The National Institutes of Health forecasts that by 2030, the number of Americans over age 65 will double to 71.5 million, or 20 percent of the U.S. population. Kaiser Permanente Georgia’s Elder Care program is designed to address the unique needs of this growing group.

Led by Dr. Carole Gardner, a board-certified geriatrician, the interdisciplinary Elder Care team works with physicians, other health professionals and caregivers to deliver coordinated care to senior members.  The team helps members avoid unnecessary hospital stays, emergency room visits and costly, debilitating complications. Through in-office appointments, telephone visits, and team meetings to discuss patient care, the team develops and implements care plans for the program’s patients. Team members’ disciplines include nursing, social work, clinical pharmacy, and geriatric psychiatry.

Who is eligible for Elder Care?

Kaiser Permanente’s Elder Care program is designed to address the needs of members age 65 or older and Medicare members under age 65.

The Elder Care team evaluates and coordinates care for members referred for problems such as memory loss or falls and those recently hospitalized and at high risk for hospitalization. The team is available to provide the Welcome to Medicare physical exam, a one-time specific assessment intended to promote health and detect disease for newly enrolled beneficiaries within the first 12 months of Medicare Part B coverage.

Specific programs and services provided through the Elder Care department include the Special Needs Plan (SNP) and Chronic Care Improvement Program (CCIP). For SNP members, who are dual eligible for Medicare and Medicaid, the team provides additional assistance and oversight, including more intensive care management. The team-developed individualized care plan helps each member receive appropriate care, with special emphasis on transitions across care settings and end-of-life issues.

Through the CCIP, the team assists high-risk members with two or more chronic conditions, including diabetes, heart failure, coronary artery disease and chronic obstructive pulmonary disease (COPD). Team members develop an individualized care plan that includes self-care guidance and support, setting specific goals for each member and referring to other Kaiser Permanente population care programs as appropriate. When goals are achieved, members are discharged from the CCIP.

Health Education Classes

Kaiser Permanente offers a number of no-cost classes to help members manage medical concerns such as kidney disease, insulin usage, pain management and heart disease. Team members teach senior-related health education classes addressing caregiver needs, fall prevention, normal aging and common conditions and medication issues. Elder Care team members participate in Healthy Aging seminars which are offered in senior centers, churches and retirement communities.

Convenient Care

Kaiser Permanente has more than 20 conveniently located medical offices throughout metro Atlanta. Most include an on-site pharmacy, laboratory and radiology services. Many are open in the evening and some offer weekend appointments.

Dedicated Medical Professionals

In Georgia, care is provided by members of The Southeast Permanente Medical Group (TSPMG), one of Georgia’s largest multi-specialty medical groups. More than 96% of TSPMG doctors have been recognized by one or more of their specialty groups, and many received training from some of the nation’s top medical schools, including Emory University, Harvard University and Duke University. When they visit a TSPMG clinician, members have secure, online access to their medical records and many lab results through kp.org.

Learn More

To learn more about the Elder Care program or refer a patient, please contact Sharon Henderson, RN, Manager for Elder Care, at 404-364-7042. You can learn more about Kaiser Permanente, and our integrated approach to care, at www.kp.org.