CAPABLE Care + Connect : A Qualitative Study to Adapt CAPABLE for Home-Based Primary Care and Foster Social Connection

Abstract

Fostering social connection among homebound older adults and their care partners presents a distinct challenge. Evidence on strategies to address social isolation and functional impairment for homebound individuals is limited. This study aims to inform adaptation and implementation of the CAPABLE program within a home-based primary care practice. We conducted interviews with older adults, care partners, CAPABLE clinicians, and home-based primary care staff (n = 12). We explored factors influencing social connection and program implementation for a home-based primary care population. We identified facilitators of social connection, barriers to social connection, conditions contributing to social isolation, and strategies to foster social connection for homebound older adults and their care partners. Results will inform CAPABLE adaptation and integration within a home-based primary care setting. An implication of this work is demonstration of the potential impact of CAPABLE on social connection for homebound individuals and care partners.

What This Paper Adds

• Unaddressed mood disorders, sensory impairments, and social needs can contribute to and exacerbate social isolation among homebound older adults with functional difficulties.

• Communication tools and in-person visits with trusted entities can facilitate social connection for older adults who are homebound and their care partners.

• The PRISM/RE-AIM framework can be applied to a pre-implementation qualitative research study designed to inform program planning and intervention adaptation.

Applications of Study Findings

• The social work and psychology disciplines can promote access to mental health services and mitigate the non-medical needs of homebound patients and care partners in HBPC.

• Client-driven goal setting and individualized care planning are valuable features that enhance the effectiveness of community-based interventions like the CAPABLE program.

• This study builds on momentum to improve home and community-based services for aging populations and care partners by filling a gap in care and support.

Introduction

Older adults with physical dependency and economic constraints often encounter barriers in accessing healthcare despite demonstrating a considerable demand for medical care services (Ramraj & Logaraj, 2021). Approximately two million older Americans are completely homebound (Ornstein et al., 2015). This is greater than the nation’s institutionalized nursing home population of 1.3 million (National Academies of Sciences, Engineering, and Medicine [NASEM], 2022a). Homebound older adults experience higher rates of cardiovascular, cerebrovascular, neurocognitive, and musculoskeletal diseases (Qiu et al., 2010).

Older adults who are homebound face various challenges that hinder their ability to function in and leave their homes, such as mobility limitations, chronic comorbidities, and a lack of social support (Ko & Noh, 2021). 1 in 4 older adults are socially isolated and approximately 40% experience loneliness (Cudjoe et al., 2020; Cudjoe & Kotwal, 2020). Older adults who are homebound are at particular risk for social isolation and loneliness due to reduced size and diversity of social networks, reduced frequency of social contacts, changes in living arrangements or environment (e.g., residential moves), changes in health status, and loss or bereavement (NASEM, 2020; Qiu et al., 2010). Social isolation poses significant public health concerns, given its adverse effects on wellbeing including accelerated cognitive and functional decline, poorer mental health, more frequent hospitalization, increased healthcare costs, and mortality (Cole & Nguyen, 2020; Cudjoe et al., 2022; Gale et al., 2018; Shankar et al., 2017). However, identifying ways to foster social connection among older adults, particularly homebound individuals, presents unique challenges and barriers (NASEM, 2020). Addressing barriers to social connection may assist older adults who are homebound with accessing care and assistance to support remaining in their homes and communities as they age.

Home-based primary care (HBPC) delivers longitudinal, interdisciplinary medical care to frail patients (Ornstein et al., 2011). The HBPC delivery model offers high-quality, cost-effective, person- and family-centered care for those who have significant difficulty with leaving their homes and with accessing traditional outpatient primary care services (Schwabenbauer et al., 2021). HBPC offers a unique window into the lives of frail, homebound populations and focuses on their medical, functional, and social needs (Kim & Jang, 2018; Ritchie & Leff, 2018). The prevalence of social isolation necessitates that HBPC practices consider evidence-based strategies to address physical dysfunction as well as social isolation through home and community-based interventions.

