BACKGROUND/OBJECTIVES Of older adults, 42% report problems with daily function, and physical function is the most important consideration for aging individuals. Thus, we implemented a model of care focused on improving physical function and examined health and use outcomes and satisfaction. DESIGN A 3‐year participatory, single‐group pretrial/posttrial benchmarked to a usual care cohort that was evaluated prior to the study. SETTING Four Medicaid home and community‐based waiver sites in Michigan. PARTICIPANTS The participants included 34 clinicians and 270 Medicaid beneficiaries 50 years and older. INTERVENTION Community Aging in Place, Advancing Better Living for Elders (CAPABLE), an evidence‐based model of care that improved physical function in older adults, was implemented using evidence‐based strategies. MEASUREMENT Characteristics (age, race, and sex), health outcomes (comorbidities, instrumental/activities of daily living [I/ADLs], pain, depression, and falls), and emergency department and hospitalization visits preintervention/postintervention and in the usual care cohort were examined. We also measured Medicaid beneficiary's satisfaction with care for those who received CAPABLE. RESULTS Improved mean ± SD ADLs (preintervention, 8.51 ± 3.08; postintervention, 7.80 ± 2.86; P = .01) and IADLs (preintervention, 6.43 ± 1.31; postintervention, 5.62 ± 1.09; P < .01), a decrease in falls by 14% (from 34.8% preintervention to 20.8% postintervention; P < .01), and fewer hospitalizations (from 0.43 ± 1.51 preintervention to 0.23 ± 0.60 postintervention; P = .03) were found. Post‐CAPABLE means were significantly better compared with a usual care cohort for IADLs (6.73 ± 1.27; P < .01) and hospitalizations (0.47 ± 2.66; P < .01). Satisfaction with care was high, and 98.1% recommended CAPABLE as a way to help remain living in the community. CONCLUSION Improved ADLs and IADLs, a reduction in fall rates, fewer hospitalizations, and high satisfaction with care occurred in this population as a result of the use of CAPABLE. CAPABLE may be one solution to helping vulnerable, low‐income older adults with poor physical function to remain living in the community. J Am Geriatr Soc 67:363–370, 2019.

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Background: Programs to reduce disability are crucial to the quality of life for older adults with disabilities. Reducing disability is also important to avert unnecessary and costly hospitalizations, relocation, or nursing home placements. Few programs reduce disability and few have been replicated and scaled beyond initial research settings. CAPABLE is one such program initially tested in a randomized control trial and has now been tested and replicated in multiple settings. CAPABLE, a 10-session, home-based interprofessional program, provides an occupational therapist, nurse, and handyworker to address older adults' self-identified functional goals by enhancing individual capacity and home environmental supports. We examine evidence for the CAPABLE program from clinical trials embedded in different health systems on outcomes that matter most to older adults with disability.Methods: Six trials with peer-reviewed publications or reports were identified and included in this review. Participants' outcomes included basic and instrumental activities of daily living (ADLs, IADLs), fall efficacy, depression, pain, and cost savings.

This review provides clinicians with the state of the science in relation to combined motivational interviewing and cognitive behavioural therapy interventions that promote medication adherence. A summary of intervention components and talking points are provided to aid nurses in informing decision-making and translating evidence into practice.

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