Strategic Scaling & Sustainable Funding for National Aging-in-Place Care
Project overview
Key challenge
CAPABLE is a proven aging-in-place program developed by Johns Hopkins, operating across 39 sites nationally with high client satisfaction.
Despite its impact, the program faces unstable funding. A core barrier is the complexity of the landscape itself — fragmented funding streams, workforce dynamics, and knowledge flows across sites make it difficult for both the national center and local sites to see the full picture and act strategically.
Clients
Johns Hopkins School of Nursing
CAPABLE National Center
CAPABLE local sites
Outcome
Our team mapped out complex ecosystem of aging-in-place where CAPABLE operates in for knowledge sharing, and designed strategic opportunity direction & concepts. These strategies cover 4 core dimensions of securing funding with new business model, leveraging impacts & facilitating the program.
Impact
The report and visual artifacts has been used by CAPABLE at aging conferences to communicate the program
Report and diagrams adopted by 30+ local sites as a reference tool
Industry
Healthcare
Eldercare
Non-profit
Time
Feb - May 2025
14 weeks
Team member
Yanting Wang
Samantha Chandra
Daniela Velez
Anushree Joshi
Ashlyn
Akshay Pagar
June Pruk
Kristin John
My Role
Conduct design research
Synthesize research into diagrams
Draw illustration as facilitation
Develop funding strategy
Tool
Figma & FigJam
Procreate
Excel
Indesign
Microsoft office
NotebookLM
Claude
Chatgpt
Skill
Interview
System mapping
Journey mapping
Information design
Illustration
Facilitation
The Story
Context
In the evolving field of community health, Johns Hopkins School of Nursing, faced a challenge:
How to scale CAPABLE,
a non-profit aging-in-place program nationwide amid fragmented and unstable funding with widely varying local conditions.
There are currently 38 CAPABLE sites across the country.
Why Scaling CAPABLE Matters now?
Industry trend
Our aging society:
People wants to age with dignity and comfort
Compared with nursing home, aging in place is both preferred and cost-effective, yet access remains limited by fragmented care systems and underfunded services.
CAPABLE has demonstrated measurable reductions in hospitalizations, improvements in daily living activities, and cost savings of over $15,000 per participant for Medicare.
Problems
Varying local conditions hinder standardization and overwhelm implementers.
“There is no ‘standard CAPABLE.’
Every site adapts to its own constraints and resources.” – Strategic Partnership Specialist at CAPABLE National Center
“It’s not just one party working with another. It’s two different city departments that may or may not have a lot of connection with each other. They may or may not normally work together... and at one point, there were like eight or nine different people I was talking to, all delegates of the Department of Housing. So yes, it was very, very complex.”
- CAPABLE Program Administrator, City Government Agency.”
Unstable, time-limited and braided funding threatens sustainability
“Our ARPA funding actually expired at the end of December 2024... I know the Mayor’s Office for Persons with Disabilities is also interested in the CAPABLE model, just to see if there may be other funding opportunities to replicate the model.”
– CAPABLE Program Administrator, City Government Agency
“There’s no like package (of funding) that includes the OT, the nurse and the home mods, so each individual portion of CAPABLE is covered by a different bucket of money, or pocket of money, and that’s where the problems occur.”
– Strategic Partnership Specialist at CAPABLE National Center
Process overview
My work highlights
Conduct research and analysis for funding flow; design model prototypes (federal to local funding flows, Kentucky local site model, and value map)
Create Illustration for team facilitation & stakeholders communication in strategy development and final report
Develop strategy concepts framework for team and the funding strategy concept
Synthesis process deeper dive
Identifying dependencies
Within every system, interconnections exist among various elements (such as objects, people, and ideas).
While these relationships aren’t necessarily comprehensive, we 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—in
other words, principles for growth.
Offload Work
We offload work from the center to the edges
Foster Alliances
We build strong alliances with people who share our values
Showcase Impact
We are loud about showing our impact
Systems-Level Data
We prioritize collecting data of the system, not just about client results
Knowledge Sharing
We make knowledge sharing across the system easier
People Empowerment
We empower, celebrate, and take care of the people in the system
Solutions overview
With these barriers identified from research, we use diagram models to map out the current systems and design 4 strategic directions
Problems
Varying local conditions hinder standardization and overwhelm implementers.
Unstable, time-limited and braided funding threatens sustainability
Solutions
Solutions dive-in
Modeling the CAPABLE Ecosystem
The 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
Key insights:
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.
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 CAPABLE Local Site Map
To better understand local variations, we studied 4 CAPABLE sites in the U.S to uncover site and stage-specific insights.
The Kentucky site model — the site where I conducted primary research, is shown here as an example.
Then we highlight the facilitators and barriers of each local sites.
Translating insights into strategy concepts
To achieve sustainable national growth, CAPABLE must:
Secure and diversify funding sources while stabilizing site operations.
Facilitate smooth program delivery, reducing onboarding friction and workforce gaps.
Leverage and communicate impact to strengthen policy and public support.
Strategy for Growth
CAPABLE Commons
Bringing Aging-in-Place Services to Senior Housing
Offload Work
Foster Alliances
Partnering with housing developers and property managers to diversify funding resources and reduce traveling costs of medical staff
CAPABLE Compas
Activating readiness through contextualized guidance
Offload Work
People Empowerment
A tool that transforms the established “Initial Implementation Readiness Self-Assessment" into a digital platform that enhances the implementation journey for the CAPABLE sites.
CAPABLE InsightHub
Developing cohesive team connection and data practices
Systems-Level Data
Showcase Impact
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.
Data Story Engine
Building support by linking goals and data through engaging narratives
Offload Work
Foster Alliances
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.