Care Synergy Becomes National Center for Johns Hopkins’ CAPABLE Program

The hospice, palliative care, and home health network Care Synergy has become the national center for the Community Aging in Place, Advancing Better Living for Elders (CAPABLE) program, developed by Johns Hopkins University.

CAPABLE is a patient-directed initiative designed to keep seniors in their homes through interventions designed to improve mobility, function, and quality of life. The Johns Hopkins School of Nursing launched CAPABLE in 2009 and since then has overseen the program nationally.

With this new agreement, Care Synergy will be taking over those management functions.


“We really do see the opportunity to make a difference in people’s lives — especially as people are aging — and you think of the costs associated with leaving their homes and going into assisted living or a long-term care environment,” Tricia Ford, vice president of operations for Care Synergy, told Hospice News. “In post-acute care, we see people further down in their health trajectory. If we could reach these people sooner, their lives could be longer, and their quality of life could be improved. It really makes sense to take this and expand it as much as we can.”

Care Synergy provides back-office and administrative support to a network of nonprofit, home-based care providers, primarily in Colorado. Its affiliates include the Colorado Visiting Nurse Association (CVNA), The Denver Hospice, Pathways, and Pikes Peak Hospice and Palliative Care, among others.

Care Synergy is also part of Responsive Care Solutions, an Accountable Care Organization (ACO) with 10 members nationwide, including hospice and senior services providers like Empath Health, Bluegrass Care Navigators, and Ohio’s Hospice.


Care Synergy was one of several organizations that threw their hats in the ring to become the new national center for CAPABLE. Their affiliate CVNA has participated in the program since 2017, and they first brought up the prospect of taking up the banner following a request for proposals from Johns Hopkins earlier this year, according to Ford.

After considering the idea and assessing their capabilities, Care Synergy reached out to Johns Hopkins. Within a matter of weeks, Ford was on a plane to Baltimore to participate in an interview process.

Care Synergy and Johns Hopkins finalized their agreement last week, and the transition became effective Oct. 1.

“This partnership comes at an exciting time,” Sarah Szanton, dean of the Johns Hopkins University School of Nursing, said. “CAPABLE has expanded rapidly over the past several years and untapped opportunities await. Care Synergy’s experience and expertise will complement our resources and serve to expand CAPABLE to even more locations across the country.”

CAPABLE is a five-month program during which the patient or client receives home visits from an occupational therapist (OT), a registered nurse (RN), and a home modifications contractor. These professionals collaborate with the individual in the home to identify their goals and design customized interventions around those objectives.

The program has developed a track record of reducing high-acuity health care utilization and assocaiated costs, according to a 2017 study in Health Affairs. Johns Hopkins reports on its website that CAPABLE can yield more than a six times return on investment.

CAPABLE began with a 2009 pilot at a Johns Hopkins site in Baltimore and since has expanded to more than 40 locations in 21 states. Now, the program is poised for further growth, Szanton told Hospice News. A number of states have or are planning to implement and scale CAPABLE using funds from the American Rescue Plan of 2021 or their Medicaid programs, including Connecticut, Massachusetts, Vermont, and Care Synergy’s home state of Colorado, among others.

The program has also attracted international interest, according to Ford.

“We have a site in Sydney, Australia already. In Nova Scotia, we’ve had a number of conversations. It just fits in so many different areas, because we don’t call it a medical model,” Ford told Hospice News. “Housing agencies are interested in it, and Medicaid. Medicare is thinking about it. There are so many different opportunities to save costs and improve the quality care that it generates interest in many different areas of government.”

As currently designed, CAPABLE is not adapted specifically for hospice patients. The program seeks to reach patients further upstream and is oriented towards the patients’ customized goals. This can include health care concerns like advance care planning and medication reconciliation, as well as matters like installing better kitchen lighting or supporting sufficient mobility to complete daily tasks.

That said, opportunities may exist down the road for closer collaborations with palliative care.

“Hospice is ahead of the rest of medical care in terms of aligning care with what matters to people, focusing on their symptoms, and allowing them to be as independent as they can in the time they have,” Szanton told Hospice News. “So when we started off, we required that participants not have a terminal illness. As the world is switching more to palliative care and thinking about palliation as a long process and not something that’s within the last six months of life, I think there is a much stronger fit between the two.”

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