For Providers

Specialty Consultations: CGAs, transition visits, wound care, foot care, continence care, and ostomy care

Comprehensive Geriatrics Assessment

A Comprehensive Geriatric Assessment is medical consultation completed in a clinic by a Geriatrician and a nurse with further referrals made to providers in the community as needed. This team reviews a senior’s medical needs and investigates for common geriatric conditions. Just as importantly, there is an extensive review of a senior’s daily activities, interests, and support networks.
This evaluation encompasses the functional, psychological, cognitive, and social realities of the senior. By using this approach a Comprehensive Geriatric Assessment can help identify areas in which a senior may need further support currently and can also help an individual and his or her family plan for the future.
How can a comprehensive geriatric assessment help primary care providers?
Primary care physicians in Family and Internal Medicine have extensive experience caring for older patients. For many of them this is their most rewarding work. Nevertheless, many find that addressing the most pressing medical issues absorbs all of their available clinical time with complex elderly patients.
As a consultant we can tailor our services to the needs of the referring provider. For some providers this will include full medical co-management and for others simply a concise summary with recommendations.
How can a comprehensive geriatric assessment help primary care providers?
  • Review all medical and psychiatric diagnoses with a focus on common geriatric conditions
  • Identify medical, social, and functional needs of patients and their families
  • Review all medications with a focus on drug interactions, side effects, and necessity
  • Provide education and information about community elder-based services and programs
  • Assist with advanced care planning such as living wills and establishing goals of care
  • Provide education and support to limit caregiver burnout
  • Formulate a comprehensive plan to improve function and quality of life and optimize patient independence
How can a comprehensive geriatric assessment help primary care providers?
  • Dementia
  • Polypharmacy (effects of taking 5 or more medications)
  • Frailty and weight loss
  • Incontinence
  • Falls
  • Impairments of vision, hearing, and dentition
  • Depression and Anxiety
  • Transitions from home to supported living environments (Assisted Living or Nursing Home)
  • Home Safety Evaluation
  • Advanced Care Planning (i.e. Living Wills and Goals of Care conversations)
  • Osteoporosis
  • Constipation
  • Pain

Transition Visits

Transitioning from one site of care to another poses one of the biggest challenges and risks in modern healthcare. Senior Care Partners aims to help patients make a smooth transition home from the hospital or skilled nursing facility. Following discharge, Senior Care Partners can provide a transition visit, a clinic visit soon after discharge, to ensure a smooth transition back to primary care providers or to provide ongoing medical care for those without an established provider in the community.
Prior to discharge, our physicians and nurse practitioners perform a comprehensive review of each patient’s case in preparation for discharge home. Typically patients are scheduled to see their primary care physician shortly thereafter. However, in between discharge and the time of primary care follow up, issues often arise that can interfere with maintaining optimal health and function.
Our team, having followed the patient from hospital to skilled nursing facility, is well equipped to address these issues. Issues can include confusion about medication changes, unexpected home medical equipment needs, and changes in clinical status. These visits will be targeted to the specific needs identified for each patient in order to smoothly transition their care back over to their PCP. We aim to see patients within 1-2 weeks of discharge in order to address these issues immediately and ultimately to avoid unnecessary re-hospitalizations.