Care Transformation Center Blog

How well is your organization supporting senior patients?

Every 8 seconds, someone in the United States turns 65, and nearly two-thirds of adults 65 and older have at least one chronic health condition. It’s no surprise that senior patients need more resources (and often specially-tailored resources) at all stages of the care continuum, including the inpatient, outpatient, and post-acute care settings, and even in the ED. However, many health systems do not know where to begin reallocating resources or how to redesign their care offerings to meet the needs of this older population.

Rethinking inpatient evaluation and management

One place to start is the inpatient setting where pioneer organizations have developed Geriatric Evaluation and Management (GEM) units. These units are designed for senior patients who are selected to transfer from acute care units to receive prolonged sub-acute care to improve their functional status.

GEM unit staff specialize in the care of the frail elderly who are experiencing complex medical problems such as:

  • Stroke
  • Self-care problems
  • Falls
  • Urinary incontinence
  • Frequent hospitalizations

The advanced multidisciplinary care team supporting a GEM unit typically includes:

  • Geriatrician
  • Clinical nurse specialist
  • Social worker
  • Occupational and physical therapists
  • Nutritionist
  • Pharmacist
  • Audiologist
  • Psychologist

This team provides a comprehensive geriatric assessment, detailed treatment plans, and attention to the rehabilitative needs of older patients. And at the end of a patient’s stay in a GEM unit, the discharge planning process includes coordinating follow-up for patients with a geriatric clinic or home care intervention team.

Redesigning outpatient clinics with seniors in mind

In the outpatient setting, leading organizations have created geriatric assessment clinics. The physical layout of a geriatric assessment clinic often includes an environment modified to promote the safety and comfort of elderly patients including:

  • Skid-proof floors
  • Handrails in hallways
  • Sound-proof walls
  • Seated scales
  • Reclining chairs

Geriatric assessment clinic offerings go beyond just the clinical, offering self-management and strength building courses on topics such as fall prevention, pilates, and t’ai chi.

In advanced programs, clinic staff often provide in-home assessments of a patient’s home environment to identify safety hazards and discuss social and personal barriers to care.

For more information on our research in this terrain, email me at

Infographic: 6 must have characteristics for senior living environments

Get a snapshot of the impact on-campus physician services, a home-like clinical environment, and other characteristics could have on resident health in a senior living community.

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