updated: October 15, 2025

Record last verified: 2025-10

Locations

US (1)