FEATURE ARTICLE

Nursing Strategies for Promoting

and Maintaining Function among
Community-Living Older Adults:
The CAPABLE Intervention
Anthony T. Pho, MSN, MPH, CRNP, RN
Elizabeth K. Tanner, PhD, RN, FNGNA
Jill Roth, BSN, RN
Meghan E. Greeley, MSN, MPH, CRNP, RN
Carmalyn D. Dorsey, MSN, RN
Sarah L. Szanton, PhD, CRNP, RN

Although many programs aim to help older

adults age in place, few target both the home
environment and individual physical function.
We present an interprofessional intervention
called CAPABLEdCommunity Aging in Place:
Advancing Better Living for Elders. CAPABLEs
innovative approach incorporates a nurse,
occupational therapist (OT), and handyman
to address both individual and environmental
factors that contribute to disability. The nurse
component of CAPABLE addresses key barriers to functional independence such as
pain, depression, strength and balance, medication management, and poor communication
with the primary care provider. This article focuses primarily on the nursing aspect of the intervention and how it interrelates with the
content and processes of the OT and handyman. (Geriatr Nurs 2012;33:439-445)
he Institute of Medicines Future of Nursing report,1 health care reform legislation,
the current fiscal environment, and the burgeoning older adult population all provide a new
policy environment for nursing practice. The concurrent focus on aging at home through community services rather than just within institutional
settings means that large numbers of older adults
will require home-based services to support this
goal. This convergence of policy changes and
health care needs for older adults requires that
nurses develop and test new approaches to practice that enhance health.
The purpose of this article is to describe one
such approach for promoting aging at home that
is responsive to changes in policy and demographics. This is an interprofessional intervention called

Geriatric Nursing, Volume 33, Number 6

CAPABLEdCommunity Aging in Place: Advancing Better Living for Elders.2 CAPABLE is an intervention that addresses disability in older adults
from both individual and environmental perspectives. The CAPABLE intervention includes a series
of services that could be ordered through Medicare
Part B, an Accountable Care Organization could
elect to cover, or states could offer to decrease
the Medicaid budget by decreasing admissions to
nursing homes. CAPABLE is for nurses and occupational therapists (OTs) who work with older
adults and wish to decrease disability, and therefore risk of institutionalization, in this population.
First, we describe the need for CAPABLE and
factors that informed the development of the
intervention. Second, we describe the interprofessional nature of the intervention and how specific
roles function. We use a case example to exemplify CAPABLE and describe the implementation
of specific evidence-based interventions. This article primarily focuses on the nursing aspect of the
intervention. Feasibility and outcomes have been
described in detail elsewhere.2

Need for CAPABLE

The number of older adults is expected to double
to 71 million by 2030.3 Among current older adults,
42% report a functional limitation, or disability.4
Despite a small decline in disability rates in recent
years, the absolute number of older adults with disabilities is predicted to increase, particularly
among low-income, minority, and low-education
older adults.4 Many hope to age at home or age
in place5; however, disability can prevent older
adults from staying at home. One goal of Healthy
People 2020 focuses on the attainment of longer
439

Table 1.
CAPABLE Intervention Team Roles
Problem Area
Pain: My knees
hurt every day

Role
OT

Interventions
-

Handyman

RN

Fatigue & Weakness:

I feel weak,
especially when
standing while
cooking

OT

Handyman

RN

Strength & Balance:

I cant go down
my front steps

OT

Handyman

RN

Outcomes

Assess for environmental and

mechanical factors that may
be exacerbating joint pain
Teach range of motion exercises
that may alleviate pain
Install stairway rails outside and
inside home
Assess pain levels with and
without activity
Review current medication
regimens and assess for
adequacy/adherence
Encourage dialogue with primary
care provider to review current
analgesia regimens and dosing
Suggest nonpharmacologic
therapies to decrease pain
Assess how client performs task
Suggest sitting to perform task
Educate in energy conservation
techniques
Design activities to increase
standing tolerance
Assess equipment needs (order
& train)
Make recommended modifications
in kitchen, e.g., move chair and
table near sink
Install lower shelves as necessary
Deliver patient education
regarding nutrition and cycle
of weakness, frailty
Suggest easily accessible sources
of protein and complex
carbohydrates
Assess for orthostatic hypotension
Implement strength protocol,
e.g., tai chi, CDC/NIA exercises,
strength bands
Assess how client performs task
Identify availability of alternate
entrance/exit
Educate about safe environment
Determine equipment needs
(order and train)
Assess need for home health PT
Installs hand rails on both sides
of steps
Assess use of medications that
may cause dizziness as a side
effect

Pain is reduced to a level

such that client is now
standing to cook and
can walk down the front
stairs if those are the
goals she identified.

