Targeting Function at Home in Older Adults: How to Promote
and Disseminate Promising Models of Care?
n this issue of the Journal of the American Geriatrics
Society, Szanton and colleagues reported that an in-
home, multidisciplinary team intervention targeting risk
factors for functional decline called the Community Aging
in Place, Advancing Better Living for Elders (CAPABLE),
was associated with signiﬁcantly lower Medicaid expendi-
The focus on Medicaid costs was highly appropri-
ate because this study enrolled only older adults who were
dually eligible for Medicare and Medicaid. All study enrol-
lees were required to have self-reported difﬁculty perform-
ing at least one activity of daily living (ADL) or two
instrumental ADLs (IADLs). Although this study demon-
strated Medicaid cost savings, previous publications have
shown that receipt of CAPABLE services is associated with
clinically signiﬁcant improvements over time in self-
reported performance of ADLs and IADLs
and with sav-
ings in Medicare costs.
Although none of these studies
were randomized trials, the comparator group was con-
structed using rigorous matching techniques, and as the
authors noted, they are conducting a randomized trial of
CAPABLE in which the control group receives attention
similar to that given in the CAPABLE protocol.
Optimization of physical function in community-
dwelling older adults, the hallmark of the CAPABLE
intervention, is highly consistent with sound geriatric care.
If the evidence to date demonstrates that CAPABLE can
achieve the aim of reducing disability in lower-income older
adults living at home while saving money for the Medicare
and Medicaid programs, what considerations must be
addressed and resolved to stimulate its wide adoption? Con-
siderations can be classiﬁed according to the organization,
delivery, and ﬁnancing of the CAPABLE care model.
Organization of CAPABLE relates to the composition of
the care team and its underlying, guiding principles related
to function and personal choice. CAPABLE team members
include a nurse, occupational therapist, and handyman.
What workforce issues does the prospect of replicating
The predecessor program to CAPABLE included occu-
pational and physical therapists
; CAPABLE added nurse
and handyman services and excluded physical therapists.
Occupational therapists as a profession share with
geriatricians a central focus on function as a cornerstone of
practice and individualized goal setting. Although the CAP-
ABLE model by design employs occupational therapists to
treat older adults with physical disability who are cogni-
tively intact, occupational therapists have been core
members of in-home, multidisciplinary teams for older
adults with dementia and their family caregivers in success-
ful randomized trials.
Productive aging is a rapidly grow-
ing area of research and practice in the occupational therapy
profession, and many studies have demonstrated the value
of interventions with older adults when occupational thera-
pists are core team members.
collaborations between geriatricians and occupational
therapists would help accelerate dissemination of successful
evidence-based in-home care models focused on function of
older adults with or without neurocognitive impairment.
Nurses serve as critically important clinicians in in-
home geriatric care models. Nurse practitioners are
featured as team leaders in the Geriatric Resources for
Assessment and Care of Elders team care model, an early
and successful care model implemented and evaluated
extensively in lower income older adults in an urban set-
ting very similar to the CAPABLE study sample.
CAPABLE, registered nurses were used as team members;
although they have a more limited scope of practice than
nurse practitioners, their focus in CAPABLE is on assess-
ment of older adults’ health problems, goal setting, and
communication with ofﬁce-based primary care provi-
Handyman services are a creative addition to an
in-home care team focused on optimizing function and
adds a novel dimension to the deﬁnition of the direct care
workforce that must grow to meet ever-increasing
demands of an aging society.
In terms of the underlying principles of CAPABLE,
key features of the model include a focus on risk factors
for functional decline in the home setting while permitting
older adults with disabilities to express their own function-
related goals for treatment. CAPABLE considers not only
the functional capacity of older adults, but also attends to
the home living environment as an important factor in
addressing disability. Competence-environmental press, a
long-standing person-environment ﬁt theory in the psychol-
ogy of aging ﬁeld,
frames the function-related goals of
CAPABLE. This theory is also highly consistent with the
twin aims of making homes safer and optimizing individu-
als’ function that characterize fall prevention strategies for
community-dwelling older adults.
older adults in the ambulatory care setting could reinforce
This editorial comments on the article by Szanton et al.
JAGS 0:1–3, 2017
© 2017, Copyright the Authors
Journal compilation © 2017, The American Geriatrics Society 0002-8614/18/$15.00
JAGS 66:433–435, 2018
2017, Copyright the Authors
2017, The American Geriatrics Society 0002-8614/17/$15.00