Bringing Systems Clarity to Aging in Place
2025
Johns Hopkins School of Nursing + Institute of Design at Illinois Tech
Equipped CAPABLE to develop systematic growth strategy through 8-area opportunity model addressing sustainability and expansion across 65+ implementation sites. Delivered frameworks transforming evidence-based initiatives into scalable healthcare infrastructure, supporting programs with 7x investment returns and $22,000 per-participant savings through systematic opportunity assessment and design principles.
65+
implementation sites
7x
$22K
saving per participant
Aging in place has evolved from personal choice to a healthcare infrastructure imperative. With 10,000 adults turning 65 each day and 74% of people over 85 experiencing functional limitations, the U.S. faces rising care costs and infrastructure strain. CAPABLE offers a 15-year evidence base, with consistently strong clinical outcomes and cost savings, yet remains underutilized due to fragmented funding, workforce constraints, and operational bottlenecks. This project identifies systemic leverage points to scale aging-in-place programs without diluting mission, enabling evidence-based care models like CAPABLE to expand sustainably and equitably.
Surface —
Evidence-based programs like CAPABLE face high-stakes scaling demands, yet lack the systemic visibility needed to adapt across diverse environments. Strong clinical proof does not translate into sustainable growth without systematic understanding of stakeholder dependencies, resource flows, and implementation dynamics.
Analysis of 65+ CAPABLE implementation sites through 12 expert interviews and 50+ visual ecosystem models revealed systematic barriers constraining expansion. Traditional program evaluation approaches overlook system-wide interdependencies that determine scaling success.
Three critical bottlenecks emerged: fragmented data utilization across sites, unclear implementation readiness frameworks, and misaligned partnership formation processes. These barriers create operational friction that prevents programs from adapting to diverse local contexts while maintaining fidelity.
Visual modeling made invisible system dynamics visible, clarifying where breakdowns occur and where strategic interventions can stabilize growth without compromising core values of dignity, self-efficacy, and contextual care.
Shift —
Strategic Implementation Framework: From Assessment to Scale
Systematic design methodology using visual modeling and stakeholder-driven analysis enabled opportunity clustering that transformed 100+ initial ideas into strategic intervention points. The CAPABLE Opportunity Area Model emerged through iterative clustering, organizing scaling challenges into 8 strategic areas that address both operational stability and strategic expansion.
CAPABLE Opportunity Area Model: Strategic Clustering for Systematic Growth
Sustain Cluster (3 areas) establishes foundational operational stability: Securing Funding diversifies revenue streams and maintains site funding; Facilitating Program streamlines onboarding and supports frontline staff; Leveraging Impact systematizes data collection and ROI communication. These areas create the operational foundation necessary for sustainable scaling.
Growth Cluster (5 areas) enables strategic expansion capabilities: Partnership & Alliance builds strategic relationships; CAPABLE Advocacy develops policy influence; Public Relations enhances visibility; Knowledge Sharing creates coordinated learning; Streamlining Process reduces operational friction. These areas leverage stable operations for strategic expansion.
Solution Architecture Across Clusters
Design principles connect opportunity areas, enabling coordinated intervention rather than isolated improvements. This clustered approach directly addresses the system-wide interdependencies identified through visual modeling, providing systematic frameworks that enable growth while preserving program fidelity and community trust.
Sustain —
Building Systematic Thinking Infrastructure for Adaptive Growth
Sustainability is shaped by what programs can interpret and adapt. This project developed thinking infrastructure that enables evidence-based programs to navigate scaling complexity through shared understanding and structured analysis.
Knowledge Infrastructure Created
The Opportunity Area Model clarified decision points and tradeoffs across scale, providing systematic reference points for growth strategy development. The 3-Stage Thinking Toolkit created structured pathways from ecosystem understanding to implementation design, enabling organizations to move systematically from analysis to action.
Transferable Methods
Visual modeling and opportunity clustering methodology enables other healthcare programs to conduct structured scaling analysis without external design teams. The approach provides comprehensive mapping of stakeholder dependencies and implementation friction, creating replicable frameworks for identifying strategic intervention points.
Replicable Decision Frameworks
The report and toolkit create reusable scaffolding for growth strategy development. This enables internal capacity-building across CAPABLE National Center, site administrators, and clinical teams, focused on helping teams adapt to varied contexts while preserving core values.
Systemic Contribution
The work builds organizational capacity to respond intelligently and repeatably across healthcare ecosystems, creating strategic thinking infrastructure that empowers evidence-based programs to achieve sustainable scaling through adaptive decision-making frameworks.