Implementing CAPABLE in Permanent Supportive Housing
Phase: NA
Conditions: Accidental Fall, Frailty, Depression, Activities of Daily Living, Housing Problems
Sponsor: University of Southern California

Title: Implementing CAPABLE in Permanent Supportive Housing 
NCT number: 04076319 
 
 
 
 
Document Type: Study Protocol with Statistical Analysis Plan 
Document Date: 26 February 2024 

Specific Aims 
Permanent supportive housing (PSH) using a Housing First approach is an evidence-
based intervention to end chronic homelessness by providing low-barrier affordable housing 
paired with flexible health and social services.1 In Los Angeles County (LAC), where the 
number of PSH units is expected to increase dramatically over the next 10 years,2 clinical 
guidelines and standards for support services are lacking. This is especially problematic given 
that the target population is older and prematurely ageing. The chronically homeless population 
in the United States has an average age approaching 60 years old3 and experiences accelerated 
aging,4 including an elevated prevalence of geriatric syndromes such as functional impairment, 
falls, and urinary incontinence that can jeopardize PSH tenants’ ability to live independently and 
age in place.5–7 Current support services are not equipped to address these needs, which 
ultimately jeopardizes the success of PSH to maintain high rates of housing stability while 
tenants “age in place.”8 
We proposed conducting a pilot project to implement the CAPABLE model in PSH. 
CAPABLE, which stands for Community Aging in Place—Advancing Better Living for Elders, 
is a client-directed, home-based intervention that consists of time-limited services (no more than 
6 months) from an occupational therapist (OT), a nurse, and a handyman working collaboratively 
with the older adult client.9 CAPABLE was developed to support older adults who are returning 
to independent living after hospitalization and has been shown to improve functioning (activities 
of daily living [ADLs] and instrumental activities of daily living [IADLs]), decrease falls and 
nursing home admissions, and reduce health care costs based on multiple studies including 
several randomized controlled trials.9–17 CAPABLE has the potential to be used in PSH as a 
model of support services that can address needs of prematurely aging tenants, which could help 
transform PSH from an intervention that ends homelessness to an intervention that addresses 
homelessness and supports successful aging in place. 
 
The specific aims of this study were to: 
1. Examine the impact of CAPABLE on PSH client outcomes (e.g., ADLs, IADLs, 
falls). This aim was accomplished using a pre–post design with a waitlist control 
group. 
2. Determine what adaptations, if any, need to be made to implement CAPABLE in 
PSH. We accomplished this aim by using the dynamic adaptation process (DAP) 
implementation approach, which was designed to allow for an evidence-based 
practice to be adapted in a planned and considered, rather than ad hoc, manner. 
 
Background and Significance 
The chronically homeless population in the United States represents a stable, aging 
cohort whose functional age is significantly older than its chronological age.3,18 Born at the 
end of the baby boomer generation, this predominantly male and African American population 
first became visible in the 1980s. More than three decades into the homelessness crisis, nearly 
half of homeless adults are aged 50 or older, a significant increase from only 11% in the early 
1990s and 32% in 2003.3,18 Homeless adults aged 50 or older have chronic disease rates like 
housed adults aged 65 or older.4,19–21 Homeless adults also have a higher prevalence of geriatric 
syndromes (e.g., functional and cognitive impairments, frailty, depression, hearing and visual 
impairments, urinary incontinence) compared to population-based samples that are 2 decades 

older.4,22 Such premature aging has resulted in homeless adults having age-adjusted mortality 
rates three to four times higher than housed adults.23,24 
 
PSH has become the leading homelessness policy in the United States regardless of 
age. PSH refers to immediate access to affordable, independent housing along with home- and 
community-based services that are intended to support a population with complex behavioral 
health and social needs.25,26 PSH through a Housing First approach has been recognized as the 
“clear solution” to chronic homelessness by the U.S. federal government.1 This represents a 
remarkable policy shift during the past decade from a previous focus on shelters and transitional 
housing. PSH has been shown to increase quality of life27,28 and reduce overall public costs by 
removing people from the institutional circuit of hospitals, jails, shelters, and life on the 
streets10,3 and placing them in independent community living.29–31 In 2013, there were more than 
280,000 PSH units across the country, a figure that has been increasing by an average of more 
than 10,000 units annually since 2006.32,33 In LAC, local health service systems and tax 
initiatives are supporting the development of more than 20,000 units of PSH over the next 10 
years.2 To date, there has been limited research that considers whether and how PSH programs 
can help residents maintain independent living as they age (i.e., “age in place”).8 
 