Client acquires additional

nutrition
ADLs enabled

Client able to go to
community activities
Increased strength and
community engagement
Increased QOL

(Continued )

440

Geriatric Nursing, Volume 33, Number 6

Table 1.
Continued
Problem Area

Role

Interventions
-

Fear of Falls: Im
afraid of falling

OT

Handyman

RN

Outcomes

Work with client on strength and

balance
Practice safe methods for going up
and down stairs with client
Teach problem-solving strategies
for getting up from the floor
Teach how to explain to someone
how to assist the client to get up
after a fall
Teach home safety to prevent falls
Practice proper reaching techniques
with client
Assess equipment needs (order
and train)
Install grab bars
Order reach tools
Initiate strength and balance
exercises with client
Encourage range of motion
exercises
Practice safe navigation of stairs
with client

Client able to perform

more ADLs without
fear of falling, which
increases activity and
strength and forestalls
further decrease in
ADL ability

ADL 5 activities of daily living; CAPABLE 5 Community Aging in Place: Advancing Better Living for Elders; CDC/NIA 5
Centers for Disease Control of Prevention/National Institute on Aging; OT 5 occupational therapist; QOL 5 quality of life.

lives free of preventable disease, disability, injury,

and premature death.6 Nurses are particularly well
positioned to help older adults remain in their
homes and age in place because they may be
keenly aware of functional limitations and may
have credibility when suggesting solutions.
Disability can be understood as the gap between
an individuals competence or abilities and the demands of the environment.7 The greater this gap,
the greater the level of disability and likelihood
that an older adult will not be able to remain living
independently at home. Interventions that address
disability at both the individual and environmental
levels are more likely to improve disability8; however, few have been implemented. CAPABLE is
an intervention that addresses disability in older
adults from both individual and environmental
perspectives.2

How CAPABLE Differs from Current

Practice
Although based on current evidence, the
CAPABLE intervention differs from traditional
Geriatric Nursing, Volume 33, Number 6

home care practice in 4 ways: 1) although nurses

and other clinicians care about patient function,
they often do not use specific strategies to improve
their function. CAPABLE training provides RNs
and OTs with knowledge and skills to identify
and remove barriers to daily functioning; 2) CAPABLE training provides the assessment skills and
evidence-based tools to enable clinicians to engage
in a client-centered approach. This includes motivational interviewing techniques, use of problem
solving, and specific strategies to engage clients
in their self-care management; 3) Although this
program is designed for older adults with at least
1 basic activity of daily living (ADL) limitation or
2 instrumental ADL (IADL) limitations, it is a preventive program designed to manage and slow
functional decline and prevent institutionalization
and; 4) Ability to function is a result of the combination of an individuals intrinsic characteristics
(e.g., strength, balance, pain) and the environment
in which they live. Therefore, CAPABLE emphasizes systematic attention to patients physical
and social environment in the design of their treatment plan.

441

The interprofessional approach is a key strategy in CAPABLE. Systematic reviews include

studies that describe home-based interventions
to improve function in older adults.9 These interventions are typically delivered discreetly by an
OT, RN, or PT and do not consistently consider
the physical environment as a contributor to
disability. By using an intervention team that
includes an OT, handyman, and RN together,
CAPABLE contemporaneously addresses both
individual function and the environment.
CAPABLEs Interprofessional Components
CAPABLE is delivered through a series of 10
home visits by the intervention team over the
course of 6 months. Each visit is up to 60 minutes.
The OT delivers 6 home visits and the RN 4 home
visits. The client identifies priority areas, and the
OT and RN work with the client to establish goals
during initial visits. These are spaced over time to
allow clients to practice new strategies introduced by the intervention team. The handyman
provides modifications and repairs to the home,
as directed by the OT. The primary components
of the intervention include assessment with interactive identification of barriers to function, education, and collaborative discussions regarding
solutions. Additionally, the intervention team
works with CAPABLE clients to provide training
on solutions so that clients can then practice
strategies on their own. First, clients meet with
the OT for 2 visits during which she or he helps
clients identify and prioritize physical performance problem areas and environmental issues,
such as the lack of a stairway railing or bathroom
handrails. The RN visits start soon after the first
OT visit, and initial nursing sessions focus on assessing medical issues that affect daily function
such as pain, depression, strength and balance,
medication management, and poor communication with the primary care provider. These are
commonly identified and highly challenging problems in older adults. The issues are well researched in the literature, including high-quality
systematic reviews,10 Both the OT and RN assessments use a protocol that was standardized for
CAPABLE.
The OT focuses exclusively on what hinders individuals from performing their IADLs and ADLs
without difficulty. The OT makes recommendations to reduce environmental barriers, thereby
improving the person-environment fit and in442

