SOCIABLE Seniors Optimizing Community Integration to Advance Better Living With ESRD

Questionnaires: Participants will be asked to answer questions about: * social support and social functioning * pain and depression * physical function Study intervention: Participants will be randomly assigned (by chance, like the flip of a coin) to one of two groups: participant either will receive SOCIABLE (Seniors Optimizing Community Integration to Advance Better Living with ESRD) services now, or will receive the same services in six months from now. Participants have a 50:50 chance of getting into each group SOCIABLE services involve receiving visits with a nurse interviewer. Participants will decide how you want to improve your social function and social support. Participants will also receive: * a group of services called CAPABLE which include home visits from a nurse (RN) and an occupational therapist (OT) and a handyman for repairs if you need them and * help with improving social support All participants will receive 10 home visits (6 OT, 4 RN) plus minor home repairs and assistive devices over a 4 month period of time.