Geriatric Assessment and Intervention Network (GAIN)

Health professional teams providing comprehensive assessments and creating care plans with seniors and families to optimize function and independence and keep seniors living at home.

GAIN teams provide specialized geriatric care to support frail seniors living at home or in retirement residences, who have multiple complex medical and social problems including:

  • Cognitive impairment
  • Responsive behaviours
  • Decreased function
  • Falls or risk of falls
  • Impaired mobility
  • Incontinence and/or
  • Multiple medications

Frail older adults experiencing changes in support needs, safety concerns, psychosocial and mental health concerns or frequent health service usage will benefit from the services offered by their local GAIN team. Depending on the needs of a particular individual, an interprofessional care team is created to provide the required support to increase the capacity for frail older adults to remain in their home in the community.

GAIN teams draw upon the expertise of nurse practitioners, physiotherapists, occupational therapists, social workers, pharmacists, personal support workers, dedicated GAIN/Community Care Access Centre Coordinators, dedicated Behavioural Supports Ontario (BSO) clinicians, collaborating Geriatricians and other specialists.

Referrals to GAIN are accepted from primary care providers, hospitals, community organizations and seniors and caregivers.

To access Behavioural Supports Ontario (BSO) services for persons living in the community, please submit a referral to your local GAIN Team.

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