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.
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