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The Roger C. Lipitz Center for Integrated Health Care

Center Resources and Products

Data Sources & Instruments | Models of Care

Data Sources & Instruments

NHATS: National Health and Aging Trends Study

NHATS is an ongoing national study to enable analyses of disability trends and trajectories in older people. The study is a platform for scientific inquiry to guide efforts to reduce disability, maximize functioning, and enhance older adults' quality of life. The rich (and de-identified) database, run by Lipitz Core Faculty member, Judith Kasper, PhD, is available to those interested in analyzing aging data.
For more information, please visit


Pra™ and PraPlus™ : Probability of Repeated Admission Instruments

The Pra™ is a screening instrument used to identify members of older populations who are at high risk for using health services heavily in the future. The PraPlus™ is a screening instrument used to identify members of older populations who are at high risk for using health services heavily in the future and to begin the process of evaluating their needs.

The Pra™ and the PraPlus™ are protected by copyright. Any use of these instruments must be licensed.

Many organizations use the Pra™ or the PraPlus™ to screen older populations to identify individuals who are at risk for using health services heavily in the future. They then offer special forms of health care, such as case management, comprehensive geriatric assessment (CGA) or geriatric evaluation and management (GEM) to these at-risk individuals.
For more information, please read the FAQs or visit the Johns Hopkins Technology Ventures (JHTV) website.

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Models of Care

Guided Care

Guided Care was developed by a team of researchers at Johns Hopkins including many current and past members of the Lipitz Center for Integrated care in response to the growing challenges of caring for primary care patients with complex health needs, including the growing population of older adults in the United States. The model trains a Guided Care nurse who facilitates patient-centered care.
For more information about Guided care, visit: 


CAPABLE: Community Aging in Place—Advancing Better Living for Elders  

The CAPABLE program, led by Lipitz affiliated faculty and Director of the Center for Innovative Care in Aging, Sarah Szanton, enables senior adults to remain in their home by assisting seniors in projects to improve safety and functionality of the home as tailored to each person's needs. This is accomplished by matching a registered nurse, occupational therapist and licensed handyman to assist individual seniors in their home over a 5 month period.
For more information about CAPABLE, see our blog post or visit:


Hospital at Home

Dr. Bruce Leff, Director of the Center for Transformative Geriatric Research and Lipitz affiliate, led a study team aimed at providing safe and effective hospital-level care in the home with support from the John A Hartford Foundation. The Hospital at Home model offers eligible emergency department patients transportation home to receive extended nursing care including at least once daily nursing and physician visits, tailored to the patient's health care needs. In addition to this, skilled nursing services, pharmacy services, respiratory therapy, diagnostic tests and treatments including ECGs, X-rays, oxygen therapy, IV fluids, IV antibiotics and other IV medicines are offered to patients in the comforts of their home.  These services are provided until the patient is stable enough to be "discharged", transferring their care to primary care physician.
For more information about Hospital at Home, visit:


Mind at Home: Maximizing INDependence at Home 

Mind at Home links people with Alzheimers disease or related dementias to community-based agencies and resources, and medical and mental health care providers. The model offers in-home assessments by non-clinical community workers and mental health clinicians to devise an individualized care plan including referral to resources, assessment of safety, dementia care education, behavior management skills training, informal counseling, problem solving, monitoring and planning for urgent needs. This project has concluded, and is no longer enrolling participants.
For more information about Mind at Home, visit:

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