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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, Johns Hopkins researchers have explored the development of geriatrics health service delivery at all levels of the health system, from the patient and providers to the hospital 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:

  • Geriatric service line "portfolio" models of care
  • Clinical interventions to improve care transitions
  • Key elements of optimal care transitions
  • Health system-level factors associated with hospital re-admissions
  • Community-based long-term care
  • Program of All-inclusive Care for the Elderly (PACE)
  • Hospital at home
  • Physician house calls and living independently at home
  • Skilled home care, assisted living, and long-term care
  • Guided care
  • Models of multidisciplinary care for patients with dementia


Susannah Cafardi
Richard (Chip) O. Davis, PhD
Howard Wayne Francis, MD
Ayse Gurses, PhD
Albert Wu

Johns Hopkins Quality and Safety Research Group
Johns Hopkins Center for Innovation in Quality Patient Care
National PACE Association Research Committee
University of Maryland Department of Pharmaceutical Health Services Research

Faculty investigators

Alicia Arbaje, MD
Michele Bellantoni, MD
Romsai Boonyasai, MD, MPH
Cynthia Boyd, MD, MPH
William Greenough, III, MD
Jennifer Hayashi, MD
Bruce Leff, MD
Matthew McNabney, MD
Esther Oh, MD
Sevil Yasar, MD, PhD


Erin Giovannetti


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.