A significant portion of the population that now resides in PSH is at high risk of 
premature onset of geriatric syndromes, which can jeopardize aging in place. Prior research 
with currently homeless adults suggested that PSH residents experience early onset of geriatric 
syndromes at disproportionately high rates.7,22 This was confirmed in the only study to explore 
rates of geriatric syndromes among PSH tenants.22 Geriatric syndromes, which are often 
multifactorial and cross discrete disease categories, can undermine the significant investment in 
PSH in cities across the United States.34 High rates of geriatric syndromes among the increasing 
number of adults who have transitioned from homelessness to independent community living 
will likely result in higher health care utilization and increased morbidity, mortality, and 
institutionalization.25-29 The recognition that PSH tenants will face challenges aging in place has 
only recently been articulated.22,27 To date, research has not examined the capacity of PSH to 
address geriatric syndromes. 
 
CAPABLE is an evidence-based practice designed to address many of the geriatric 
conditions experienced by PSH tenants. CAPABLE is approved by the National Council on 
Aging as an evidence-based falls prevention program and is recognized by federal and state 
agencies as an effective program for improving health and decreasing costs among older adults.10 
As of August 2018, CAPABLE is being offered through programs in 22 organizations across 12 
states in the United States and Australia.11 CAPABLE has the potential to be used in PSH as a 
model of support services that can address needs of prematurely aging tenants. 
 
Preliminary Studies 
Tenants Aging in Place (TAP) study (R21AG050009; PI: Henwood). As part of the PI’s 
recently completed NIA-funded R21 study, 237 adults aged 45 or older were recruited from two 
PSH agencies in Los Angeles, California. Residents completed in-person interviews on 
demographics, housing and homelessness history, and overall health status. We also assessed 
common geriatric syndromes. Despite their average age of only 57 years old, we found 42% of 
respondents had difficulty performing ADLs (e.g., bathing, dressing) and 68% reported having 

difficulty performing IADLs (e.g., taking transportation, managing medication). More than half 
of the sample (56%) had experienced one or more falls in the past year.22 Based on these 
findings and with the support of a planning grant from the Unihealth Foundation that covered 
staff time at our partner organizations, during the past 12 months, we have explored existing 
evidence-based practices that have potential to meet the needs of older adult PSH tenants. The 
CAPABLE model was determined to be the best fit given client needs and existing 
organizational capacity. 
 
Methods 
For this study, we worked with one of our existing community partners, the Skid Row 
Housing Trust (SRHT), to pilot the CAPABLE model. SRHT had the required staffing for 
CAPABLE, including an advanced practice OT staff member, nurses from LAC DHS who are 
assigned to SRHT tenants through their existing Housing for Health program, and existing 
handyman resources. CAPABLE training is required for nurses and OTs, which will be provided 
by our partners at Johns Hopkins University, where the intervention was developed. The training 
took approximately 20 hours to complete and included: five 60-minute on-line learning modules 
(self-paced, recommended to be completed over the course of two weeks); up to an 8-hour live 
(virtual) training; and five coaching calls or webinars. The implementation of CAPABLE over 6 
months was used to accomplish both study aims. 
The program was initially scheduled to begin in March 2020 but due to the onset of the 
COVID-19 pandemic was delayed until February 2021. During this time, study measures were 
updated to be maximally consistent with other CAPABLE studies in collaboration with Johns 
Hopkins School of Nursing (JHSN) that provided Electronic Data Capture (REDCap) data 
dictionaries. JHSN also provided on-line CAPABLE training to RNs and OTs along with 
ongoing technical assistance phone calls throughout the project. For this pilot, the trained OT 
was a full-time staff member at the PSH agency, and the two trained RNs worked part-time 
through an online scheduling platform with oversight from a local federally qualified health 
center. 
Site description. SRHT is one of the largest providers of PSH in LAC. Founded in 1989, 
the SRHT operates nearly 1,600 housing units in 24 buildings, providing housing for nearly 
1,200 adults aged 50 or older. SRHT predominantly serves adults with disabilities who are high 
utilizers of public health or mental health services. SRHT employs approximately 75 support and 
medical staff members, including case managers, program managers, paraprofessionals, 
substance abuse professionals, OTs, social workers, psychologists, psychiatrists, nurses, primary 
care physicians, and a hoarding specialist.4 
 
