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Senior and Geriatric Health

Senior and Geriatric Health

We have extensive experience in medical care for seniors that is centered around preventing and treating conditions, diseases, and disabilities that are commonly encountered in aging. We use a team-based approach to provide a variety of health-related services for older adults, including care management, specialized medical care, independence, and social or psychological needs. Because aging is inevitable and the health care needs of older adults are not the same as for younger populations, we will partner with you to optimize both your health and quality of life as you age and plan for end of life.

Our doctor and nurse practitioners team with a registered nurse, care manager, and mental health counselor to address the unique health issues that may arise as patients age. We will collaborate with your pharmacists and any specialists to coordinate your care and be there for you when you have questions or health needs. This may include balance issues, hearing and vision loss, osteoporosis, osteoarthritis, dementia, frailty, incontinence, and independent living goals. Our doctor and nurse practitioners have advanced knowledge regarding safe drug therapy for seniors, health maintenance, the impact of aging on illness patterns and rehabilitation.

Medicare Annual Wellness Visits

Medicare covers a yearly appointment with your primary care provider (PCP) to create or update a personalized prevention plan. This plan may help prevent illness based on your current health and risk factors. Medicare does not cover a head-to-toe physical but pays 100% for these health risk assessments:

“Welcome to Medicare Visit” – Within the first 12 months of your Medicare enrollment, this preventive visit is to promote general health and help prevent diseases.

  • Check your height, weight, blood pressure, body mass index (BMI), and vision
  • Review your medical and social history
  • Review your potential for depression and other mental health conditions
  • Review your ability to function safely in the home and community
  • Provide you with education, counseling, and referrals related to your risk factors and other health needs
  • Give you a checklist and/or written plan with information about other preventive services you may need

Annual Wellness Visit – After your first 12 months of Medicare benefits, you can schedule a yearly wellness visit to develop your prevention plan.

  • Check your height, weight, blood pressure, and other routine measurements
  • Give you a health risk assessment that may include a questionnaire that you complete before or during the visit; the questionnaire asks about your health status, injury risks, behavioral risks, and urgent health needs
  • Review your functional ability and level of safety, including screening for hearing impairments and your risk of falling
  • Assess your ability to perform daily living activities (such as bathing and dressing) and your level of safety at home
  • Learn about your medical and family history
  • Make a list of your current providers, durable medical equipment (DME) suppliers, and medications, including prescription medications as well as vitamins and supplements you may take
  • Create a written 5-10 year screening schedule or checklist
  • Include for consideration your health status, screening history, and eligibility for age-appropriate, Medicare-covered preventive services
  • Screen for cognitive impairment, including diseases such as Alzheimer’s and other forms of dementia using both tests, observations, and/or reports by you and others
  • Screen for depression
  • Provide health advice and referrals to health education and/or preventive counseling services aimed at reducing identified risk factors and promoting wellness, including counseling related to weight loss, physical activity, smoking cessation, fall prevention, nutrition, and more

Cognitive Assessment & Care Plan Services

If we detect a cognitive impairment during your Annual Wellness Visit or other routine visit, we can perform a more detailed cognitive assessment and care plan with you. This is a visit with your doctor or nurse practitioner.

A comprehensive assessment includes:

  • An exam with a focus on observing cognition
  • Reviewing your medical history, reports and records
  • Conducting a functional assessment of Activities of Daily Living, including decision-making capacity
  • An assessment of dementia
  • Reconciling and review for high-risk medications, if applicable
  • Screening to evaluate for neuropsychiatric and behavioral symptoms, including depression and anxiety
  • A safety evaluation for home and motor vehicle operation
  • Identifying social supports, including how much caregivers know and are willing to provide care
  • Addressing Advance Care Planning and any palliative care needs

Advanced Care Planning

What type of health care would you want if you became too sick to tell the doctor yourself? Our team will help you plan ahead to make sure you get the medical care you want. Medicare pays for a face-to-face visit to discuss patients’ health care wishes if they become unable to make decisions about their care. This can be part of your Annual Wellness Visit or a stand-alone visit.

We can help you use the Taking Steps approach to making health choices.

Taking Steps includes:

  1. Choose an agent to advocate for you if you are unable
  2. Make a plan
  3. Set your limits

In addition to keeping you healthy, we help our older patients manage the following common concerns:

  • Multiple medical conditions: Often, older adults have more than one chronic medical condition that they must manage on a regular basis, and our teams use technology and chronic care management to develop a plan patients can follow.
  • Multiple medications with adverse side effects: For older patients who must take multiple medications to manage a variety of health conditions, we use technology to make sure the mix of medicines does not trigger negative interactions.
  • Noticeable memory or cognitive impairment: When memory issues and forgetfulness seem to become a more regular occurrence, we provide comprehensive cognition assessment with treatment or referral to specialized care.
  • Reduced mobility: Mobility is of the utmost importance for older adults and their ability to stay independent and healthy, so can we ensure that medications are not the cause of dizziness, provide exercises to improve strength and balance, and refer the patient to a physical therapist.
  • Have an age-related disease: If the patient has already been diagnosed with an age-related disease or condition, such as incontinence, dementia, or osteoporosis, our team can provide treatment or coordinate referral to a specialist who can help.
  • Transitions in care: Our care manager works closely with our local hospitals to coordinate our patients’ care while in the hospital, which leads to shorter stays and lower readmission rates. We will reach out to you after a hospitalization to make sure you have your medications and a follow-up appointment with us, and so you know what signs and symptoms to look for.

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