The HBPC program of a large healthcare center in Baltimore, Maryland, USA is the primary context for this study. This practice employs an interdisciplinary team to provide primary care services to older adults who are homebound in urban and suburban neighborhoods in and around Baltimore, Maryland. The team consists of physicians, nurse practitioners, registered nurses, community health workers, medical assistants, rotating medical trainees (residents and fellows), and administrative coordinators. Their goal is to address primary care needs in the home, reduce care burdens, reduce the strain of complicated transport challenges, and eliminate the foregoing of primary care due to inaccessibility.

HBPC patients can face mobility limitations and social isolation related to the layout of their homes while care partners often experience significant care tasks and responsibilities (LaFave et al., 2021). The CAPABLE Care + Connect intervention intends to build on the growing body of literature examining the effectiveness and adaptability of the CAPABLE (Community Aging in Place, Advancing Better Living for Elders) program in different care settings. The purpose is to make the home environment more functional and make the lives of homebound older adults and care partners more meaningfully connected. The CAPABLE program is a multi-component behavioral and home repair intervention for functionally impaired community-dwelling individuals that has demonstrated its ability to improve activities of daily living (ADL) performance, instrumental activities of daily living (IADL) performance, and depressive symptoms (Szanton et al., 2016). CAPABLE is a 4-month program comprised of 10 home visits from nurses (RN), occupational therapists (OT), and handy workers. Comprehensive assessments and tailored goal setting are conducted to address mobility, self-care, ADLs, and IADLs. Handy workers provide home repairs and modifications. CAPABLE has been recognized for its effectiveness in improving independence and safety for older adults, particularly those who are homebound and experiencing functional difficulties (Szanton et al., 2021). To date, there are 39 CAPABLE program sites, including rural, suburban, and urban locations across 22 states.

CAPABLE Care + Connect aims to address the needs of older adults experiencing impaired physical function and limited social connection by complementing an existing HBPC program. Complementing an established HBPC practice with the CAPABLE intervention could provide an enhanced mechanism to support health, function, and social connection within an integrated delivery model. The CAPABLE Care + Connect program will test the implementation of CAPABLE within the infrastructure of HBPC. It will focus on older adults and their care partners who are at risk for or experiencing social isolation and/or loneliness. This qualitative study was conducted to elicit stakeholder insights, feedback, and observations. We used qualitative methods to identify adaptation strategies for integrating CAPABLE within HBPC, two evidence-based models for improving the lives of older adults (Holtrop et al., 2018).

Methods

Study Design

This paper describes the study conducted to determine adaptation strategies for implementing CAPABLE in a HBPC practice and to explore the experiences of social connection among HBPC patients and their care partners. We garnered perspectives on two areas to inform intervention adaptations. The first was social isolation, loneliness, and unmet social needs for older adults who are homebound and their care partners. The second was CAPABLE intervention implementation within an HBPC practice context. We conducted 12 semi-structured interviews with diverse stakeholders including older adult HBPC patients, care partners of HBPC patients, CAPABLE program clinical providers, and HBPC clinical and non-clinical staff members. All patients and care partners were recruited from the HBPC practice. Respective care partners were designated as such by HBPC patients themselves or by HBPC staff.

Setting and Participants

The eligibility criteria for HBPC patients included in this study are as follows: (1) Enrolled in HBPC for at least 6 months prior to date of consent; (2) Age 65 years or older; (3) At risk for or experiencing social isolation or loneliness as defined by a Lubben Social Network Scale 6-item score less than or equal to 12 points (Lubben et al., 2006) or a UCLA Loneliness Scale 3-item score of 6 to 9 points (Hughes et al., 2004); (4) Normal cognition or mild cognitive impairment as defined by a MoCA (Montreal Cognitive Assessment) score of greater than 23 points (Nasreddine et al., 2005); (5) English speaking; (6) Ability to participate in 45–60 min virtual or in-person meeting. Patients were excluded if they were a previous CAPABLE program participant within the last 2 years. The eligibility criteria for care partners included in this study are as follows: (1) Identified as an unpaid care partner or family caregiver of the patient by either the patient themselves or by referring HBPC provider; (2) Provides at least 5 hours of direct care per week; (3) Able to participate in a 45–60 min virtual or in-person meeting; (4) English speaking.

