Geriatric Medicine Fellowship Program

Aging in place refers to the ability of older adults to live safely, independently, and comfortably in their own homes and communities, regardless of age, income, or ability level.

For many people, remaining at home supports emotional well-being, preserves social connections, and promotes a sense of autonomy. Our services are designed to help individuals maintain independence while ensuring access to the care and support they need.

We support aging in place through:

• Comprehensive medical care focused on the needs of older adults
• Care coordination across health care, community services, and family caregivers
• Home-based support services and community resources
• Preventive care and wellness programs that maintain function and independence
• Planning and guidance for future health and care needs

Our approach recognizes that successful aging in place depends not only on medical care but also on functional ability, social support, and safe living environments.

Our care model aligns with the principles of an Age-Friendly Health System, which focuses on what matters most to older adults and integrates care across settings.

Age-friendly care is organized around four key elements often referred to as the 5Ms:

What Matters

We start by understanding each patient’s goals, preferences, and values. Care plans are developed collaboratively to ensure that medical decisions align with what matters most to the individual. By integrating patient priorities into clinical decision-making, we help ensure that treatment plans support independence, quality of life, and meaningful outcomes.

Medication

Medication safety is a central component of geriatric care. We regularly review medications to:

• Reduce unnecessary medications
• Avoid drugs that may cause harm in older adults
• Identify and address polypharmacy and prescribing cascades
• Simplify treatment plans when possible
• Improve symptom control while minimizing side effects and treatment burden

Mentation

We proactively assess and address conditions that affect cognitive and emotional health,
including:

• Memory concerns and dementia
• Delirium and confusion
• Depression and anxiety
• Sleep disorders and behavioral health concerns

Early recognition and management of cognitive and mental health conditions supports independence, safety, and overall well-being.

Mobility

Maintaining mobility and physical function is essential for independence. We support safe movement and physical activity by:

• Assessing fall risk
• Promoting strength and balance
• Supporting rehabilitation and functional recovery
• Addressing pain and musculoskeletal conditions

Preserving mobility helps prevent disability, reduces hospitalization risk, and supports aging in place.

Multimorbidity

Many older adults live with multiple chronic conditions that interact in complex ways. Our care model prioritizes coordinated management of these conditions by:

• Integrating care across specialties and care settings
• Prioritizing treatments based on patient goals and overall prognosis
• Reducing treatment burden and unnecessary interventions
• Focusing on functional outcomes and quality of life

This approach helps ensure that care plans remain realistic, coordinated, and aligned with what matters most to each patient.

5M Framework in the Geriatric Department

• Mind
• Matters Most
• Multi-complexity
• Medications
• Mobility

Aging often involves multiple medical conditions, medications, and care providers. Our services are organized to ensure integrated, coordinated care that addresses the whole person.

This includes:

• Comprehensive geriatric assessment
• Chronic disease management
• Preventive care and screening
• Functional and cognitive evaluation
• Care transitions after hospitalization
• Support for caregivers and families
• Advance care planning and future care discussions

Our goal is to help older adults maintain independence, preserve function, and live well in the environments they value most.

Family members and caregivers play a critical role in supporting aging in place. We provide guidance and resources to help caregivers navigate complex care needs while maintaining their own well-being.

Services may include:

• Care planning consultations
• Education about common conditions of aging
• Community resource referrals
• Support with long-term care planning

Supporting aging in place requires collaboration beyond the clinic. We partner with community organizations, home health services, rehabilitation programs, and social support agencies to ensure that older adults have access to the resources needed to remain active, safe, and connected.

Our commitment is to deliver age-friendly, person-centered care that helps individuals live with dignity, independence, and purpose as they age. By aligning our services around aging in place and the principles of age-friendly care, we aim to create a health care environment where older adults receive the right care, at the right time, in the place that matters most—their home and community.