# K23 Study 3: A Feasibility Study of CAPABLE Transitions for Older Adults with ADRD

> **NIH NIH K23** · UNIVERSITY OF ROCHESTER · 2020 · $81,699

## Abstract

PROJECT SUMMARY/ABSTRACT
Parent Award: This application seeks funding to expand the research objectives for the National Institute on
Aging-funded Mentored Patient-Oriented Research Career Award, entitled: “Characterizing and Optimizing the
Skilled Nursing Facility (SNF) to Home Transition” (K23 AG058757). This K23 parent award aims to develop and
test an SNF-to-home care transitions intervention. We are requesting additional funds to enable us to examine
the feasibility of this intervention among older adults with dementia.
Background: Every year SNFs admit 250,000+ older adults with Alzheimer’s disease and related dementia
(ADRD) for post-acute care. Compared to those without ADRD, SNF residents with ADRD are more likely to
have poor post-SNF discharge outcomes. A community-based intervention consisting of a nurse, occupational
therapist, and handyman (Community Aging in Place, Advancing Better Living for Elders (CAPABLE)) delivered
a package of interventions to harness an older adult’s motivation by addressing functional goals that the older
adult prioritizes as well as modifying home factors in support of these goals and to improve home safety. Although
CAPABLE reduced functional impairment, home hazards, and use of inpatient services among functionally
impaired older adults, it excluded older adults with frequent hospitalizations or cognitive impairment.
Original Objectives: We have adapted CAPABLE to serve as a foundation for a new intervention – CAPABLE
Transitions, which occurs within a Medicare-certified home health agency (CHHA) to help those with recent acute
medical needs transition home. The primary objective is to conduct a feasibility study to test and refine
procedures relating to: 1) Participant screening, enrollment, and retention, 2) fidelity to and perceived benefit of
the intervention, and 3) data completeness for our outcomes. The secondary objective is to obtain preliminary
data on home time, quality of life, and medical services use at 3 and 6 months following SNF discharge. The
original design did not address the particular needs of older adults with ADRD and their caregivers.
Expanded Objectives: Additional funds from this supplement will enable us examine the feasibility of CAPABLE
Transitions specifically among those with ADRD and their caregivers.
More ADRD Participants: With additional funds, we will provide CAPABLE Transitions to a total of 24 people
with ADRD discharged from an SNF, a large enough subgroup to facilitate ADRD-specific feasibility analyses.
Enhanced Innovation: More ADRD participants will allow us to examine whether we can deliver a
multidisciplinary, CHHA-based in-home intervention to people with ADRD and their caregivers.
Increased Impact: Additional funds will provide the resources needed to examine CAPABLE Transitions’
feasibility among those with ADRD and to obtain ADRD-specific data that would be instrumental for future grant
applications (e.g., R34, R01) to test the mechanisms and efficacy of ...

## Key facts

- **NIH application ID:** 10117768
- **Project number:** 3K23AG058757-03S1
- **Recipient organization:** UNIVERSITY OF ROCHESTER
- **Principal Investigator:** Adam C Simning
- **Activity code:** K23 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2020
- **Award amount:** $81,699
- **Award type:** 3
- **Project period:** 2018-07-01 → 2023-05-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10117768

## Citation

> US National Institutes of Health, RePORTER application 10117768, K23 Study 3: A Feasibility Study of CAPABLE Transitions for Older Adults with ADRD (3K23AG058757-03S1). Retrieved via AI Analytics 2026-05-24 from https://api.ai-analytics.org/grant/nih/10117768. Licensed CC0.

---

*[NIH grants dataset](/datasets/nih-grants) · CC0 1.0*