How Geisinger’s innovative program is redefining primary care for older adults.
As Central Pennsylvania’s population ages, the region’s leading healthcare system is exploring new models to meet the unique needs of older adults. Geisinger’s 65 Forward program, led by Dr. Cybele Pacheco, director of senior-focused primary care, is one such initiative, offering an innovative approach to primary care for Medicare Advantage members.
Dr. Pacheco emphasized that older adults are not simply “older versions” of the average patient – just as pediatric patients are not “small adults.” Aging introduces distinct biomedical and functional considerations: changes in medication metabolism and pharmacodynamics, increased vulnerability to balance and mobility issues, and a heightened need for coordinated, interdisciplinary care. She noted that these factors require a deliberately tailored approach, not a scaledup version of traditional primary care.
“Practicing medicine in Central Pennsylvania is probably the majority of the impetus behind any of our care models when we develop them,” Dr. Pacheco said. “We have a traditional primary care office, our senior-focused 65 Forward clinic, a PACE program for all-inclusive care of the elderly, as well as community-based and hospital-at-home programs. These entry points allow us to meet patients where they are, whether at home or in the clinic.”
The PACE program (Program for All-Inclusive Care of the Elderly) is a national initiative providing wraparound services to nursing home–eligible patients, enabling them to live independently at home. Geisinger also offers primary care services in skilled nursing facilities and provides intensive care at home for patients who are home-bound. Within this spectrum of services, 65 Forward fills a critical niche: delivering intensive, senior-focused primary care in a clinic setting.
“One of the drivers behind 65 Forward was understanding the needs of an aging population,” she said. “We wanted to ensure that our communities receive care sensitive to these needs, with a focus on maintaining independence and quality of life.”
While expanding access to Geisinger Gold, the organization’s Medicare Advantage plan, was part of the initial plan, Dr. Pacheco noted that the program quickly revealed a broader need. Many older adults already receive excellent care from existing providers, yet the 65 Forward cohort highlighted the importance of intensive primary care – particularly for patients with multiple chronic conditions who require more support than traditional primary care can provide.
At the heart of 65 Forward is a value-based care model, which focuses on outcomes rather than volume. Providers are evaluated not by the number of patient visits but by quality metrics, including panel outcomes, utilization patterns, and the management of medications within the health system to optimize cost and safety.
“Value-based care is really about action,” Dr. Pacheco said. “It’s about spending time with patients, proactive outreach, and integrated support services. Our goal is to improve overall health outcomes while controlling costs, rather than simply generating more visits.”
This approach contrasts sharply with traditional fee-for-service models, where providers are often incentivized by volume rather than outcomes. Dr. Pacheco noted that primary care, when done right, can be protective against unnecessary utilization and overall healthcare costs, especially for older adults. Regular, coordinated primary care prevents complications, reduces hospitalizations, and keeps patients healthier longer.
Since its inception, 65 Forward has grown into a model demonstrating the benefits of personalized, senior-focused care. By combining intensive primary care with a value-based approach, the program aims to set a new standard for how health systems care for aging populations – not just in Central Pennsylvania, but as an example for broader adoption.
“Primary care is the cornerstone of health,” Dr. Pacheco said. “And for older adults, it needs to be intensive, proactive, and coordinated. That’s what 65 Forward delivers every day.”
Data-driven teams
At Geisinger’s 65 Forward program, delivering senior-focused primary care goes far beyond traditional office visits. The model emphasizes data-driven, proactive care and smaller, highly coordinated teams, ensuring that older adults receive personalized attention while optimizing health outcomes.
Dr. Pacheco said: “In a value-based care model, we lead with data. It drives our clinical decision-making rather than relying on gut feelings.”
For example, the team closely monitors drivers of hospital utilization, such as sepsisrelated admissions. By reviewing recent hospitalizations and emerging clinical patterns, providers can quickly identify patients who require tighter followup or intensified care management. This enables timely intervention, reduces the risk of complications, and ensures the approach remains condition-focused and tactical – directing attention to the patients who need it most.
Beyond clinical outcomes, 65 Forward places a high priority on patient experience and trust. “People have a choice,” Dr. Pacheco explained. “We focus on seamless workflows, standardized check-ins, and follow-ups across our clinics. Trust and relationship are the foundation – patients need to know that when they don’t feel well, we’ll see them.”
To maintain that level of access, 65 Forward uses smaller provider panels, which allow clinicians to spend more time with each patient. While this approach increases administrative costs, it ensures higher-quality care and better management of complex patient needs.
The clinic team includes doctors, a telemedicine advanced practitioner, registered nurses, medical assistants, licensed practical nurses, patient access representatives, and embedded pharmacists. Many staff members are cross-trained, allowing them to perform multiple roles, streamline workflows, and enhance patient experience. Telemedicine also plays a key role in building digital literacy among older adults, offering another avenue for accessible, high-quality care.
Dr. Pacheco emphasized that metrics are central to success. “We track everything from patient feedback to total cost of care,” she said. “Scaling the model is challenging because it’s expensive, but bending total cost of care is mission-critical. Even if the program performs well clinically, it must also be sustainable for both the health system and patients.”
