Rural Geriatric Glue: A Nurse Practitioner–Led Model of Care for Enhancing Primary Care for Frail Older Adults within an Ecosystem Approach

OBJECTIVES: 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. DESIGN: Retrospective. SETTING: Primary care; cross-sector. PARTICIPANTS: Older adults living in a rural area in southwestern Ontario, Canada. MEASUREMENTS: 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.