A geriatric care team is a group of doctors and specialists who focus on the medical and practical needs of older adults, not a single person or a place you go to
The team typically includes a primary care doctor trained in geriatrics, a nurse coordinator, a social worker, and sometimes a physical therapist, pharmacist, or mental health counselor. They work together to manage multiple health conditions at once, coordinate appointments across different specialists, and help with the non-medical side of aging—like home safety, transportation, and family planning. The team may be based at a hospital, a clinic, or a senior center, or they may come to your parent's home.
What makes this different from seeing separate doctors is that everyone on the team talks to each other. Your parent's geriatrician knows what the cardiologist prescribed, what the social worker found out about their living situation, and whether they are actually taking their medications. This coordination prevents the common problem where one doctor prescribes something that conflicts with another doctor's treatment, or where your parent falls through the cracks between specialists.
Key Takeaways
- A geriatric care team coordinates medical care across multiple conditions and specialists, which is different from managing each doctor separately.
- The team includes a geriatrician or primary care doctor, a nurse coordinator, and a social worker at minimum, with other specialists added based on your parent's needs.
- You will need to share medical records, current medications, and information about your parent's living situation and daily routines at the first visit.
- The team will likely recommend changes to medications, home modifications, or support services, and will follow up regularly to see what is working.
- Finding a geriatric team often means calling your parent's current doctor for a referral, or contacting a local hospital's geriatric medicine department directly.
Who is on the team and what each person does
The geriatrician or primary care doctor trained in geriatrics leads the team. This doctor has extra training in how aging changes the body, how medications work differently in older adults, and how to manage multiple conditions without making things worse. They see your parent regularly and make decisions about treatment based on what matters most to your parent—not just what the textbook says.
The nurse coordinator is often the person you will talk to most. They track appointments, make sure test results get to the right doctor, remind your parent about medications, and call to check in between visits. They are the person who knows your parent's routine and can spot when something has changed.
The social worker figures out what your parent needs outside the doctor's office: whether they can afford medications, whether their home is safe to live in alone, whether they need help with meals or transportation, and what community programs exist. They also help with the harder conversations—like whether your parent should still be driving, or whether it is time to move to a different living situation.
Other team members may include a physical therapist (to help with strength and balance), a pharmacist (to review all medications and catch problems), a mental health counselor (for depression or anxiety, which are common in older adults), or a nutritionist. The team adds these specialists based on what your parent actually needs, not automatically.
What happens at the first visit
Bring a list of all current medications, including over-the-counter drugs and supplements. Bring recent test results and records from other doctors if you have them. If your parent has trouble remembering details, bring a family member who knows their medical history. The first visit is longer than a regular doctor's appointment—usually 60 to 90 minutes—because the team is building a full picture.
The geriatrician will ask about your parent's medical history, but also about daily life: Can they get out of bed alone? Do they cook their own meals? Who lives with them? Do they drive? Have they fallen recently? These questions matter because they shape what treatment makes sense. For example, a medication that causes dizziness might be a bad choice for someone who lives alone and has fallen before.
The social worker will ask about finances, family support, and what your parent wants for the future. This is when you mention if your parent is struggling to pay for medications, if they are isolated, or if you are worried about their safety at home. The team uses this information to make a plan.
What the team will likely recommend
Geriatric teams often find that older adults are taking too many medications. The pharmacist will review everything your parent takes and may recommend stopping some drugs that are not helping or that are causing side effects. This is not about cutting corners—it is about recognizing that the risks of some medications outweigh the benefits as people age.
The team may recommend home modifications: grab bars in the bathroom, better lighting, removing tripping hazards, or a medical alert device. They may suggest physical therapy to improve balance and strength, which prevents falls. They may refer your parent to a community program—a senior center, a meal delivery service, a transportation program—to address isolation or practical needs.
If your parent has memory problems, the team will likely order cognitive testing and may refer to a neurologist or memory specialist. If depression or anxiety shows up, they will recommend counseling or medication. The team thinks about the whole person, not just one disease.
How often you will see the team and what follow-up looks like
Most geriatric teams see patients every three months for a regular visit, though this changes based on how stable your parent's health is. Between visits, the nurse coordinator may call to check in, especially if your parent is adjusting to a new medication or dealing with a recent health change.
After each visit, you should receive a summary of what was discussed and what the plan is. This summary goes to your parent's other doctors too, so everyone stays on the same page. If your parent is hospitalized or goes to the emergency room, tell the hospital that they are part of a geriatric care team—the team may be able to help with discharge planning and follow-up.
The team will adjust the plan as your parent's needs change. If a medication is not working, they will try something else. If your parent's living situation becomes unsafe, they will help explore options. This is not a one-time assessment—it is ongoing coordination.
How to find a geriatric care team
Ask your parent's current primary care doctor for a referral to a geriatrician or geriatric medicine program. Many primary care doctors have relationships with local geriatric teams and can send your parent directly. If your parent does not have a primary care doctor, call the geriatric medicine department at the nearest hospital and ask how to get your free guide.
Some geriatric teams are based at academic medical centers or large health systems and may have a waiting list. Others are in private practices or community health centers and may have shorter wait times. Ask about wait times when you call, and ask whether the team accepts your parent's insurance.
If your parent is homebound or has severe mobility problems, ask whether the team offers home visits. Some geriatric programs specialize in house calls and coordinate care entirely from your parent's home. This is less common but exists in many areas.
What to bring and how to prepare
Before the first appointment, gather: a list of all medications with doses and how often they are taken, a list of all doctors your parent sees and what they treat, recent lab results or test reports, a list of any allergies or bad reactions to medications, and information about your parent's living situation (who lives with them, whether they live alone, whether they rent or own). If your parent has a notebook or folder where they keep medical papers, bring that.
Write down questions or concerns before the visit. If you are worried about your parent's memory, their safety at home, their mood, or whether they can manage medications alone, mention it. The team cannot help with problems they do not know about.
If your parent has trouble communicating or understanding, bring a family member who can help translate or advocate. The team needs accurate information to make a good plan, and sometimes your parent will not mention something that matters—like that they are not taking a medication because it makes them nauseous, or that they are falling at night.
Frequently Asked Questions
Does my parent need a referral from their regular doctor to see a geriatric team?
Most insurance plans require a referral, so ask your parent's current doctor first. If your parent does not have a primary care doctor, call the geriatric medicine department directly and ask what they need. Some programs will see patients without a referral if you pay out of pocket, though this is less common.
What if my parent does not want to see a geriatrician?
Start by asking why. If they think it means they are "old" or "sick," explain that geriatricians specialize in keeping older adults independent and managing multiple conditions well. If they are happy with their current doctor, ask that doctor whether they have training in geriatrics or whether they would be open to consulting with a geriatric team. Sometimes a conversation with the doctor your parent trusts makes a difference.
Will the geriatric team take over my parent's care from their other doctors?
No. The geriatric team coordinates with other doctors but does not replace them. Your parent's cardiologist still manages heart disease, the eye doctor still handles vision, and so on. The geriatrician makes sure all these treatments work together and do not conflict.
How much does a geriatric care team cost?
Cost depends on your parent's insurance and the program. Most Medicare plans cover geriatric visits the same way they cover regular doctor visits. If your parent has Medicaid or private insurance, coverage varies. Ask about cost when you call to schedule, and ask whether the program offers financial help if cost is a barrier.
Can a geriatric team help if my parent is in a nursing home or assisted living?
Some geriatric teams work with facilities and will coordinate care for residents. Others focus on community-dwelling older adults. Ask the facility's doctor whether they work with an outside geriatric team, or call a local geriatric program and ask whether they serve people in your parent's facility.