title: Rural geriatric glue: a nurse practitioner-led model of care for enhancing primary care for frail older adults within an ecosystem approach.
abstract: OBJECTIVE
  This article describes the implementation of the Care for Seniors model of care, an innovative approach to improving care coordination and integration, and provides preliminary evidence of effective use of specialist resources and acute care services.
  
  
  METHODS
  Retrospective.
  
  
  METHODS
  Primary care; cross-sector.
  
  
  METHODS
  Older adults living in a rural area in southwestern Ontario, Canada.
  
  
  METHODS
  Number of new geriatrician referrals and follow-up visits before and after the launch of the Care for Seniors program, number of Nurse Practitioner visits in a primary care setting, in-home, retirement home and hospital, number of discharges home from hospital and length of hospital stay between.
  
  
  RESULTS
  In the 2 years before the launch of the program, the total number of visits to the geriatrician for individuals from this FHT was relatively low, 21 and 15, respectively for 2005-06 and 2006-07, increasing to 73 for the 2011-12 year. Although the absolute number of individuals supported by the NP-Geri has remained relatively the same, the numbers seen in the primary care office or in the senior's clinic has declined over time, and the number of home visits has increased, as have visits in the retirement homes. The percentage of individuals discharged home increased from 19% in 2008-09 to 31% in 2009-10 and 26% in 2011-12 and the average length of stay decreased over time.
  
  
  CONCLUSIONS
  This model of care represents a promising collaboration between primary care and specialist care for improving care to frail older adults living in rural communities, potentially improving timely access to health care and crisis intervention.
authors.affiliation: Division of Geriatric Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada; Division of Geriatrics, Department of Medicine, St Mary's General Hospital, Kitchener, ON, Canada.
authors.forename: Sadhana
authors.initials: S
authors.lastname: Prasad
authors.forename: Wendy
authors.initials: W
authors.lastname: Dunn
authors.forename: Loretta M
authors.initials: LM
authors.lastname: Hillier
authors.forename: Carrie A
authors.initials: CA
authors.lastname: McAiney
authors.forename: Rex
authors.initials: R
authors.lastname: Warren
authors.forename: Paul
authors.initials: P
authors.lastname: Rutherford
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D016330:Frail Elderly; D005851:Geriatric Nursing / Q000458:organization & administration*; D006297:Health Services Accessibility; D006699:Home Care Services / Q000458:organization & administration; D006707:Homes for the Aged; D006801:Humans; D009722:Nurse Practitioners; D009864:Ontario; D010348:Patient Care Team / Q000458:organization & administration*; D011320:Primary Health Care / Q000458:organization & administration*; D015397:Program Evaluation; D012017:Referral and Consultation; D012189:Retrospective Studies; D019035:Rural Health Services / Q000458:organization & administration*
keywords: chronic disease management; frail older adults; geriatric care; nurse practitioner; primary care