What are the steps to initiate a geriatric community wellness program?

Initiating a Geriatric Community Wellness Program

To start a geriatric community wellness program, establish a multidisciplinary leadership team with a designated Medical Director and Nurse Manager, then systematically implement education, community partnerships, quality monitoring, and transition-of-care resources following the structured framework outlined in geriatric emergency department guidelines. 1

Step 1: Establish Leadership and Governance Structure

Designate a Geriatric Medical Director and Geriatric Nurse Manager to develop and monitor the program, with quarterly reporting to oversight committees. 1 This leadership structure is essential for program accountability and sustainability.

• Assemble a multidisciplinary team including hospital-based leadership and outpatient community resources. 1
• Create an interface with out-of-hospital care, emergency departments, alternative care facilities, and hospital-wide quality improvement activities. 1
• Establish mechanisms to identify geriatric patients (65 years and older) systematically. 1

Step 2: Build Community Partnerships and Resources

Establish relationships with community organizations before program launch to ensure seamless care coordination and resource availability. 1

Essential Community Resources to Secure:

• Primary care physicians and "medical homes" for ongoing follow-up. 1
• Case managers to assist with compliance and care coordination. 1
• Medical transportation services for access to care. 1
• Home health and outpatient nursing resources. 1
• Meal programs and activities of daily living support services. 1
• Prescription assistance programs. 1
• Medical equipment suppliers. 1

The American Geriatrics Society emphasizes that community geriatrics requires matching complex community-based services to the complex needs of older adults through systematic care coordination. 2

Step 3: Implement Comprehensive Staff Education

Launch initial "go-live" implementation sessions that increase staff awareness of geriatric population needs before accepting patients. 1

Required Educational Components:

• Geriatric emergency medicine didactic sessions for physicians, nurses, and multidisciplinary staff focused on geriatric-specific care issues. 1
• Competency-based training using mixed methods: didactic lectures, case conferences, case simulations, clinical audits, journal clubs, web-based materials, and supervised patient care. 1
• In-service education on geriatric-specific equipment. 1
• Training for Emergency Medical Services (EMS) personnel who transport older persons. 1
• Educational self-management materials for older adults and their families. 1

Staff physicians should complete 4 hours of CME annually specifically focused on geriatric patient care. 1 Nursing staff should complete 8 hours of Board-approved continuing education in geriatric topics every two years. 1

Step 4: Implement the Geriatric 5Ms Framework

Structure your program around the "Geriatric 5Ms" framework recommended by the American Geriatrics Society to address multiple domains simultaneously and reduce morbidity, mortality, and improve quality of life. 2

The Five Ms:

• Mind: Screen annually for cognitive impairment and depression using validated tools. 2
• Mobility: Implement multicomponent exercise programs focusing on strength, balance, and gait training; address environmental fall hazards. 2
• Medications: Review all medications regularly to identify potentially inappropriate medications and deprescribe high-risk drugs. 2
• What Matters Most: Identify each patient's meaningful health outcome goals and care preferences; involve family/caregivers in planning. 2
• Multicomplexity: Address the intersection of multiple chronic conditions with social determinants of health through coordinated specialty care. 2

Step 5: Establish Quality Improvement Infrastructure

Create a formal quality improvement program with quarterly reporting to collect and monitor data for staff education and program success. 1

Quality Metrics to Track:

• Identification of indicators, methods to collect data, results and conclusions. 1
• Recognition of improvement and actions taken. 1
• Assessment of effectiveness of actions and communication processes. 1
• Catheter use and catheter-associated urinary tract infections (CAUTIs). 1
• Restraint use with documented indications. 1

Coordinate education with peer review cases based on local experiences as the program grows and staff competency changes. 1

Step 6: Develop Systematic Care Management Processes

Implement a structured care management process that includes screening, comprehensive assessment, care plan development, implementation, and ongoing monitoring with dynamic adjustment. 2

Comprehensive Geriatric Assessment Domains:

• Medical status including comorbidities and medication review. 3, 4
• Cognitive function using validated screening tools. 2, 3
• Mood and psychological health. 3, 5
• Functional status including activities of daily living. 3, 5
• Social supports and living conditions. 3, 5
• Gait, falls risk, and mobility. 3, 5
• Nutritional status. 3, 5
• Sensory impairments (hearing and vision). 3, 5
• Incontinence screening. 3, 5

Step 7: Establish Transition of Care Protocols

Develop robust discharge planning and follow-up systems to prevent hospital admissions and facilitate safe community living, as acute hospitalization increases rates of delirium, nosocomial infections, iatrogenic complications, and functional decline. 1

• Implement telephone follow-up and telemedicine alternatives for post-discharge monitoring. 1
• Conduct safety assessments for mobility and home environment. 1
• Provide clear discharge instructions accounting for cognitive dysfunction, lower health literacy, and financial impediments. 1

Step 8: Engage Community Awareness and Outreach

Introduce the program to community-based organizations caring for geriatric patients with opportunity for input before launch. 1

• Conduct community awareness campaigns. 1
• Involve older adults actively in program development, as they should be valued and supported with necessary infrastructure. 6
• Include intergenerational components in programming. 6

Critical Implementation Pitfalls to Avoid

• Do not attribute symptoms to "old age" without investigation. 7
• Do not overlook medication burden—systematically review all medications for appropriateness and deprescribing opportunities. 2, 7
• Do not ignore cognitive status, as it affects informed consent, medication adherence, and self-care abilities. 2, 7
• Do not fail to assess frailty, as it predicts outcomes better than chronological age alone. 7
• Do not miss atypical presentations—elderly patients often lack typical symptoms of illness. 7

Addressing the Geriatric Specialist Shortage

With only 8.6 geriatricians per 100,000 people in the US, primary care providers and community health workers must develop geriatric competencies to deliver this care effectively. 2 This reality makes structured educational programs and standardized assessment tools even more critical for program success.