Aim 1: Examine the impact of CAPABLE on PSH client outcomes. 
Implementation of CAPABLE. We trained two registered nurses (RNs) and an OT to 
handle a caseload of 50 PSH tenants. In most cases, the OT made six visits, the RN made four 
visits, and a handyman made one to two visits to modify the client’s home during a 6-month 
period. However, the program can be completed in fewer visits, with a minimum of four OT 
visits and three RN visits. CAPABLE home visits are key to meeting participants “where they 
are.” The first visits for the OT and RN were usually 90 minutes each, and the later ones are 
usually an hour each. Visits are spaced to enable older adults to practice new strategies learned in 
the previous visit. Visits were allowed to be rescheduled given unforeseen circumstances. There 
was a clear conclusion or graduation, with the older adult understanding how to use their new 

skills and apply them to future situations.10 For this study, we planned to recruit 100 eligible 
SRHT tenants. As a result, a waitlist control design was used, for a case-crossover between- and 
within-subject comparison of the CAPABLE intervention effect.  
Participant recruitment and data collection. Starting in December 2020, the PSH support 
staff began identifying eligible participants for the CAPABLE program. PSH tenants were 
eligible for the study if they were over the age of 50, had some or a lot of difficulty performing 
ADLs, and were cognitively intact or had only mild cognitive impairment. Tenants who were 
perceived to meet these criteria received details about the CAPABLE program from the trained 
OT, who also asked whether tenants would be interested in participating in a study. Interested 
tenants were referred to the research team to be screened to confirm eligibility status, obtain 
informed consent, and randomly assigned to either the intervention or waitlist control group 
using a random number generator.  
Between December 2020 and January 2021, 75 PSH tenants were referred to the research 
team. Fifteen PSH tenants declined to participate, resulting in 60 individuals who answered a 
survey-administered baseline assessment and were randomized into the intervention or waitlist 
control group. The CAPABLE team then received the list of 30 tenants randomized to initially 
receive the intervention. Two tenants decided they no longer wanted to participate in the 
program and one could not be recontacted (the team later discovered this person had died), 
leaving 27 who received the intervention starting in February 2021. In June 2021, the 30 tenants 
in the waitlist control group completed a follow-up research assessment, along with the 17 who 
had finished the CAPABLE intervention at that time. By September 2021, the remaining 10 
tenants all completed the CAPABLE program but only nine had completed the follow-up 
research assessment; one person declined to complete but was contacted 6 months later and 
completed the follow-up assessment at that time. 
Most intervention visits occurred in person at the participant’s residence (a few visits by 
the nurse were conducted by phone if the tenant was able to share progress and could follow 
guidance through this format). All research data collection was conducted by telephone as part of 
COVID-19 safety protocols. PSH tenants received a $20 gift card for completing the baseline 
assessment and a $25 gift card for completing the follow-up assessment. 
All data were collected and managed using the REDCap platform. Measures collected 
only at baseline included demographic characteristics, years in current PSH unit, and cumulative 
years spent homeless. Tenants were also asked about history and number of falls, emergency 
room visits, and overnight hospitalizations within the last year at baseline; these items were 
asked again at follow-up but used only a 6-month retrospective. Additional health-related 
outcomes measured at baseline and follow-up included information on: ADLs and IADLs; falls 
efficacy; depression; pain interference with usual activities; self-rated health; and overall quality 
of life. A description of primary outcome measures are included in the following table: 
 
Table 1. Description of primary outcome measures. 
 