creasing independence in IADLs/ADL function.11

The handyman modifies the environment in
accordance with the OTs recommendations to
allow the client to implement these strategies in
a safe and functional manner. The handyman is
not limited to a set number of visits, but a
$1,000 maximum budget in a pilot study of CAPABLE was found to cover most safety and function
modifications. Communication between the team
members enhances care as each member alerts
others of the focus of his or her visits. Coordinated patient-driven services decreased the number of ADL limitations from 2.3 to 0.7 in a pilot
study.2 Because deficits in ADL function are key
driver of nursing home admission, this approach
is both patient centered and policy focused.12
Nursing interventions used in CAPABLE are
evidenced-based and emphasize low-cost solutions that foster problem-solving approaches to
build self-efficacy and encourage patients to use
their new skills with other problems. Specific interventions were selected on the basis of their
success with similar populations. The following
case scenario illustrates the application of the CAPABLE intervention and how the intervention
team engages with the client. The discussion describes how the RN component coordinates
with the other 2 roles. See Table 1 for a summary
of how each member of the intervention team
works to address specific problems and improve
ADL and IADL function.
Case Scenario
Mrs. Wilson is a 72- year-old African American
woman who has lived alone since her husband
died 8 years ago. She has 1 daughter who visits often. Her medical history is significant for hypertension, heart failure, diabetes mellitus, and
osteoarthritis. She ambulates with a cane but reports severe pain in her joints, especially her
knees, and reports difficulty traversing the front
steps to her house. She complains of fatigue
and is afraid of falling.
Mrs. Wilson identifies a number of problems
that may contribute to her disability. She meets
with the OT first to assess her individualized functional goals. The OT also discusses what she needs
to do to address those goals, including physical
changes to her home and assistive devices and
strategies to use to meet her goals. On the first
nursing visit, the nurse and the patient complete
a protocol-driven assessment that addresses
Geriatric Nursing, Volume 33, Number 6

pain, depression, medication adherence, strength,

balance, and primary care communication. This
assessment is called the Client-Clinician Assessment Protocol (C-CAP-RN) and was patterned after an OT assessment used in a randomized
controlled trial of a home intervention to reduce
functional difficulties in older adults called
ABLE.13 In addition to the OT-oriented approach
presented, the ABLE intervention, CAPABLE
addresses medical problems cited earlier (e.g.,
pain, medication adherence, etc.) Unlike other
nursing assessments, CAPABLE is almost entirely
focused on how medical problems, such as pain,
affect an individuals function. In Mrs. Wilsons
case, she identifies pain, fatigue, and fear of falling
as her priority problems to address.
My knees hurt every day. Pain is a common
complaint in the elderly and interferes with function because of inability to stand, decreased mobility, and potential depression.14 Clinicians have
a range of pharmacologic options for analgesia.
Assessing the quality of pain and the adequacy
of the current pain regimen is a logical first
step. CAPABLE uses both pharmacologic and
nonpharmacologic solutions. A review of the literature identified several nursing interventions
that were ideal for CAPABLE because they
were low cost in nature and could be readily implemented by the RN in the home environment.
The use of topical nonsteroidal antiinflammatory drugs has been validated as an effective means of treating acute pain without the
systemic effects of oral analgesics.15 Systematic
reviews have also validated the application of
topical heat to reduce lower back pain.16 Mindbody interventions have also been shown to improve pain in older adults.17 A report describing
a structured review of mind-body interventions
noted that progressive muscle relaxation combined with guided imagery was effective at reducing osteoarthritis pain in older adults.17 CAPABLE
incorporates such interventions because they
provided some support for effectiveness in similar older adult populations. These solutions are
evidenced based. However, there is no evidencebased solution that can summarily address highly
challenging problems such as pain in older adults.
I feel weak, especially when standing while
cooking. I cant go down my front steps. Fatigue
and weakness are also common complaints in the
elderly. The CAPABLE RN works with the client
to assess underlying factors that may be contribute to weakness. CAPABLE incorporates a variety
Geriatric Nursing, Volume 33, Number 6

of strategies to increase strength and endurance.