Participants from the selected program site were recruited via snowball sampling and purposive sampling techniques (Sadler et al., 2010). While we recognize the risk of bias with non-probability sampling, our researchers found this strategy useful for an understudied and hard-to-reach population. The eligibility criteria for CAPABLE clinical providers were: (1) Completed the online training modules necessary to provide CAPABLE intervention services; (2) Served CAPABLE program patients within the last three years; (3) Able to participate in a 45–60 min virtual or in-person meeting; (4) English speaking. The eligibility criteria for HBPC staff members included in the study are as follows: (1) Participated in HBPC for at least 6 months; (2) Able to participate in a 45–60 min virtual or in-person meeting; (3) English speaking. Those who expressed interest and availability were scheduled and verbally consented. The learnings generated from this study will directly inform the adaptation and implementation of one specific CAPABLE program site in the hopes of demonstrating how this home-based intervention could be incorporated into other similar home-based primary care practices.

Enrollment

Initial screening for patient eligibility was performed by referring HBPC providers. The CAPABLE Care + Connect research program coordinator determined and confirmed whether the referred patient or care partner met all eligibility criteria. After the referral, patients or care partners were contacted by telephone. A telephone script was used by the administrative member of the research team to describe the study to the potential participant and obtain verbal consent. This administrative member of the research team scheduled the interviews via Zoom teleconference with the primary interviewer and notetaker. The primary interviewer was an advanced practice provider with clinical experience in HBPC and formal training in qualitative methods. The notetaker was a Registered Nurse with formal training in qualitative methods and experience in research focused on older adults with disabilities. Each participant who completed an interview received a US$50 gift card.

Data Collection

We developed a semi-structured interview guide divided into two sections: (1) Social isolation for older adults who are homebound and care partners and (2) CAPABLE adaptation for the HBPC setting. The PRISM (Practical Implementation Sustainability Model)/RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework guided the section about adapting CAPABLE for this HBPC setting to ensure contextual factors and domains of implementation science were considered (Holtrop et al., 2021; Jolles et al., 2024). Questions were developed initially with input from our institutional expert stakeholders and research team members. The semi-structured interview guide was drafted by our core team of researchers. This draft was shared with a larger cadre of geriatric clinical and social service experts for feedback. Small iterative revisions were made based on this feedback. These changes included simplifying language, reordering questions, and tailoring scripted information sections and question structure to each interviewee role. Interviews were conducted from January to April 2024. We iteratively adjusted the questions during the early interview period based on feedback to improve clarity of wording and improve flow of format. For the social isolation interview section, questions focused on learning about personal or observed experiences with social isolation as well as potential strategies to address social isolation and foster social connection within the context of the CAPABLE program. For the adaptation interview section, questions focused on strengths and challenges of integrating the programs, referral and communication processes, and mitigation of barriers to adaptation (King et al., 2020).

Data Analysis

We used rapid qualitative analysis approaches described by Lewinski et al. (2021). The qualitative analysis process was adapted from the existing literature and was conducted with the intent to organize, reduce, and synthesize narrative data collected via transcribed interviews into coded themes (See Table 1 for details). Structured notes were taken as a preliminary step to coding extracted sections of text. The use of qualitative data analysis software was not indicated. Our goal was thematic information saturation, and our focus was on feasibility rather than generalizability at this juncture.

Table 1.

