--- url: 'https://www.healthinaging.org/outpatient-care' title: 'Outpatient Care' author: name: 'LiChia Chansanchai' url: 'https://www.healthinaging.org/user/100' date: '2026-11-09T15:36:51+00:00' updated: '2026-11-09T15:56:57+00:00' type: page summary: 'Outpatient Care > Outpatient Care for Older Adults Traditional medical care focuses on one health problem at a time. But this does not always work well for older adults who have many health problems. Geriatric care is different. It looks at the whole person. Several programs use this approach and help older adults stay healthier. Traditional medical care outside the hospital focuses on finding, treating, and curing one disease or health problem. This type of care does not work well for most older adults because they may:' published: true --- ## [Outpatient Care](/outpatient-care) # Outpatient Care for Older Adults Traditional medical care focuses on one health problem at a time. But this does not always work well for older adults who have many health problems. Geriatric care is different. It looks at the whole person. Several programs use this approach and help older adults stay healthier. Traditional medical care outside the hospital focuses on finding, treating, and curing one disease or health problem. This type of care does not work well for most older adults because they may: - Have more than one health problem. - Take many medicines. - Be frail or have a disability. - Have dementia or another brain health problem. - Need complex care. Ageism (unfair treatment of older adults) can also happen in traditional medical care. Older adults may be denied care that could help them, or get care they do not want. Health care providers may not listen when older adults describe their symptoms. Geriatric medical care is the best option for most older adults. This type of care focuses on the whole person and all of their health problems—not just one. Geriatric care works with the older adult and their caregivers to manage health problems, help with daily activities, and improve quality of life. There are several geriatric care programs. These programs include primary care, specialist visits, and coordinating many types of care. ## Geriatrics in Primary Care Person-centered care is key to a good geriatric care program. This type of care includes: - Building and regularly updating a care plan based on the older adult’s goals and choices. - Building a care team made up of the older adult, their caregivers, and health care professionals. One person on the team is the main point of contact. - Coordinating all health and support services. Team members share information and communicate clearly. - Training health care providers and, when needed, the older adult and their caregivers. - Measuring how well the care is working, including feedback from the older adult and their caregivers. Person-centered care alone is not enough. Older adults also need care based on geriatric medical principles. These include: - All clinicians, such as doctors, must have geriatric care training. They need to know the health conditions and challenges that older adults face. - An interdisciplinary team must be available. This means that health care professionals must have the knowledge and training to diagnose and treat older adults and manage multiple health conditions. - Access to care must meet the needs of older adults. ## Geriatric Person-Centered Care Programs Many programs successfully treat the complex care needs of older adults. These programs all include a full review of the older adult’s health, ongoing monitoring, and treatment by teams of geriatric-trained professionals. ### Patient-Centered Medical Home This model builds on strong primary care to manage health care for older adults. For example: - The Comprehensive Primary Care Plus (CPC+) program gives older adults: 1) access to the same health care providers over time, 2) care that is managed across different types of providers, and 3) full, coordinated care that involves the older adult and their caregiver in making decisions. - Accountable care organizations manage the full range of care older adults may need. They are responsible for the quality and cost of care for the people they serve. These organizations are paid for each service they provide. They may face financial penalties if care quality does not meet certain standards. ### Enhanced Primary Care **Guided Care** uses enhanced primary care to improve quality of life for older adults who have more than one long-term health problem. The program also works to reduce unnecessary health care costs. Key parts include: - Disease management, self-management, and case management, which help the older adult get the services they need and want. - Lifestyle changes to improve health and the ability to do daily activities. - Care support during moves between home and medical or long-term care settings. - Education and support for caregivers. - Geriatric evaluation and management. A specially trained registered nurse works with primary care doctors and office staff to manage the older adult’s care. [**The Geriatric Resources for Assessment and Care of Elders (GRACE)**](https://graceteamcare.indiana.edu/) program is a detailed “medical home” for older adults who are at high risk for health problems. It provides: - Home-based geriatric assessment and long-term care management by a nurse practitioner and social worker team. - Team coordination with a primary care doctor and a group of geriatric-trained professionals. - Personalized care planning during weekly team meetings. Care