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.