Medical Health
The assessment may review:
- Current and past diagnoses
- Symptoms
- Recent hospitalizations
- Surgical history
- Allergies
- Preventive-care needs
- Current treatment
- Clinical risks
- Treating professionals
- Unresolved follow up needs
Comprehensive Geriatric Care
Seeing the Whole Person Behind Every Condition
Hospitals Without Walls™ provides a framework for coordinated care addressing the medical, functional, cognitive, emotional, social, environmental, and caregiver needs of older adults.
Our goal is to identify what matters most, translate assessment findings into an actionable care plan, and connect appropriately qualified professionals and services around the patient.
Aging Is Individual
The Same Diagnosis Does Not Create the Same Needs
Older adults with similar diagnoses may differ substantially in:
- Physical health
- Frailty
- Mobility
- Memory and cognition
- Medication burden
- Emotional health
- Nutrition
- Living environment
- Social support
- Caregiver availability
- Personal goals
- Ability to follow a treatment plan
Chronological age alone does not determine health, function, decision making capacity, independence, or appropriate treatment.
Comprehensive geriatric care considers the patient’s complete circumstances rather than treating each diagnosis or symptom in isolation.
What Is Comprehensive Geriatric Care?
Assessment Connected to an Individualized Management Plan
Comprehensive geriatric care is a multidimensional approach to identifying an older adult’s needs, strengths, risks, priorities, and available resources.
It may include:
- Medical review
- Medication review
- Functional assessment
- Frailty assessment
- Mobility and fall-risk evaluation
- Cognitive assessment
- Behavioral and emotional-health assessment
- Nutrition and hydration review
- Continence assessment
- Vision and hearing considerations
- Pain and symptom assessment
- Social needs evaluation
- Home safety assessment
- Caregiver assessment
- Palliative care needs
- Advance care-planning preferences
- Development and coordination of an individualized care plan
Assessment alone is not enough. Material findings should lead to appropriate recommendations, responsible parties, follow up, and reassessment.
Who May Benefit?
Care Designed Around Need Not Age Alone
Comprehensive geriatric care may be appropriate for older adults who:
- Live with multiple chronic conditions
- Take numerous medications
- Have experienced repeated hospital or emergency visits
- Recently returned home after hospitalization
- Show signs of frailty or declining function
- Have fallen or fear falling
- Experience memory or behavioral changes
- Have difficulty completing daily activities
- Live with chronic pain or serious illness
- Have nutritional or weight concerns
- Depend substantially on caregivers
- Experience social isolation
- Have difficulty navigating healthcare
- Face questions about remaining safely at home
- Need coordinated palliative or supportive care
Eligibility for a particular service depends on individual need, consent, location, provider availability, payer requirements, and applicable law.
Our Whole-Person Assessment
A Structured View of the Older Adult’s Health and Life
Medications
The assessment may examine:
- Prescription medications
- Nonprescription medications
- Vitamins and supplements
- Allergies and adverse reactions
- Apparent duplication
- Possible discrepancies
- Adherence barriers
- Medication access
- Monitoring requirements
- Need for prescriber or pharmacist review
Only appropriately authorized professionals may prescribe, discontinue, or alter medication.
Function
Functional assessment may consider the patient’s ability to:
- Bathe
- Dress
- Use the toilet
- Transfer
- Eat
- Walk
- Prepare meals
- Manage medication
- Use transportation
- Shop
- Manage finances
- Communicate
- Obtain help during an emergency
The purpose is to understand what the patient can do independently, where assistance is needed, and which interventions may support safety and function.
Frailty
Frailty assessment may consider:
- Weakness
- Slowness
- Reduced activity
- Exhaustion
- Weight loss
- Mobility
- Resilience after illness
- Accumulated health deficits
- Dependence in daily activities
Frailty is not an inevitable consequence of age and should not be assumed from appearance alone.
Mobility and Falls
The assessment may address:
- Prior falls
- Walking and balance
- Lower-body strength
- Transfers
- Assistive devices
- Footwear
- Vision
- Medication-related risks
- Environmental hazards
- Fear of falling
- Need for rehabilitation
No intervention can eliminate every fall, but modifiable risks should be identified and addressed when possible.
Cognition
Cognitive assessment may consider:
- Memory
- Attention
- Orientation
- Language
- Judgment
- Behavioral changes
- Ability to understand instructions
- Ability to manage medication or finances
- Decision-making concerns
- Reports from authorized family members or caregivers
A screening result does not, by itself, establish a diagnosis or legal incapacity. New or worsening cognitive changes require appropriate clinical evaluation.
Emotional and Behavioral Health
The assessment may address:
- Depression
- Anxiety
- Grief
- Loneliness
- Sleep
- Coping
- Trauma
- Substance-related concerns
- Behavioral symptoms
- Risk of harm
- Need for qualified behavioral-health services
Urgent safety concerns require immediate escalation.