Measure 
Description 
Katz Activities of 
Daily Living Scale 
The modified Katz ADL Scale was used to rate ability to bathe, 
dress, transfer, toilet, and eat using three categories: no difficulty, a 
little or some difficulty, or a lot of difficulty or inability to perform.36 
The Brief Instrumental 
Functioning Scale 
The Brief Instrumental Functioning Scale was used to assess ability 
to perform six IADLs on a scale similar to the Katz ADL Scale.37 

Falls 
History of falls during the past year was assessed by asking: “Did 
you fall to the ground in the past year?” 38 The number of falls in the 
past year was also assessed. 
Falls efficacy 
Participants rated their confidence they could do each of 10 
activities without falling on a 10-point scale, with total scores 
ranging from 10 (not very confident) to 100 (very confident) using 
the Tinetti Falls Efficacy Scale. 
Depression 
Eight of the nine items in the Patient Health Questionnaire-9 were 
used to measure depression, rated on a 4-point scale of how 
frequently participants were bothered by the eight problems during a 
2-week period (0 = not at all, 1 = several days, 2 = more than half 
the days, and 3 = nearly every day). 39 Items were summed to obtain 
a score with minimum and maximum values of 0 to 24, respectively, 
whereby higher scores represent greater depressive symptoms. 
Pain interference with 
usual activities 
Pain interference with usual activities was assessed using an item 
from the 3-item PEG to assess average pain intensity (P), 
interference with enjoyment of life (E), and interference with 
general activity (G) on a 10-point Likert scale from 0 (does not 
interfere) to 10 (completely interferes). 
 
 
Statistical Analysis Plan. We conducted a power analysis using G*Power to estimate the power 
obtained with 100 individuals proposed for this pilot. When specifying an effect size of .30 and a 
correlation among repeated measures of .70, 70 participants across two groups were needed to 
achieve an exact power of .80. This allowed our study to have up to a 30% overall dropout rate 
while maintaining sufficient power. 
The balance between the intervention and control groups at baseline was assessed using 
Fisher’s exact test for nominal variables, the Cochran–Mantel–Haenszel test for ordinal 
variables, and two-sample t-tests for continuous and count variables. Given that the main 
analytic goal of this pilot study was to consider the effect size of the intervention, we calculated 
within- and between-group standardized mean differences (Cohen’s d) between time points. 
These tests were also used to compare differences in falls, ER visits, and hospitalizations 
between the groups at follow-up. To consider statistically significant changes in key outcomes in 
each study group (i.e., intervention versus control) between baseline and follow-up, we also used 
paired t-tests. Between-group analyses included a two-sample t-test to test whether the mean 
change in outcomes between baseline and follow-up differed between the intervention and 
control groups.  
Aim 2: Determine what adaptations, if any, need to be made to implement CAPABLE in 
PSH. 
Adaptation of CAPABLE. Following the DAP implementation approach, which was 
designed to allow an evidence-based practice to be adapted in a planned and considered, rather 
than ad hoc, manner,40 our investigative team monitored the implementation of CAPABLE and 
worked in conjunction with program leaders, clinicians, clients, county health systems, and 
model developers to make any adaptations to the model that would also preserve fidelity to core 
components. For example, we expected that within PSH, CAPABLE would need to include 

collaboration with existing PSH case workers and social workers. DAP is a continuously 
iterative process, in that ongoing experience can inform continued adaptation as needed. 
Although DAP can be used during all four phases of the implementation conceptual model 
known as EPIS (i.e., exploration, preparation, implementation, and sustainment),41,42 this study 
focused on two of the phases: preparation and implementation. The initial exploration phase was 
completed as part of our previous work (see Preliminary Studies section), and the 
implementation phase represents this next step.  
Data collection and monitoring. The investigative team (Henwood and Pitts) had primary 
responsibility for monitoring the implementation of CAPABLE through weekly case reviews and 
note taking on any possible deviations from the model. The investigative team met monthly with 
the larger implementation resource team (IRT), which included the developers of the CAPABLE 
model, via a conference call to discuss fidelity to CAPABLE and consider adaptation needs. 
With DAP, adaptations were explicit and done in a planned way by the IRT, in conjunction with 
service providers and coaches, to preserve fidelity to core components. This was accomplished 
by reviewing weekly implementation monitoring with the IRT. Discussion and decisions were 
documented through an ongoing audit trail.43  
Data analysis. At the end of the implementation phase, the IRT reviewed all 
implementation decisions documented in the audit trail and determined what adaptations of 
CAPABLE should be included for PSH. These decisions were formalized through a written 
manual to be used for future implementation and research projects. 
 
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