Rapid Qualitative Analysis Approach

Step 1	Create interview guides	- Tailor interview guides to each stakeholder role. - Conduct interview using the semi-structured interview guide informed by PRISM/RE-AIM framework and team member expertise on HBPC and CAPABLE models.
Step 2	Collect primary data	- Record and transcribe interview recordings automatically via Zoom technology and save. - Take simple electronic notes using template created and organized in order that questions are asked to help summarize the interviews.
Step 3	Post-interview debrief	- Primary interviewer and note taker debrief via Zoom immediately after interview. - Give feedback regarding how the interview progressed, including whether improvements can be made to our approach. - Iteratively revise the interview guide based on data collection experiences and responses to make it clearer and more concise. - Review and discuss notes summarizing the interview. - Decide whether additional information power is needed in the form of more key informant interviews.
Step 4	Data extraction and reduction	- Use all interview summary notes to create and fill in the data extraction tables sorted by each participant ID. - Interviewers meet simultaneously to identify and select key sections of text including takeaways, illustrative quotes and highlights from each interview’s reduced data. - Key takeaways, surprises and salient quotes are put into the data extraction table organized by each interview guide question/probe. - Assign a neutral name or tag to each question that will be used later to help sort extracted content.
Step 5	Analysis matrix and coding	- Create matrix in Microsoft Excel with rows for each participant ID. - All extracted sections of text are entered into matrix. - Sort extracted content by participant ID and neutral name or question tag. - For validation, the coders selected one interview and double-coded the same interview for comparison. - The remaining interviews were divided evenly between analysts for the first round of independent, deductive coding using different colors and code names. - After the first round of coding, the analysts meet to review, discuss, interpret and revise codes together. - Consolidate themes and recognize patterns. - Consolidated themes and key takeaways are brought back to the larger research team for further inquiry, discussion, and feedback. - Synthesize findings.

All selected sections of text from the individual interview summary notes forms were entered into one common matrix for all 12 participants. The interviews were then evenly divided between the two analysts for the first round of independent, deductive, and inductive coding. After the first round of coding, the analysts met to review, discuss, interpret, revise, and validate each other’s assigned themes, and code names. Decisions were made during those iterative meetings to consolidate themes while also recognizing patterns and synthesizing findings. These consolidated themes were then brought before the larger research team for further inquiry, discussion, and feedback. Investigators worked as a team to ensure that their collective knowledge and expertise guided the analysis. The entire research team engaged in a collaborative manner.

Results

Table 2 displays the demographic characteristics for all study participants. Two patients were interviewed; one was female. Three care partners were interviewed; one was male. All seven staff members interviewed were female. All patients identified as White non-Hispanic. Nearly 70% (66.7) of care partners identified as White non-Hispanic. Over one-quarter (28.6%) of staff members identified as Black non-Hispanic. Most care partners were the adult children of HBPC patients (66.7%). The average HBPC patient age was 85.5 years, and the average care partner age was 64.7 years.

Table 2.

Participant Demographics

Characteristics	Staff members(n = 7)	HBPC patients (n = 2)	Care partners(n = 3)
Female (%)	100.0	50.0	66.7
Age, M (in years)	47.7	85.5	64.7
Self-identified race and ethnicity (%)
Black Non-Hispanic	28.6	0	33.3
White Non-Hispanic	71.4	100.0	66.7
Staff relationships
CAPABLE program staff (%) Role (#)	n = 2 (28.6)	​	​
PT/OT	1	​	​
RN	1	​	​
HBPC practice staff (%) Role (#)	n = 5 (71.4)	​	​
NP	1	​	​
Admin	2	​	​
PT/OT	2	​	​
Care partner relationships (%)
Sibling	​	​	1 (33.3)
Adult Child	​	​	2 (66.7)

Six common themes emerged inductively from interviews and discussions with all participants about social connection experiences. These six social connection themes and illustrative quotes are described below. In Figure 1, we display identified risk factors for social isolation and barriers to social connection for older adults who are homebound and their care partners. These risk factors emerged from discussions and perspectives about social connection and social isolation during our interviews. Key takeaways and strategies are highlighted related to implementation in the HBPC setting and adapting the CAPABLE program for the HBPC practice. In Figure 2, we provide a graphic depiction of these additional learnings related to implementation and adaptation strategies with some explanatory quotes.

Figure 1.

Risk Factors for social isolation

Figure 2.

Adapting the CAPABLE to HBPC practice setting

Theme 1: Prioritizing Care Needs Over Social Needs

This theme emerged revealing the experience of prioritizing daily care needs and activities of daily living over social connection needs due to time and energy constraints. When discussing the adverse impacts of homebound status on social connection, HBPC patients and care partners emphasized that the important need for human relationships and interactions is often left unmet when the functional challenges faced by homebound populations take precedence during day-to-day activities. While acknowledging the rewarding and gratifying nature of caring for loved ones, care partners also emphasized the voluntary sacrifices made to support their aging loved ones at home.