Nutrition and Hydration
The assessment may consider:
- Weight changes
- Appetite
- Food access
- Hydration
- Dental concerns
- Swallowing
- Dietary restrictions
- Ability to prepare meals
- Need for specialized evaluation
Sensory Health
Vision and hearing difficulties may affect:
- Communication
- Medication management
- Mobility
- Fall risk
- Social engagement
- Cognitive testing
- Ability to follow instructions
Appropriate screening, accommodation, and referral should be considered.
Pain and Symptoms
The assessment may address:
- Pain
- Shortness of breath
- Fatigue
- Nausea
- Constipation
- Sleep disturbance
- Dizziness
- Other burdensome symptoms
- Effects on function and quality of life
New, severe, or concerning symptoms require appropriate clinical evaluation.
Social and Environmental Needs
The assessment may consider:
- Living arrangement
- Social support
- Transportation
- Food access
- Housing stability
- Utilities
- Financial barriers
- Health literacy
- Language
- Cultural preferences
- Home accessibility
- Emergency preparedness
- Possible abuse, neglect, or exploitation
Identified concerns should be connected to appropriate healthcare, protective, emergency, or community resources.
Caregiver Capacity
Caregiver assessment may consider:
- Who provides assistance
- Which tasks the caregiver performs
- Caregiver understanding
- Physical and emotional capacity
- Availability
- Stress and burden
- Need for education
- Need for respite or additional support
- Backup planning
A care plan should not assign responsibilities that a caregiver cannot safely or willingly perform.
Goals, Values, and Preferences
The patient should be asked:
- What matters most?
- Which symptoms or limitations are most burdensome?
- What activities are most important?
- What level of independence does the patient wish to preserve?
- Which treatments or tradeoffs are acceptable?
- Who should participate in decisions?
- What outcomes would represent meaningful improvement?
Patient preferences should guide care within the boundaries of safety, informed consent, professional responsibility, and applicable law.
From Assessment to Action
A Care Plan With Defined Responsibilities
Assessment findings may lead to a coordinated plan identifying:
- 1Immediate safety concerns
- 2Priority medical needs
- 3Medication related actions
- 4Functional and rehabilitation needs
- 5Cognitive or behavioral-health referrals
- 6Nutrition and home-safety interventions
- 7Caregiver education and support
- 8Palliative and serious illness needs
- 9Community resources
- 10Responsible professionals and organizations
- 11Communication and escalation procedures
- 12Follow up and reassessment intervals
The care plan should complement the treating professionals’ clinical plans and should not independently alter lawful orders.
Chronic Conditions and Multimorbidity
Coordinating Interacting Conditions
Older adults may live with several conditions simultaneously, including:
- Heart disease
- Hypertension
- Diabetes
- Chronic pulmonary disease
- Kidney disease
- Arthritis
- Neurologic disease
- Dementia
- Depression or anxiety
- Chronic wounds
- Chronic pain
- Sensory impairment
Treating one condition without considering the others may create competing recommendations, medication burden, or an unrealistic care plan.
Our model supports communication among authorized professionals so treatment priorities can be considered together.
Medication Safety
The Right Medication Information Across Every Setting
Medication-related support may include:
- Creating the best available medication list
- Comparing records after transitions
- Identifying apparent discrepancies
- Reviewing allergies and adverse reactions
- Identifying adherence or access barriers
- Communicating concerns to authorized prescribers
- Facilitating pharmacist review
- Educating patients and caregivers
- Tracking required follow-up
Medication review does not replace individualized prescribing judgment.
No medication should be started, stopped, or changed except by an appropriately authorized professional.
Frailty and Functional Decline
Identifying Vulnerability Before a Crisis
Frailty may reduce the ability to recover from illness, injury, hospitalization, or another stressor.
A coordinated plan may include:
- Medical evaluation
- Medication review
- Nutrition support
- Strength and balance interventions
- Rehabilitation
- Fall-risk reduction
- Assistive equipment
- Home modifications
- Caregiver support
- Monitoring
- Advance-care planning
- Palliative support
Frailty should not be used to deny beneficial treatment automatically. Decisions must consider the individual patient’s condition, goals, likely benefits, burdens, and informed preferences.
Cognitive Health
Taking Memory and Behavioral Changes Seriously
Possible cognitive changes may have reversible, treatable, progressive, or multiple causes.
Appropriate evaluation may include review of:
- Onset and progression
- Medication effects
- Infection or acute illness
- Mood
- Sleep
- Sensory impairment
- Metabolic or other medical factors
- Daily function
- Safety
- Reports from authorized caregivers
Sudden confusion may represent delirium or another urgent medical condition and requires prompt evaluation.
Fall Prevention
Addressing Multiple Contributing Risks
A fall-prevention plan may include:
- Review of previous falls
- Mobility and balance assessment
- Strength evaluation
- Medication review
- Vision and hearing assessment
- Foot and footwear review
- Assistive-device evaluation
- Home-hazard assessment
- Rehabilitation
- Patient and caregiver education
- Follow-up after a fall
Falls are not an unavoidable or harmless part of aging.
A suspected serious injury, head injury, or acute change requires prompt clinical or emergency evaluation.
Palliative and Supportive Care
Supporting Comfort, Function, and Quality of Life
Palliative care may be appropriate at any stage of serious illness and may be provided alongside disease-directed treatment.
