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This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #2, #30, #34, #41, #50


Learning Objectives

  • Describe the common goals of geriatrics models of care.

  • Understand the importance of the patient’s perspective when developing and managing geriatrics practice models.

  • Describe how geriatrics models fit into the context of various payment mechanisms.

  • Describe the key components of geriatrics models in these settings: hospital, transitions, home care, outpatient, and long-term care.

  • Outline key strategies in sustaining and disseminating geriatrics models of care.

Key Clinical Points

  1. Multiple, evidence-based practice models are available to help interdisciplinary teams to improve care for populations of vulnerable older individuals.

  2. Choosing the geriatrics model which can best fit into your practice setting depends on the challenges which your team is trying to address, your ability to make the case for a change, and your skills to lead an interdisciplinary team toward improved care.

  3. Measuring key outcomes at baseline and over time can assist the team in efforts to improve care.

  4. Assessing the fidelity of the key components of the model intervention is important to implementing and sustaining geriatrics models of care.

  5. Disseminating geriatrics models may require novel strategies to incorporate the key components of geriatrics models into the workflow and processes of routine care of older patients.


Over the past decade multiple geriatrics models of care have emerged. Some of these programs were originally evaluated in randomized clinical trials while others were designed as quality improvement projects. Identifying the needs of seniors as they navigate the complex health care system will allow geriatrics leaders and health care organizations to replicate evidence-based medicine models of care. Geriatrics models of care that take into account patients with multiple comorbid conditions and use interdisciplinary approaches as part of their interventions have proven to be successful.

Common goals of these geriatrics models of care include engaging patients in their plan of care, enabling patients to remain safely in the least restrictive site of care, and focusing on prevention strategies that optimize patients’ functional status and quality of life.

In order to find a geriatrics model of care that fits the needs of a hospital or a health care organization, it is essential to determine the hospital or health care system’s priorities. Geriatrics leaders in the organization need to build a case for the inclusion of geriatrics models of care to fit with those priorities, capitalizing on the evidence-based practices. Working with the organization, geriatrics leaders seek to identify the resources that are available to support a new model, define where the model fits within other programs, and create a strategy to implement the model.

The Patient’s Perspective in Geriatrics Models

The perspective of the patient is important to geriatrics practice models. First, patients who are served by models of ...

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