Douglas C. Duke, MD, CCFP, Seniors Health, Northeast Community Health Centre, Edmonton, AB.
Teresa Genge, MN, Nurse Practitioner, Seniors Health, Northeast Community Health Centre, Edmonton, AB.

The delivery of relevant and coordinated health care to community-dwelling frail older adults is challenging. The community-based program described in this article applies a collaborative and flexible approach to the management and coordination of care of frail older adults. Although a feature of the program is its small size, its connection with professionals and services within a comprehensive health care system creates a much larger “virtual team.” Effectiveness of care is maintained through ongoing communication with care providers and the development of connections within the larger team.
Key words: frail older adults, geriatric evaluation and management, community-based care.

Hannah Hoag, MSc
Contributing Author,
Geriatrics & Aging.

Approximately 8% of Canadians over the age of 65 suffer from some form of dementia. Alzheimer disease accounts for the majority of dementia cases (64%), with vascular dementia the next most common form. This translates to 364,000 Canadians, 65 years of age and older with dementia, and approximately 109,900 new diagnoses this year.¹

The individual suffering from dementia requires a safe physical environment and access to supportive services offering dynamic care that can change with his or her symptoms. Accurately determining the needs of each individual may be difficult for the general practitioner or may be confounded by a clinical environment that the patient may find overwhelming and intimidating. Psychogeriatric home visit services might provide the answer.

In 1980, the Queen Street Mental Health Centre launched the Psychogeriatric Assessment Consultation and Education (PACE) program in Toronto's East-End. A needs assessment of the community and pilot project had previously determined that aging and elderly citizens desired community-based mental health services that would allow them to receive complete assessment, care and follow-up from the comfort of their own homes.

Since then, the Queen Street Mental Health Centre has amalgamated with the Addiction Research Foundation, the Clarke Institute of Psychiatry and The Donwood Institute to form the Centre for Addiction and Mental Health (CAMH).