The intervention promotes strength by encouraging clients to discuss their concerns and by
tailoring home-based exercise programs. CAPABLE leverages illustrated Centers for Disease
Control and Prevention and National Institute
on Aging training regimens and exercise guidelines readily available for free on the Internet.18-20
The CAPABLE RN also uses paper-based weekly
calendar grids with days of the week as useful
tools to teach patients to track exercises performed and to record progress. The CAPABLE
RN also works with clients to understand how
their weakness affects their function (such as
not being able to stand to cook) and also to incorporate these simple exercises. Customized exercise regimens take into consideration that the
client may have mobility issues and remain
seated for most of the day. In such a case, the
CAPABLE RN might recommend strategies such
as doing leg exercises during TV commercials.
Im afraid of falling. Fear of falls contributes to
falls in the elderly.21 CAPABLE acknowledges
that such fears must be addressed to improve balance confidence, including practical measures
such as what to do if you fall, how to get up
from a fall, and how to ask for help. In CAPABLE,
the OT places each client on the floor and problem
solves with him or her about how to get up. Studies have shown that improving balance confidence is as important as improving balance
ability in older adults, and therefore the intervention team considers environmental updates, such
as railings, that would increase confidence.22 To
foster both balance ability and confidents in clients, CAPABLE also uses low-impact exercises
such as tai chi as part of the intervention. Several
studies that have shown that tai chi exercises can
improve balance and prevent falls.23,24 Tai chi is
now recommended by the American Geriatrics
Society as a multifactorial exercise intervention
to improve balance, gait, and strength training.25
Therefore, tai chi is a viable option for a range
of client abilities. It can be adapted to the ability
of the individual, even those suffering from the effects of osteoarthritis, and can even be performed
while seated in a chair.26 Finally the CAPABLE
RN introduces tai chi to every client who demonstrates weakness or balance issues.25 This demonstration can range from simplified forms of tai
chi such as moving weight to the edge of balance
or swinging arms from side to side and to use of tai
chi DVDs together.
443

Summary
The CAPABLE intervention described here offers an interprofessional evidence-based approach
to common problems confronting older adults
who have conditions that affect mobility and independence. Combining nursing strategies with
handyman repairs and skills-based occupational
therapy decreased older adults ADL limitations
by more than 1 full ADL limitation in a pilot study
of the CAPABLE intervention.2 Health care policy
that removes payment barriers to nursing care in
the home and promotes aging in place as a costeffective alternative to institutional care will be
an important consideration in the continuing evolution of healthcare reform. The rapidly growing
older adult population and the desire by most to
age at home demands interprofessional strategies
such as the combined CAPABLE intervention to
improve functional ability.

10.

11.

12.

13.

14.

15.

16.

References
1. Institute of Medicine. The future of nursing: leading
change, advancing health. 2010. Available at www.iom.
edu/Reports/2010/The-Future-of-Nursing-LeadingChange-Advancing-Health.aspx. Cited October 13, 2011.
2. Szanton SL, Thorpe RJ, Boyd C, et al. Community aging in
place, advancing better living for elders: a bio-behavioralenvironmental intervention to improve function and
health-related quality of life in disabled older adults. J Am
Geriatr Soc 2011;1-7.
3. U.S. Census Bureau. U.S. Population Projections
[Projected Population by Single Year of Age, Sex, Race,
and Hispanic Origin for the United States: July 1, 2000 to
July 1, 2050]. 2008. Available at www.census.gov/
population/www/projections/files/nation/download/
NP2008_D1.xls. Cited August 17, 2010.
4. Federal Interagency Forum on Aging Related Statistics.
2008 Older Americans: Key Indicators of Well-Being.
2008. Available at www.agingstats.gov/Main_Site/Data/
Data_2008.aspx. Cited February 20, 2012.
5. Centers for Disease Control & Prevention. National
Nursing Home Survey (Trends 1973e2004). 2004.
Available at www.cdc.gov/nchs/data/nnhsd/
nursinghomes1973-2004.pdf. Cited March 15,
2011.
6. Lawton M. Environment and other determinants on
well-being of older people. Gerontologist 1983;232:
349-57.
7. Heathy People 2020. Washington, DC: U.S. Department of
Health, & Human Services; 2010.
8. Verbrugge L, Jette A. The disablement process. Soc Sci
Med 1994;38:1-14.
9. Beswick AD, Rees K, Dieppe P, et al. Complex
interventions to improve physical function and
maintain independent living in elderly people:

444

17.

18.

19.

20.

21.

22.

23.

24.