It may address:
- Pain
- Shortness of breath
- Fatigue
- Nausea
- Anxiety
- Emotional distress
- Functional decline
- Communication about goals
- Family and caregiver concerns
- Spiritual needs, when desired
- Advance-care planning
Palliative care is distinct from hospice. Hospice involves separate eligibility, certification, election, and coverage requirements.
Caregiver and Family Support
Caring for the Patient Includes Supporting the Care Environment
With the patient’s permission or other lawful authority, family members and caregivers may participate in:
- Care planning
- Medication education
- Appointment coordination
- Mobility and safety support
- Monitoring of changes
- Hospital transitions
- Nutrition
- Emergency planning
- Advance-care planning
- Community-resource navigation
Family relationships do not automatically create authority to access protected health information or make healthcare decisions.
Aging in the Preferred Setting
Supporting Independence When It Is Safe and Feasible
Many older adults wish to remain in their homes or communities. A coordinated plan may help identify the services, equipment, modifications, monitoring, caregiver assistance, and healthcare support required to pursue that goal.
Remaining in a preferred setting depends on:
- Clinical stability
- Functional ability
- Cognitive and behavioral needs
- Environmental safety
- Available caregivers
- Available professional services
- Financial and coverage considerations
- The patient’s informed preferences
Hospitals Without Walls™ does not promise that every person can remain safely at home indefinitely.
When the current setting cannot safely meet the patient’s needs, appropriate alternatives should be discussed.
Telehealth, Mobile Care, and Monitoring
Extending Access Beyond the Medical Office
When appropriate and legally permitted, geriatric care may be supported through:
- Telehealth consultations
- Mobile professional visits
- Remote patient monitoring
- Virtual caregiver conferences
- Post-discharge follow-up
- Medication-related communication
- Behavioral-health services
- Palliative-care support
- Care coordination
Technology must be adapted to the patient’s cognition, hearing, vision, language, comfort, connectivity, and ability to use the equipment.
Technology does not replace emergency services or required in-person care.
Care Transitions
Protecting Continuity When the Setting Changes
Transitions among hospitals, skilled nursing facilities, medical practices, home health agencies, senior communities, and homes may create risks involving:
- Medication discrepancies
- Incomplete information
- Pending tests
- Missed follow-up
- Equipment delays
- Functional decline
- Caregiver uncertainty
- Conflicting instructions
A coordinated transition may include review of transfer information, medication reconciliation, appointment coordination, equipment and service follow-up, patient and caregiver education, review of warning signs, communication with authorized professionals, and reassessment of the care plan.
No transitional-care program can guarantee prevention of every complication or readmission.
Interdisciplinary Care
Different Professionals With One Coordinated Direction
Depending on need, the care team may include:
- Physicians
- Advanced-practice professionals
- Nurses
- Pharmacists
- Physical therapists
- Occupational therapists
- Speech-language pathologists
- Dietitians
- Behavioral-health professionals
- Social workers
- Palliative-care professionals
- Care coordinators
- Community-service professionals
Not every patient requires every discipline.
Each professional remains responsible for services provided within that professional’s qualifications, authority, and scope of practice.
Quality and Outcomes
Measuring More Than Diagnoses
A comprehensive geriatric program may evaluate:
- Access to appropriate services
- Completion of assessments
- Care plan implementation
- Medication reconciliation
- Falls and injuries
- Functional status
- Symptom burden
- Healthcare utilization
- Patient-defined goals
- Patient experience
- Caregiver experience
- Successful transitions
- Ability to remain in the preferred setting
- Program cost
Measures must identify their definitions, population, data sources, exclusions, reporting periods, analytical methods, and limitations.
Published evidence regarding comprehensive geriatric assessment varies by population, setting, intervention, and outcome. Results observed in one setting should not be represented as guaranteed in another.
Request Comprehensive Geriatric Care
Let Us Understand the Complete Picture
Hospitals Without Walls™ works with patients, authorized families, physicians, hospitals, health plans, facilities, home health agencies, government organizations, and community partners.
Tell us:
- Who needs assistance
- Where the individual lives
- Which conditions or concerns are present
- Which professionals are currently involved
- What has changed recently
- Which outcomes matter most
- What coverage or authorization may apply
We will evaluate whether an appropriate, available, and lawful service pathway can be identified.
Important Notice
Hospitals Without Walls™ provides an organizational framework for comprehensive, coordinated care. It does not guarantee that every assessment or service described on this page is available to every person.
A geriatric screening or assessment does not independently establish a diagnosis, medical necessity, insurance coverage, legal incapacity, or eligibility for a particular benefit.
Clinical services must be provided by appropriately licensed or authorized professionals. Recommendations must be individualized and coordinated with the patient’s treating professionals.
No improvement in health, function, independence, hospitalization, longevity, cost, or quality of life is guaranteed.
This page provides general educational and organizational information and does not replace individualized medical advice, diagnosis, or treatment.
If an older adult may be experiencing a medical emergency or a sudden change in condition, call 911 or obtain immediate emergency assistance.