Senior Services and Continuum Integration

As you get older and your health needs change, there may be times when you need specialized care at different facilities or from different providers. At VCU Health, our continuum integration services aim to provide smooth, seamless care from medical professionals who follow your progress from location to location. No matter how many inpatient, outpatient or home health services you need, we’ll make sure your care is well-coordinated and your various caregivers are kept well-informed.  

Our geriatric continuing care program team offers a multidisciplinary program led by board-certified physicians and nurse practitioners who meet patients wherever they are, whether it be a nursing facility, the hospital or house calls. Through collaboration with a broad range of interprofessional staff of clinicians and administrators, we provide a comprehensive program of compassionate clinical care for adults of any age who have complex needs.

To make an appointment or ask medical questions, please call us at (804) 254-3500.

A whole team that focuses on you 

Our team provides superior, evidence-based care to meet your needs and goals. We also offer patient education, self-management support and equal access for all patients. The team includes: 

• Doctors and nurse practitioners who will provide your medical and mental health care
• Clinical nurses to help you and the team coordinate your care
• A social worker to help with community resources and advance care planning 
• A psychiatrist to help with therapy and medications 
• A pharmacist to help you learn how to manage your medications 
• Administrative staff to coordinate office visits and answer calls

Lab and x-ray services are available on-site. For more information on what we offer, visit our locations page. 

Services

VCU Health has a range of clinical services for geriatric care and adults with functional limitations (i.e. significant disease burdens like spina bifida, hypertension and diabetes or early onsite dementia). These include:

• Ambulatory care (comprehensive primary care that includes help from a licensed social worker, psychiatrist and pharmacist)
• House calls (permanent, in-home primary care provided by a physician or nurse practitioner for VCU Health patients unable to come to VCU Health's ambulatory clinic. Patients must live within a 15 mile radius of VCU Medical Center)
• Transitional care
• Inpatient consults
• Nursing facility attending service (experts managing your rehabilitation) 
• Geriatric specialists

We are here for you

Your access to health care is important to us. That’s why we offer:

• Same day sick appointments
• Convenient parking
• Easy access: we are on the bus line (Route 91)
• Pharmacy support
• House calls after hospitalization and for homebound patients
• Providers in area nursing homes
• A shared electronic health record
• 24/7 phone contact with physicians

After Hours

Coverage of the geriatric clinic is provided 24-7-365 by a faculty member, available at (804) 254-3500.