“…When my mother got sick and started having her health problems, I made a decision on my own to just avoid everything. And I’m gonna stay home and take care of my mother. And that was the end of that. And that’s what I’ve done for the last 5 years. So, I’m here 24/7. If I’m lucky, I leave the house 2 hours a week...” (Care Partner ID09)

“It's very…I'm lonesome. My wife's, you know, trying to take care of me and the house and all her paperwork. We don't have time to really have her sit with me. And like for instance…my son has a company… and he's very busy, but I wanted to call him just to have him come over and sit with me for an hour or so.” (HBPC Patient ID12)

Theme 2: Sensory and Functional Impairments Amplifying Social Disconnection

Physical and environmental barriers to social connection for this population were discussed and described expansively by HBPC patients, HBPC staff, and CAPABLE staff. Our explorations of these barriers highlighted the role of sensory impairments, mobility limitations, and functional difficulties as factors that contribute to social isolation and impede social connection. Other physical and environmental barriers to social connection and to accessing needed care and assistance emerged such as lack of internet access, living alone, financial strain, inadequate transportation, poor hygiene, and unkempt household.

“…I do nothing. I’m like, I said. I can’t get out of this bed. I can’t walk. I have no use of my legs. And that’s just it. I have a granddaughter getting married in June and I can’t go to that. And I missed my grandson’s wedding a couple of years ago, because I was in a home, because of my legs.” (HBPC Patient ID12)

“…they can't leave the house because of those physical barriers that sometimes just like frustrates me because it seems like such an easy fix like, if we just put a ramp outside, you could take your wheelchair down and go wherever you needed to go. But that's obviously not, you know, cost-wise and everything, it's not an easy fix…it's like a physical barrier that you can literally see is those steps…And I think that's hard for patients to be like…if I could get down the five steps up front, but I can't.” (HBPC Staff ID08)

Theme 3: Unaddressed Mood Disorders Can Present Obstacles to Participation

Participant responses about anticipated challenges to participating in the CAPABLE intervention if experiencing social isolation helped to elucidate adaptation considerations for implementing this intervention in the HBPC setting. The mental health needs of older adults who are homebound and their care partners, especially those experiencing social isolation or loneliness, emerged as a concern and potential threat to effectively participating in and completing the CAPABLE program. HBPC staff and CAPABLE staff provided examples of how unaddressed mood disorders could adversely impact the physical and mental health of older adults who are homebound.

“For somebody who might be severely depressed, that’s a challenge. It’s just I gotta work harder to try to figure out you know what's going on or help them get the support that they need. But that definitely can be slow starting…can limit their ability to connect with the outside world…And also, their internal motivation. They have to, there’s got to be a spark somewhere that we can ignite.” (CAPABLE Staff ID01)

“I feel like my patients that are socially isolated medically do worse than the ones that aren’t. It’s challenging. I would say my severely socially isolated patients have more severe mental health concerns, anxiety and depression, and challenges caring for themselves physically or completing what they need to complete, to care for themselves medically… And just the emotional, the total of it, you know, being socially like, not having those human relationships and human connections, I definitely see more depression and anxiety…” (HBPC Staff ID08)

Theme 4: Tailoring the CAPABLE Intervention to Individualized Needs and Goals

By design, the CAPABLE program supports client-driven goal setting. This programmatic feature has been identified by prior research as a strength for older adult participants. Empowering and elevating the older adult’s voice by tailoring activities to their individually expressed functional needs emerged as a potential benefit of participating in the CAPABLE program for our study participants. Addressing what is important to the participant in an individualized way is described by CAPABLE staff and HBPC staff as a potentially transformative and revealing experience for the participant as well as for the clinicians and care partners involved.

