Cross-training of medical, dental, and psychiatric fellows enhances access to comprehensive care for homeless and formerly homeless older adults.
A comprehensive program consisting of standardized protocols, an interdisciplinary team, a specialized inpatient unit, education and training support, and community outreach improves inpatient care for the elderly.
Primary care physicians and offsite clinicians use communications technology to enhance coordination of care for geriatric patients with chronic health problems, leading to fewer emergency department visits, enhanced patient satisfaction and understanding of medications, and more referrals for needed care.
Hospital-based coaches assist nurses in developing process improvement projects to enhance geriatric care, leading to low fall rates and a decline in sepsis mortality and contributing to a reduction in nurse turnover.
An interdisciplinary, hospital-based outpatient clinic staffed by geriatricians and other health professionals cares for seniors with one or more chronic health conditions, leading to improved outcomes and lower costs.
Commonwealth Care Alliance developed a health plan that provides low-income, dually eligible, elderly enrollees in Massachusetts with a primary care team made up of a physician, nurse practitioner, and geriatric specialist who work out of the enrollee's primary care clinic.
The Payne-Phalen Living at Home/Block Nurse Program is a community-based program that provides medical and social services to neighborhood seniors, enabling them to live at home rather than in a nursing home.
As part of the Geriatric Resources for Assessment and Care of Elders (GRACE) program, social worker/nurse practitioner teams collaborate with a larger interdisciplinary team and primary care physicians to develop and implement individualized care plans for low-income seniors, leading to significant improvements in health status.
The Hospital Elder Life Program screens all patients aged 70 years and older at admission for the presence of six risk factors for delirium, and then implements targeted interventions to reduce these risks, leading to less cognitive and functional decline and lower costs.
Ethica Health and Retirement Communities developed a falls management program, the cornerstone of which is an interdisciplinary “falls team” at each nursing home that regularly assesses residents for risk of falling and develops intervention plans for those found at high risk.