Every patient referred will receive a Comprehensive Geriatric Assessment (CGA) completed by a geriatric assessor (GA) and the geriatrician/care of the elderly physician. The CGA guides a multidimensional specialized geriatric team approach to care that determines a frail older adult’s biomedical, psychosocial, functional, and environmental needs. The team initiates an appropriate treatment and follow-up plan developed with the patient/family/care partner and integrated with primary care, NELHIN Home and Community Care as well as other care partners along the specialized geriatric services (SGS) continuum of care.