“A lot of our patients being homebound experience social isolation…they’re very, very lonely so having a program that really focuses on what’s most important to them and what their goals are, I think it’d be really beneficial…their goal setting could be making goals that can improve your social isolation, such as being able to, you know, get down the two steps in the front so they can go out and see their neighbor…” (HBPC Staff ID08)

“For a typical home health intervention, we were in and out of there in 37 days…While we gave patient-centered care and we certainly talked to the patient about what their goals were, we made lots of suggestions about what we thought the goals should be. And with CAPABLE, it truly is patient-directed goals…Thinking about how people age in place and the barriers they might encounter in their own home, you could make an argument that having CAPABLE on the team for [HBPC] would allow people to stay home and age in place longer and be more successful.” (CAPABLE Staff ID03)

Theme 5: Embracing the Use of Communication Tools and Technologies

HBPC patients, HBPC care partners, and HBPC staff described activities, approaches, and strategies to foster social connection among older adults who are homebound and care partners at increased risk for social isolation. Examples include the use of assistive devices for mobility, communication technologies, and adaptive equipment for functional limitations. Older adults who are homebound can leverage video conferencing and smart technology devices as communication tools to adapt and cope with social isolation in the home environment.

“iPad and Facetime…most of the time, people aren’t aware of my hearing and that makes it very difficult with the telephone. So, with the iPad, it makes life a lot simpler.” (HBPC Patient ID12)

“…I purchased this, it’s called a Telikin© laptop…You’d be able to see people and she’d be able to tell, be able to pull, push a thing on the screen, talk to who she actually wants to…she would get a list of people that would be in there for her and then she could talk. But they also could see people. She gets to see people, and you wouldn’t have to, you know, be feeling so bad, because now, when your family calls you, you look right at the screen and you can see them.” (Care Partner ID11)

Theme 6: Value of Face-to-Face Interactions

Discussions about the added value of in-person visits and face-to-face interactions were a key feature of interviews with HBPC staff, HBPC patients, and HBPC care partners about facilitating factors and environmental drivers of social connection. Examples included informal visits from neighbors, family or friends, companionship with domestic pets, formal visits from home care providers, and formal visits from Meals on Wheels© delivery personnel. Care partners of the older adults and the older adults themselves recognize the added value of informal and formal in-person visits to facilitate social connections in the home environment.

“…if they had like a basic person who would just come and visit you. You know what I mean? Just to sit with a lot of these people, because that is what most of them are missing, just a visitor. And that, believe it or not, that is what most of them actually want, just someone to talk to…” (Care Partner ID09)

“…Socializing, visitation. I’m trying to think what would help. I guess that’s it, because it is so nice just like when Meals On Wheels© comes. It’s so nice when you have a visitor, and she’s going to talk to you for a few minutes…it’s nice to have someone you’re looking at. Not the telephone.” (HBPC Patient ID06)

The content of our interviews with HBPC patients, care partners and staff elucidate how unaddressed mood disorders such as anxiety and depression can both contribute to and exacerbate social isolation. Furthermore, HBPC staff provided information describing how unaddressed social needs and lack of social support are associated with poorer health and isolation and may also adversely impact participation in the CAPABLE program. This pre-implementation study highlights the important role of the social work, community health worker, and psychology disciplines in the HBPC model and the need to promote access to social services and mental health services in home and community-based settings to mitigate the non-medical and psychosocial needs of patients and care partners (Reckrey et al., 2014; Rine & LaBarre, 2021Rine & Labarre, 2021).

Discussion

The purpose of the CAPABLE Care + Connect intervention is to adapt an evidence-based program aimed at reducing disability and improving function among home-based primary care patients and their care partners who are at increased risk for or experiencing social isolation or loneliness. This qualitative study imparted important learnings for our team to guide the implementation of CAPABLE Care + Connect which will be discussed here (See Figure 2). Our stakeholder interviews reinforced the findings of previous work regarding the value of client-driven goal setting and individualized care planning as features that promote maintenance and sustainability of the CAPABLE program’s effects (Paone et al., 2024). Our results reinforced findings from similar caregiving literature that describes how the potentially detrimental impacts of caring for a homebound person can lead to both physical isolation and emotional stress (Wool et al., 2019). Furthermore, our observations confirm prior research about how homebound status exacerbates social isolation and how the built environment of the home is highly consequential to the capacity of older adults to age in place. Our findings pertaining to social disconnection among older adults and care partners contribute to the field of gerontology and home-based medicine. We highlight tools for mitigation such as communication and assistive technologies and exacerbating factors such as mood disorders.

