SUMMARY: The CAPABLE/GAP Registered Nurse (RN) will collaborate with older adults to deliver nursing components of the CAPABLE program after completion of required CAPABLE training through Johns Hopkins University School of Nursing. CAPABLE is a home-based program to address functional opportunities and promote independence and tenure in the community with older adults. The RN will work with CAPABLE participants to understand their goals, assess and suggest strategies in people’s homes who have volunteered to participate in CAPABLE. The CAPABLE program consists of up to four RN home visits over 4-5 months. Clinicians meet with participants in their home unless otherwise determined. The RN uses training and motivational interviewing techniques to conduct a comprehensive interview to identify and prioritize issues that matter to the participant. The RN documents the participants’ own goals in up to 3 Action Plans. The RN interacts and communicates with the CAPABLE Occupational Therapist (OT) and other team members as needed to ensure close collaboration throughout and after the program. As a part of the GAP program, the RN will be responsible for completing the nursing assessment for the Home and Community Based waiver for the State of Georgia. The RN would also assist with helping the participant with coordinating needed services. The GAP program is a home- based transitional program that helps chronically- ill older adults obtain Long Term Care Medicaid funded services, while supporting their immediate needs. CORE VALUES: The Capable RN is expected to model the Hospice Savannah Corporate Values: Excellence – I bring my best everyday. Accountability – I take responsibility for my own performance. Compassion – I impact life’s most sacred moments. Teamwork – I can’t do my job without you. Stewardship – What I do today ensures tomorrow.