Lessons learned
Since its launch in 2019, Geisinger’s 65 Forward program has provided valuable insights into how to deliver intensive, senior-focused primary care while attempting to scale the model across Central Pennsylvania. Dr. Pacheco, who also practices in the clinics, shared some of the key learnings and challenges that have shaped the program’s evolution.
One of the first lessons involved clinic footprint and location strategy. Some facilities are larger than necessary, while others might have been more effective as offshoots of existing primary care locations. “All of this is hindsight – you don’t know until you know,” Dr. Pacheco said, reflecting on decisions made early in the program’s design.
Another critical lesson has been the need for complexity-adjusted patient panels. Early on, providers were told they would all receive uniformly smaller panels, but experience quickly demonstrated that a one-size-fits-all approach doesn’t reflect the reality of patient complexity. “Higher-complexity patients require smaller panels, while lower-complexity patients allow providers to manage more,” Pacheco explained.
Shifting to complexity-based paneling has required thoughtful change management and deliberate trust-building with providers. Ensuring that clinicians understand why panel sizes may differ – and how those decisions are tied to patient acuity and risk – has been essential to sustaining engagement and maintaining confidence in the model.
The program has also sparked a mindset shift among providers. Dr. Pacheco emphasized that primary care is more demanding than most people realize. Providers must balance documentation, quality metrics, proactive outreach, and patient engagement – all while maintaining a personalized experience for each patient. Expanding panel size too quickly can risk compromising quality, patient experience, or utilization outcomes.
The providers in 65 Forward function like an Olympic-caliber team. These clinicians already excel in traditional primary care, and the smaller panel size gives them the capacity to go deeper with patients who have more complex needs. The entire care team – from pharmacists and RNs to patient access representatives – operates at the top of their license, supported by tightly integrated resources designed to deliver a value-based, senior-focused model of care.
Dr. Pacheco noted that upfront transparency about expectations and scope is essential for success. By clearly communicating roles and responsibilities and aligning panel size with patient complexity, 65 Forward ensures that providers can deliver intensive, high-quality care without sacrificing outcomes or patient experience.
These lessons highlight the careful balance required to scale a specialized primary care model: maintaining efficiency, supporting providers, and meeting the unique needs of an aging patient population, all while remaining true to the program’s value-based care philosophy.
Operating at the highest level
Care models like 65 Forward represent meaningful progress toward the kind of valuedriven, seniorfocused delivery CMS is signaling across Medicare Advantage. But the economics are complex. “These programs require substantial upfront investment and disciplined financial architecture, and we’ve seen organizations exit similar models when the economics weren’t fully aligned,” Dr. Pacheco said. The imperative now is ensuring that innovative care delivery is matched with sustainable payment design.
A critical shift lies in equipping care teams to make smarter, patient-centered decisions. Rather than defaulting to emergency department referrals, providers are encouraged to evaluate patients first, use outpatient resources when appropriate, and intervene proactively. “If you give providers the right time and space to care for patients, they’ll do the right thing,” Dr. Pacheco said. “It’s about letting our teams operate at their highest level, making the best choices for patients while managing costs effectively.”
With 65 Forward, the delivery system and the health plan are fully connected, giving Geisinger a comprehensive, real-time view of patient needs. “We can see ED use, hospitalizations, and high-risk indicators as they emerge, not months later through claims lag,” she said. “That means we can intervene sooner, manage risk more effectively, and avoid avoidable costs. The ability to act at the moment a threshold is reached is what sets this model apart.”
This dual perspective – delivering care while managing the plan – reinforces the value-based philosophy. Instead of focusing on volume, the clinic emphasizes outcomes, condition-specific interventions, and proactive patient management. “We want to be very specific rather than spreading initiatives thinly across the population,” Dr. Pacheco said. “That’s where the path forward lies: targeted, data-driven, value-based care that truly meets patients where they are.”
Training providers for a value-based model
Implementing a program like 65 Forward requires training experienced providers to think and act differently in a value-based care environment.
Dr. Cybele Pacheco emphasizes that onboarding is foundational in a value-based care environment. “If I could design it from the beginning, I would build a dedicated onboarding program specifically for value-based care,” she said. “This model requires providers to interpret data in ways that traditional medical training doesn’t prepare them for.”
Clinicians must understand patient attribution, data integrity, and the ways their decisions influence outcomes – competencies that become essential under risk-based arrangements. Epic supports this work by giving providers the ability to drill into their panels, track utilization, review medication patterns, and monitor condition-specific metrics. But working with these tools is not straightforward. Filtering, slicing, and analyzing data within an electronic medical record is inherently complex,
Beyond data literacy, onboarding also needs to develop a new mindset around proactive patient management. Knowing that 75% of a panel is current on colorectal cancer screening isn’t the goal – the goal is identifying the remaining 25% and taking concrete next steps, whether that’s scheduling colonoscopies, coordinating alternative screening methods, or arranging followups.
“In a value-based model, providers need to know exactly where to pick up the pieces,” Dr. Pacheco explained.