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The North Perth Family Health Team, Listowel, Ontario serving a population of approximately 17,000 has created a model to support seniors and families with navigation and transition from sector to sector. Wendy Dunn, Nurse Practitioner (NP), has specialized geriatric education, works closely with primary care physicians, consulting geriatrician, hospital, community agencies, and retirement homes by providing assessments where the senior is located. Regular visits are made to the local retirement homes every two weeks, the hospital weekly, a geriatric clinic with the consulting geriatrician monthly, and office and home visits as needed. Education is provided concurrently with these services, as part of chronic disease management.
                                                                              Dr Sadhana Prasad, Geriatrician
                                                                            Dr, Sadhana Prasad, Geriatrician