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Health Service Delivery for Patients with Complex Care Needs

As the U.S. population ages, the number of Americans who have chronic health conditions will greatly increase. These demographic and epidemiologic dynamics will strain the capacity and the sustainability of the acute care-oriented U.S. health care system, which now provides chronic care ineffectively and inefficiently. New health service delivery systems will need to be developed, evaluated, and disseminated into widespread practice in order to deliver high-quality, cost-effective care for older Americans.

Research focus

In recent work that includes partnerships with other health care institutions and agencies, researchers from the Center for Transformative Geriatric Research have explored the development of geriatrics health service delivery at all levels of the health system, from the patient and their family or caregivers to providers, hospitals and health system.  Using a wide array of qualitative and quantitative research techniques, investigators are finding new and better ways to care for older adults.

Current research studies

Hopkins investigators have been at the forefront of developing, evaluating, and disseminating into practice new models of geriatric health service delivery to care for an aging population. Current research studies are focused on:

  • Clinical interventions to improve transitions of older adults across the continuum of care
  • Community-based long-term care
  • Program of All-inclusive Care for the Elderly (PACE)
  • Hospital at Home
  • Home-based primary care
  • Home-based palliative care
  • Skilled home health care, assisted living, and long-term care
  • Guided care
  • Models of multidisiplinary care for people with dementia
  • Assisted living facilities

Faculty investigators

Halima Amjad, MD
Alicia Arbaje, MD
Cynthia Boyd, MD, MPH
Ariel Green, MD, MPH
William Greenough, III, MD
Bruce Leff, MD
Matthew McNabney, MD
Esther Oh, MD
Nancy Schoenborn, MD
Sevil Yasar, MD, PhD 


Susannah Cafardi
Ayse Gurses, PhD
Nicole Werner, PhD
Sara Szanton, RN, PhD
Albert Wu
Kitty Chan, PhD
Qilu Y, PhD (Westat)
Armstrong Institute for Patient Safety and Quality
Johns Hopkins Home Care Group
Johns Hopkins University Bloomberg School of Public Health, Departemtn of Health Policy and Management
Johns Hopkins School of Nursing, Departemtn of Community and Public Health
National PACE Association Research Committee
University of Maryland Department of Pharmaceutical Health Services Research


Refer a Patient

To refer a patient for a geriatric care consultation, please contact us at 410-550-0925.


Health Tips for Older Adults

Watch videos of Dr. Arbaje providing health tips as seen on ABC 2 News.