Our stakeholders recommended that the implementation of CAPABLE Care + Connect capitalize on the HBPC practice’s existing relationships and rapport within the home environment to promote and facilitate trust (See Figure 2). In response to the pre-implementation qualitative data we collected, the CAPABLE Care + Connect research team will develop a Social Connection Action Plan. This will serve as an additional worksheet to guide Registered Nurses and Occupational Therapists during goal-setting activities with participants. The development and refinement of the Social Connection Action Plan will be informed by content and clinical experts and will include prompts to assess social connection needs as well as example activities to promote social connection for the participants that select a goal related to the issue of social isolation. Additionally, in response to pre-implementation data we collected and gathered, touchpoint processes (e.g., periodic interdisciplinary team check-ins, shared documents in electronic health record) will be developed to facilitate communication between the HBPC team and the CAPABLE Care + Connect intervention team. These touchpoints for collaboration are intended to ease intervention initiation, address medical and non-medical needs that arise, promote transition into the CAPABLE program, and sustain its impact upon intervention completion. These findings will also be shared with the HBPC team members and will help to inform the development of additional adaptation strategies as indicated.

Strengths of this qualitative study include its novel study population (homebound older adults, care partners of homebound adults) and novel practice setting (home-based primary care). Other strengths include leveraging interviews to garner informative insights into a unique context, and the utilization of an interdisciplinary team of experts. Furthermore, the novelty of this project is enhanced by its application of an evidence-based intervention that builds on momentum to improve home and community-based care and services for aging populations. Unlike another pilot study testing the implementation of a home modification program in the HBPC context, strengths of the CAPABLE Care + Connect intervention are that it will be implemented using: (1) a full-length CAPABLE program that is 4-months in duration and has dedicated CAPABLE staff which are associated with greater fidelity and greater ADL improvement; (2) interventionists that have completed formal CAPABLE training; and (3) an intervention team that includes OT and RN disciplines (Schiller, 2023). We aim to translate research into clinical practice through institutional collaborations that address a priority area in gerontology and fill a gap in geriatric care. Limitations of this qualitative study are its small sample size and limited geographic area coverage. The heterogeneity of supports and needs for patients residing in rural areas compared to urban areas (e.g., Access to long-term supports and services, Community-based organization resources) was not adequately captured in the interviews. Another limitation is how variable HBPC programs are across the country in terms of team composition and model structure. Lastly, the interviews did not engage with stakeholders representing community-based organizations in the local area.

Conclusion

Factors influencing social connection for older adults who are homebound and their care partners included facilitators of social connection (e.g., routinely scheduled in-person home visits), barriers to social connection (e.g., poor mobility, poor hygiene, poor housing conditions), conditions attributing to social isolation (e.g., living alone, mood disorder), and strategies to foster social connection (e.g., home safety modifications, assistive devices, communication technologies, referral to social work). Future plans include sharing the story of how to adapt an intervention for implementation in the HBPC setting. These plans also include disseminating knowledge about the potential threats to and opportunities for social connection among older adults who are homebound and their care partners. The selected HBPC practice will proceed with implementing the CAPABLE Care + Connect pilot program to test the feasibility and acceptability of integrating this tailored intervention into a home-based primary care practice context.

This qualitative study helped us to better understand the HBPC context and population for implementation of the CAPABLE Program. It contributes to our understanding of how to translate learnings from lived experiences into the formulation of new research questions to be addressed by the intervention. This study demonstrates how rapid qualitative analysis can be applied to the field for the implementation of home and community-based interventions. It also shows how rapid qualitative analysis can help researchers broaden their framing of real-world problems and shape their ability to integrate the intervention. Our pilot study’s groundwork serves as a demonstration of how to integrate the voices of those that contributed to our learnings and adaptation. While this qualitative study is limited in its generalizability, it will be one in a collective of many generated from this work focused on adapting and implementing a home-based intervention in an understudied population and in a specialized practice.