Institute for Healthcare Improvement Selects CHCB, Inc. Age Friendly Geriatric Services Program For Older Adults Learning Community


Dr. Ahmad examines Ms. Doris Daniels.

The Institute for Healthcare Improvement (IHI), in collaboration with Mass General Brigham and the Milken Institute, has selected the Community Health Center of Buffalo, Inc. Age Friendly Geriatric Services Program to participate in the “Enhancing Rates of Cognitive Assessment for Older Adults Learning Community,” funded by the Davos Alzheimer’s Collaborative.

As a Learning Community member, CHCB, Inc. will receive a grant of $19,500 to support collaboration with healthcare organizations from across the United States in an eight-month program to accelerate progress toward timely detection, assessment, and improved outcomes for adults experiencing cognitive challenges

“We are one of the few primary care systems in Western New York to create an outpatient Geriatric Program,” explained Dr. Shahla Ahmad, MD, CCFPT, CHCB, Inc. Family, and Geriatric Medicine Physician and Age Friendly Geriatric Program lead. “This is a widely sought initiative as many elderly patients do not have access to specialized geriatric care outside the inpatient setting. We are looking forward to learning from our cohort partners on how to improve our workflow, coordination of care, and screening process within a primary care setting.”

“Our greatest goal is to enhance comprehensive elderly care to underserved urban populations,” added Dr. Ahmad.  “Our mission is to be able to screen and detect geriatric syndromes such as cognitive impairment, frailty, fall risk, polypharmacy, mental health, and malnutrition at earlier stages so appropriate intervention and coordination of care can be provided.”

According to the Institute for Healthcare Improvement, early detection of mild dementia and Alzheimer’s Disease can have a profound impact on the care and treatment of older adults, yet one study showed that physicians were unaware of cognitive impairment in more than 40 percent of their cognitively impaired patients. With improved assessment and early detection, health systems can: adapt care processes and systems to address what matters most to older adults and their caregivers; improve key outcome measures; avoid complications in the treatment of co-morbid conditions; and reduce health disparities.


About the CHCB, Inc. Age-Friendly Geriatric Program

Under the leadership of Dr. Ahmad; and coordination of Dr. Ann-Marie John, Ph.D., MSN, BSN, RN, Director, Wellness and Prevention, the Community Health Center of Buffalo, Inc., has formed a team of experienced caregivers who have specialized training in treating older adults including Dr. Kenyani Davis, MD, MPH, Chief Medical Officer; Dr. Esra Mustafa, PharmD, Clinical Pharmacist; Megan Quinn, LCSW, Manager, Behavioral Health; and Mary Walker, MSW, Care Coordinator. Working together, with additional support from Dr. Arvela R. Heider, Chief Innovation Officer, their goal is to provide personalized, coordinated care; while addressing the medical, physical, and mental/behavioral health needs that are particular to older adults.

 The CHCB, Inc. Older Adults program of comprehensive care follows the “Five M” model. Over a series of coordinated visits, the Patient, and his/her caregiver, working closely with CHCB, Inc. providers, will receive close examination and diagnoses regarding:

  • Mobility – How to best maintain movement and flexibility to prevent falls and other possible accidents.
  • Mind – Understand changes that can occur in the brain with regard to cognitive, emotional, and behavioral health; and how to best maintain and enhance “brain health.”
  • Medication – Personalized medication consultation and evaluation; and how to best manage medications for maximum effectiveness and safest use.
  • Multi-complexity – For Patients with complex or chronic illnesses, how to ensure the best care/treatment plans.
  • What Matters Most – With a priority on personal dignity, and utmost respect, engage Patients in caring conversations regarding end-of-life choices and provide guidance with the Health Care Proxy process.

As CHCB, Inc. Geriatric Services program participants, older adults and their caregivers will also have access to a host of additional care services, all located “under one roof” and all accessible in coordination with an “Age-Friendly” care visit. These additional services include:

  • Dental Services, including Dentures (Complete and Partial)
  • Telehealth includes the easy ability to visit via computer or smartphone.
  • Nutritional support, including daily diet evaluation and recommendations for enhancements for “Food as Medicine.”
  • Ophthalmology Services include scanning for Diabetic Retinopathy (Damage to the blood vessels of the light-sensitive tissue at the back of the eye (retina) caused by Diabetes)
  • Outreach Services include home visits by CHCB, Inc. Outreach Nurses who will perform home assessments, provide immunizations and medication assistance, and other care services for home-bound Older Adult Patients.
  • Care Giver mental health support, education, and resource coordination assistance
  • On-Site Physical Therapy Center featuring state-of-art rehabilitation equipment and programs specialized for Older Adults.
  • On-Site Pharmacy
  • Assistance for housing instability, food insecurity, transportation problems, utility help needs, and home safety.
  • Patient Navigators who can assist with the coordination of treatment at Roswell Park Cancer Institute.
  • Education on chronic disease management and enrollment in Diabetes and Hypertension Programs

For more information:


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