Inter-Disciplinary Outpatient Care Model Providing Comprehensive Geriatric Assessment, Care-Coordination & Co-management

"1. Comprehensive Geriatric Assessment (3 visits with a geriatrician alternating with 3 primary provider visits over 6 months)~2. Care Planning with Interdisciplinary Team~3. Care coordination~4. Co-management with Primary care~5. Social work needs assessment~6. Patient-centered telehealth using phone, home telehealth, patient portal, Video~7. Transportation provided for all visits~8. Referral to Geriatric primary care clinic and mental health per Veteran need~9. Goals of Care and Veteran preferences conversation~10. Educate primary care providers about HNHR population, home and community based services, collaboration"

No intervention or treatment will be provided.