25.

a systematic review and meta-analysis. Lancet 2008;

371(9614):725-35.
Haynes R, Ackloo E, Sahota N, et al. Interventions for
enhancing medication adherence. Cochrane Database of
Systematic Reviews 2008;2:1-159.
Lawton MP, Brody EM. Assessment of older people: Selfmaintaining and instrumental activities of daily living.
Gerontologist 1969;9:179-86.
Gaugler JE, Duval S, Anderson KA, et al. Predicting
nursing home admission in the U.S.: a meta-analysis.
BMC Geriatrics 2007;7(13):1-14.
Gitlin LN, Winter L, Dennis MP, et al. A randomized trial
of a multicomponent home intervention to reduce
functional difficulties in older adults. J Am Geriatr Soc
2006;54:809-16.
Institute of Medicine. Relieving pain in America:
a blueprint for transforming prevention, care, education,
and research. 2011. Available at www.iom.edu/Reports/
2011/Relieving-Pain-in-America-A-Blueprint-forTransforming-Prevention-Care-Education-Research.
aspx. Cited February 20, 2012.
Masey T, Derry S, Moore R, et al. Topical NSAIDs for
acute pain in adults. Cochrane Database Syst Rev 2010;6:
1-95.
French S, Carneron M, Walker B, et al. Superficial heat or
cold for lower back pain. Cochrane Database Syst Rev
2005;1:1-66.
Morone N, Greco C. Mind-Body interventions for chronic
pain in older adults: a structured review. Am Acad Pain
Med 2007;8(4):359-75.
National Institute on Aging. Go4Life DVD, everyday
exercises. 2010. Available at www.nia.nih.gov/
HealthInformation/Publications/exerciseDVD.htm.
Cited December 13, 2010.
Centers for Disease Control & Prevention, Division of
Nutrition. How much physical activity do older adults
need? 2010. Available at www.cdc.gov/physicalactivity/
everyone/guidelines/olderadults.html. Cited November
1, 2010.
Centers for Disease Control & Prevention, Division of
Nutrition. Growing strongerdstrength training for older
adults. 2010. Available at www.cdc.gov/physicalactivity/
growingstronger/exercises/index.html. Cited November
1, 2010.
Gillespie L, Robertson M, Gillespie W, et al.
Interventions for preventing falls in older people living
in the community. Cochrane Database Syst Rev;2:1193.
Cyarto E, Brown W, Marshall A. Comparative effects of
home- and group-based exercise on balance confidence
and balance ability in older adults: cluster randomized
trial. Gerontology 2008;54:272-80.
Wu G. Evaluation of the effectiveness of Tai Chi
for improving balance and preventing falls in the
older populationda review. J Am Geriatr Soc 2002;50:
746-54.
Liu H, Frank A. Tai chi as a balance improvement
exercise for older adults: a systematic review. J Geriatr
Phys Ther 2010;33(3):103-9.
American Geriatrics Society. Summary of the updated
American Geriatrics Society/British Geriatrics Society
clinical practice guideline for prevention of falls in older
Persons. J Am Geriatr Soc 2011;59:148-57.

Geriatric Nursing, Volume 33, Number 6

26. Adler P, Roberts B. The use of tai chi to improve health in

older adults. Orthop Nurs 2006;25(2):122-6.

Assistant Professor, Johns Hopkins University School of

Nursing, Baltimore, Maryland.

ANTHONY T. PHO, MSN, MPH, CRNP, RN, Staff Associate in

Medicine, Weill Cornell Medical College, New York, New
York. ELIZABETH K. TANNER, PhD, RN, FNGNA, Associate
Professor, Johns Hopkins University School of Nursing,
Baltimore, Maryland. JILL ROTH, BSN, RN, Research Nurse,
Johns Hopkins University School of Nursing, Baltimore,
Maryland. MEGHAN E. GREELEY, MSN, MPH, CRNP, RN,
Nurse Practitioner, Baltimore Medical Systems, Inc., Baltimore, Maryland. CARMALYN D. DORSEY, MSN, RN, Instructor, Johns Hopkins University School of Nursing,
Baltimore, Maryland. SARAH L. SZANTON, PhD, CRNP, RN,

ACKNOWLEDGMENTS
This publication was made possible by Grant Number
1KL2RR025006-01 from the National Center for Research
Resources (NCRR), a component of the National Institutes
of Health (NIH) and the John A. Hartford Foundations
Building Academic Geriatric Nursing Capacity Award
Program.

Geriatric Nursing, Volume 33, Number 6

0197-4572/$ - see front matter

2012 Mosby, Inc. All rights reserved.
doi:10.1016/j.gerinurse.2012.04.002

445