planning includes managing medicines, maintaining health, and planning for end-of-life care. The team may also address frailty, brain health, emotional health, and other needs. The plan is based on the older adult’s goals and choices. - Ongoing home-based care management using an electronic medical record and a web-based care tracking system. Older adults in the GRACE program use hospitals less and receive better quality care. ### Disease Management Disease management programs focus care around a single disease. The goal is to provide the right care for that condition. The most effective programs involve the older adult’s primary care doctor, specialist, or both. Successful programs that helped older adults most often included geriatric specialists. Examples include: - In the **Improving Mood—Promoting Access to Collaborative Treatment (IMPACT)** program, older adults with depression can work with a trained depression care manager. This manager works with a psychiatrist and a primary care doctor. The team provides education, care management, support for antidepressant medicine, and talk therapy. People in this program were more likely to recover from depression. - The **Aging Brain Care Medical Home** uses an advanced practice nurse who works with a team that includes a psychologist, neuropsychologist, geriatrician, and geriatric psychiatrist. The nurse also works with the older adult’s caregiver and primary care doctor. The team finds, monitors, and treats the behavioral and emotional symptoms of dementia. The focus is on behavior-based approaches rather than medicines. Both care quality and symptoms improve for older adults in this program. ### Outpatient Consultation Comprehensive geriatric assessment (CGA) looks at an older adult’s health conditions and abilities. Based on this information, geriatric professionals create a treatment plan and follow up with the older adult over time. This is considered the gold standard of geriatric care. It requires a skilled team of geriatricians, geriatric nurse clinicians, physical and occupational therapists, geriatric psychiatrists, and social workers. For it to work well, the geriatric team must take over the older adult’s direct care. This type of care can take place in a clinic or in the older adult’s home. Comprehensive geriatric assessment, combined with programs that help primary care doctors and older adults follow the recommendations, leads to better outcomes. Older adults experience less physical decline, less fatigue, and better social connections. A more focused program is **Short-term Geriatric Evaluation and Management (GEM)**. In this program, geriatric health care professionals diagnose and treat older adults’ health problems. In addition to treatment, the team can adjust medicines, provide counseling and health education, and refer older adults to other health professionals and community services. The team monitors and coordinates care between visits using regular phone calls. GEM slows decline in physical abilities, improves satisfaction with health care, and reduces the burden on caregivers. ### Program of All-Inclusive Care for the Elderly (PACE) [PACE](https://www.npaonline.org/) provides full health and long-term care to frail adults aged 55 and older who live in the community. These individuals need nursing home level of care. PACE’s goal is to keep older adults at home as long as possible by providing the right care there. PACE services include medical care, rehabilitation, hospital care, adult day care, and transportation. People may also receive some non-medical services, such as help paying a utility bill, if it helps them stay at home. In return, the organization receives a set payment for each person in the program. This payment usually comes from Medicare and Medicaid because most participants qualify for both. PACE is a permanent program under Medicare and an optional program under state Medicaid programs. PACE uses a team of health care professionals who know participants and their caregivers well. This team includes a doctor (often a geriatrician), nurse practitioner, clinic and home health nurses, social workers, rehabilitation therapists, pharmacists, dietitians, and transportation workers. Research shows that PACE provides high-quality care, though results may vary by location. ### Telehealth [Telehealth](/age-friendly-healthcare-you/care-settings/telehealth) allows older adults to see their health care providers through video calls. This could improve care for older adults who do not have easy access to health services. Older adults with disabilities or who live in areas with few health care options may benefit the most. Policy changes are needed to make telehealth better and more available to more older adults. ## Participant Selection for Outpatient Interventions Outpatient programs are designed to meet the care needs of older adults with many health problems. These programs work best when they focus on people who are at high risk of needing a lot of health care and long-term services. Finding the right participants can be challenging. Three approaches have been used to find high-risk older adults: 1. Referral from health care professionals 2. Screening of older adults by mail or telephone 3. Analysis of data The best system for finding high-risk individuals would use more than one source of information. *Last Reviewed and Updated:* **October 2026** *By:* [**AGS/HiAF Public Education Committee, HealthinAging.org Content Reviewers**](https://www.healthinaging.org/about-us/about-website/content-contributors-and-reviewers)