After a fall landed her in the hospital, Carol knew she needed some help in order to return home safely. Following a couple weeks in a short-stay rehabilitation center, along with home care services that enabled her to recover her strength, she was still a little uneasy about getting around independently and felt she could benefit from something more to help her confidence in her home.

Enter CAPABLE (Community Aging in Place – Advancing Better Living for Elders), a new program in the area that provides medical support and home repairs to improve the safety and mobility for older homeowners.

Provided by St. Luke Health Services in Oswego, the CAPABLE Program team is comprised of an Occupational Therapist, a Registered Nurse, and a handy-worker service that work together to help older adults identify their own self-care goals. To address these goals, CAPABLE evaluates both the home environment as well as the strengths and resources of the program participants themselves.

Photo 1 Carol and Jim St. Luke CAPABLE Program 23

St. Luke CAPABLE Program Team Coordinator Jim Marsh, RN (left) during a recent home visit with program participant Carol Albright (right).

“There are a few unique components of CAPABLE that make the program work,” said Jim Marsh, RN, St. Luke’s CAPABLE Program Coordinator. “We are passionate about supporting and advancing a participant’s self-determination and safety in their home.”

“In most cases in-home services are time-limited.” Marsh says this is often not enough time to truly change behaviors that can affect safety. On-going support that encourages modifications to activities to decrease risks is beneficial.

“To help ensure the success of those engaged in our program,” noted Marsh, “our CAPABLE team will typically make ten home visits over the course of four to five months.”

The program is non-clinical and puts the power of the care plan in the hands of the participant. Marsh points to CAPABLE’s client-centered approach as a key to success.

“The client is driving the bus, not the clinician,” he says. “Traditionally we in healthcare are trained in a very problem-solving mindset where the clinician determines the treatment plan. In CAPABLE, our team is more collaborative as the participants identify goals to enhance self-sufficiency and address barriers that impact their ability to remain at home independently, with a focus on quality of life,” he explained.

While engaged the Nurse may suggest working on target areas like pain, mood, medications, fall prevention, and communication with healthcare providers. The Occupational Therapist (OT) evaluates the participant’s functional performance for safety and assesses the presence of environmental barriers. The OT then works with the handy-worker to coordinate minor home modifications, repairs, or supportive devices that will help the participants meet their goals.

Photo 2 Carol St. Luke CAPABLE Program 23

St. Luke CAPABLE program participant Carol Albright is seen using a recent home modification. The addition of a grab rail is just one of the safety features installed through the St. Luke CAPABLE Program. Albright had been working with the CAPABLE team to improve her ability to move safely around her home.

Working with the St. Luke CAPABLE team, Carol identified improved mobility in the home as one of her goals. She admitted, “Before, I would do things around the house, but sometimes it was a little dangerous.” Together the team worked with Carol on improving balance and health monitoring for a chronic condition which includes a regular review of medications, and coupled with home modifications she improved her ability to move safely around her home. “I am doing chores and I feel like I am able to be around to help my family.”    

CAPABLE was developed by the Johns Hopkins University School of Nursing, and in partnership with Colorado-based Care Synergy, a network of community-based home health care, hospice and palliative care providers, they administer the program and lend resources and expertise which support the over forty CAPABLE Program sites now operating in twenty-four States across the United States. St. Luke is one of six licensed sites in New York State and the only program in the Central New York area. The program is available to residents in Oswego County and northern Onondaga and Cayuga counties.

Marsh, the CAPABLE Program’s Registered Nurse, acknowledged that the community is fortunate in that that St. Luke Health Services is able to provide CAPABLE program services completely free of charge to older adults through grant funding secured through the Mother Cabrini Health Foundation.

As it grows in capacity St. Luke will demonstrate the value of the CAPABLE Program model as a cost effective intervention that enables older adults to remain safely in their own homes while decreasing hospitalizations and reducing healthcare costs.

Photo 3 Carol St. Luke CAPABLE Program 23“I would absolutely recommend CAPABLE,” said Carol. “I was thrilled with the great job everyone did. I have been here in my home in Lycoming for many years and this is where I plan on staying thanks in part to this program.”   

Marsh summed up the team’s philosophy, “We search for opportunities to continue and advance client-acquired skills from all prior treatment providers. Our intent is that our support and basic home modifications will address needs and bolster confidence.”

For more information about the St. Luke CAPABLE Program contact Jim Marsh, RN, Program Coordinator at 315-342-3166, or visit the CAPABLE Program page.