Key Takeaways

  • Review these community-based programs approved by the Administration for Community Living to be evidence-based to support advance care planning, care transitions, and caregiver support.

  • Use the Eldercare Locator to find organizations in your area and ask if they offer these programs.

Explore these proven programs to address advance care planning, care transitions, and caregiver support.


CAPABLE is a program developed at the Johns Hopkins School of Nursing for older adults to safely age in place. The approach teams a nurse, an occupational therapist and a handy worker to modify the home environment. The program emphasizes the strengths of the older adults themselves to help them set goals and improve safety and independence.

Care Transitions Intervention®

Care Transitions Intervention®is also known as CTI® and the Skill Transfer Model®. During a 30-day program, patients with complex care needs and/or family caregivers receive specific tools while they work with a Transitions Coach®. Clients learn self-management skills that will ensure their needs are met during the transition from hospital to home. This is a low-cost, low-intensity evidence-based intervention comprised of a home visit and three phone calls.

Powerful Tools for Caregivers

Powerful Tools for Caregivers classes help caregivers take better care of themselves while caring for a friend or relative. There are over 4,600 trained Class Leaders teaching the class at different locations around the United States, as well as in Canada and Korea. The curriculum is available in English, French, Korean, and Spanish.  The caregiver class is available online or in-person, depending on location.

PREPARE For Your Care

Prepare for Your Care (PREPARE) is an online resource that helps people begin the important process of preparing for medical decision making. Using video stories and easy-to-read language, PREPARE helps people explore their personal values and preference and learn how to discuss them with family, friends, and medical providers. PREPARE also offers easy-to-read advance directives in English and Spanish for all 50 US states, a movie version that can be used for in-person or virtual group visits, and guides for facilitators.


REACH-TX is an evidence-based skills-training and support program for dementia caregivers based on the Resources for Enhancing Alzheimer’s Caregiver Health II (REACH II) intervention, optimized for delivery within community settings. REACH-TX provides risk assessment, education, skills training, support, and more to address common issues related to dementia caregiving to reduce stress and improve well-being. 

Reach Community

REACH Community has been shown to decrease burden, depressive symptoms, the impact of depressive symptoms on daily life, the potential for abuse as measured by caregiving frustrations, and the number of troubling dementia related behaviors reported. For REACH Community, a certified Program Coach provides individual sessions to the caregiver. 

Respecting Choices

Respecting Choices Advance Care Planning programs support adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care. The goal of advance care planning is to help ensure that people receive medical care that is consistent with their values, goals, and preferences during serious and chronic illness.

SHARE (Support, Health, Activities, Resources, and Education) for Dementia

SHARE is an evidence-based care planning counseling intervention for persons living with early-stage dementia and their family caregivers. Participants work with a SHARE Counselor to identify care values and preferences for care, and engage sources of support, (i.e., family, friends, and service providers). This unique program is designed to help families build a balanced and realistic plan of care for the future.

Stress-Busting Program for Family Caregivers

The Stress-Busting Program is a multi-component program focusing on support, problem-solving, education, and stress management for family caregivers. The program content includes stress and the impact of long term stress, managing difficult behaviors/conditions, grief, loss, and depression, coping strategies, positive thinking, taking care of yourself, and choosing a path to wellness. Each week a different stress management technique is demonstrated. The program was originally developed for caregivers caring for someone with dementia, but there are now adaptations available for chronic illness, and Spanish language. In addition, all programs are available in an online format or meeting room format.

TCARE® Support System (Tailored Caregiver Assessment and Referral®)

The TCARE® (Tailored Caregiver Assessment & Referral) system uses intelligent, predictive technology to precisely target & map interventions, reducing family caregivers’ burden & stress levels. Care professionals use TCARE’s web-based system to assess a family caregiver’s social determinants of health, identify specific risk factors related to stress and depression & create individualized, tailored care plans. By surfacing the right interventions, at the right time, TCARE helps every family caregiver better navigate their caregiving journey.  TCARE leverages machine learning and Artificial Intelligence technology to 1) assess the unpaid family caregiver, 2) determine risk/stress points, 3) link to local community resources.