Specialty Geriatric Care Comes to Boston’s Most Vulnerable Seniors

“Lia” moved to Malden with her family in 2014. After a challenging time, the family lost their housing and told Lia she could not move with them.  She was 69 and had a long list of medical issues, including diabetes, high blood pressure, and stage 3 kidney disease. Lia found her way to Woods Mullen shelter in Boston and there began receiving primary care in BHCHP’s embedded clinic, one of 30 sites where the organization offers care.

But her age, infirmity, and lack of income and family connections made it difficult for her to take adequate care of her health, so she was referred to BHCHP’s new geriatric pilot program, the GOLD team. (GOLD stands for Geriatric Outcomes for Living with Dignity.)  A two-year $380,000 grant from the Biogen Foundation is enabling the pilot, which will eventually support the needs of 45 senior patients and add internal expertise to improve their quality of care. In year one, the team is working with approximately 30 patients.

“Older adults make up an increasing share of the patients we see, and are some of the frailest and most vulnerable,” said Peter Smith, MD, BHCHP’s medical director. “Yet unlike many high-risk younger patients, they often lack access to insurance-funded, integrated care management programs that could support their complex needs and improve outcomes. We are very grateful that funding from the Biogen Foundation has allowed us to fill this gap.”

BHCHP’s Geriatric Services

GOLD team members have been helping Lia navigate the medical system, coordinating her care, and accompanying her to medical specialty appointments. A bad infection led to the partial amputation of Lia’s right foot, so she had to move to a skilled nursing facility. GOLD team nurse case manager Emily Cohen and medical case manager Amelia Landess have visited Lia at the facility and talk regularly with her nurse practitioner and social worker to keep on top of her care. Cohen and Landess will go wherever their patients are, whether that’s a skilled nursing facility, a shelter, or a patient’s home. 

Team members assist patients with housing searches, help them sign up for insurance benefits, social security, and SNAP, and refer them to home-based support such as meal delivery, homemaking, and visiting nurse services. They also assess their living environments for fall risks. “Some of our patients experience cognitive impairments, so we often provide strategies to help them remember to take and refill their medications, as well as attend upcoming medical appointments,” said Cohen.

BHCHP will hire a gerontologist who will perform consults for patients when their primary care provider needs specialized knowledge in geriatric care. The new physician will also provide cognitive testing and design and implement professional development and training opportunities for BHCHP staff.

Elderly, Unhoused, and Ill

The national graying of the homeless population is reflected in Boston Health Care for the Homeless Program’s experience: BHCHP’s population of patients over the age of 60 has more than doubled in the past 15 years, from 9% (1,113 patients) in 2007 to 23.2% (2,255 patients) in 2022. These elderly patients bear a heavy burden of illness: more than 70% have more than one chronic illness, with some suffering from as many as 10. They are also frequent visitors to the hospital: in 2022, they accounted for 7,300 emergency room visits (an average of 3.4 visits per patient) and nearly 1,300 hospitalizations. The GOLD team hopes its services will help to reduce the number of ER visits and hospitalizations.

“As patient needs evolve, our approach to advancing better health in our communities has to evolve as well,” said Biogen Vice President of Asset Development and Portfolio Management and the Chair of the Biogen Foundation’s Board of Directors Teresa Cachero. “We’re thrilled to be working with the experts at BHCHP to make this important adaptation to support local seniors.”

Asked how she feels about the care she has received from the GOLD team, Lia smiles broadly. “I know I’m in good hands and I know they will make sure I’m in a good place,” she said. “I am very, very, very happy.”