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Health Service Delivery for Patients with Complex Care Needs

Health Service Delivery for People 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 adults.

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, 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:

  • 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

Photo of Dr. Alicia Ines Arbaje, M.D., M.P.H.

Arbaje, Alicia Ines, M.D., M.P.H.

Assistant Professor of Medicine
Director of Transitional Care Research
Expertise, Disease and Conditions: General Internal Medicine, Geriatric Medicine
Research Interests: Designing healthcare systems to enhance safety and improve outcomes for older adults.
Photo of Dr. Cynthia Melinda Boyd, M.D., M.P.H.

Boyd, Cynthia Melinda, M.D., M.P.H.

Associate Professor of Medicine
Expertise, Disease and Conditions: Cognitive Decline in Older Adults, General Internal Medicine, Geriatric Consultation and Preventative Health, Geriatric Medicine, Osteoporosis, Paget's Disease, Primary Care of Older Adults, Sleep Disorders
Research Interests: Older people, Comorbidity, Hospitalization, Disability, Functional recovery, Chronic disease care, Quality of life
Photo of Dr. Ariel Ruth Green, M.D., M.P.H.

Green, Ariel Ruth, M.D., M.P.H.

Assistant Professor of Medicine
Expertise, Disease and Conditions: Geriatric Medicine
Photo of Dr. William B Greenough, III, M.D.

Greenough, William B, M.D. III

Professor of Medicine
Associate Medical Director; Clinical Chief, Ventilator Rehabilitation Unit, Johns Hopkins Bayview Medical Center
Associate Medical Director, The Johns Hopkins Bayview Medical Center, Division of Geriatric Medicine and Gerontology
Expertise, Disease and Conditions: Geriatric Medicine
Research Interests: Diarrhea C. difficile, Oral rehydration therapy
Photo of Dr. Bruce Allen Leff, M.D.

Leff, Bruce Allen, M.D.

Professor of Medicine
Director, Center on Aging and Health-East
Director, Program in Geriatric Health Services Research
Co-Director, Elder House Call Program
Co-director, Medicine Clerkship
Medical Director, Business Development and Strategic Alliances
Expertise, Disease and Conditions: Geriatric Medicine, Polypharmacy, Primary Care of Older Adults
Research Interests: Home care and medical house calls, Multimorbidity, Development, evaluation, and dissemination of novel models of care for older adults, notably Hospital at Home, Guided care and geriatric "portfolio" models, Case-mix issues, Medical education
Photo of Dr. Matthew Kendall McNabney, M.D.

McNabney, Matthew Kendall, M.D.

Associate Professor of Medicine
Program Director, Fellowship Training Program in Geriatric Medicine and Gerontology
Medical Director, Program for All-Inclusive Care of the Elderly (PACE)
Expertise, Disease and Conditions: Geriatric Medicine
Research Interests: Geriatrics curriculum development and evaluation for medical trainees, Models of care delivery with a focus on long-term care
Photo of Dr. Esther Seunghee Oh, M.D.

Oh, Esther Seunghee, M.D.

Assistant Professor of Medicine
Assistant Professor of Pathology
Joint Appointment in Psychiatry and Behavioral Sciences
Co-Director, Johns Hopkins Memory and Alzheimer's Treatment Center
Expertise, Disease and Conditions: Geriatric Medicine, Geriatric Psychiatry, Mood Disorders
Research Interests: Development of biomarkers for different stages of dementia, as markers of early detection as well as for markers of treatment response
Photo of Dr. Nancy Li Schoenborn, M.D.

Schoenborn, Nancy Li, M.D.

Assistant Professor of Medicine
Assistant Professor of Oncology
Expertise, Disease and Conditions: Geriatric Medicine
Research Interests: Cancer screening in older adults that incorporate patient preferences and life expectancy.
Photo of Dr. Sevil Yasar, M.D., Ph.D.

Yasar, Sevil, M.D., Ph.D.

Associate Professor of Medicine
Associate Professor of Neurology
Associate Professor
Expertise, Disease and Conditions: Dementia, Geriatric Medicine, Normal Pressure Hydrocephalus
Research Interests: Dementia, Cognitive decline, Hydrocephalus, Pharmacoepidemiology



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.