Presents model for interdisciplinary discharge planning team, with emphasis on functional status and improved coordination and continuity among providers. Describes design and implementation of such a program at university hospital. Explains how model resulted in more patients being discussed and served, with more emphasis on the functional…

Presents a model of outpatient interdisciplinary geriatric care provided at a veteran's hospital. Compares characteristics of patients served in this program with those in community-based geriatrics outpatient clinics described in the literature. (Author/ABB)