Who We Are
Seniors Care Network is responsible for the organization, coordination and governance of specialized geriatric services (SGS) in the Central East Region of Ontario Health East.
Key services include the planning, design, implementation, evaluation, quality improvement, and performance monitoring of SGS. Applied health research is a key component of Seniors Care Network’s mandate. Additionally, subject matter expertise is provided to partner organizations including Ontario Health Teams.
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What's New
Central East Cognition Referral Pathway Guidance Document
The Central East Cognition Referral Pathway Guidance Document is an evidence-informed resource designed to support the early identification of cognitive concerns and timely access to appropriate services for older adults. Intended for primary care providers and Specialized Geriatric Services, it provides a structured approach to screening, referral decision-making, and care coordination by incorporating both cognitive and frailty considerations.
The guidance document is not a clinical pathway. Rather, it supports consistent referral practices, service navigation, and transitions across the continuum of care. Tested through a regional pilot evaluation, the approach demonstrated potential for improved referral appropriateness and alignment between patient needs and service connections, helping to promote more person-centred care for older adults and their care partners.
Adapted Comprehensive Geriatric Assessments for Vulnerable Older Adults, Including those experiencing Housing instability and Homelessness
Older adults experiencing homelessness face accelerated aging and complex multimorbidity, yet they often remain underserved by traditional care models that assume housing stability. Person-centred assessment approaches, including the use of an adapted Comprehensive Geriatric Assessment (CGA) template, are needed to address the unique needs of vulnerably housed populations. The Guidance document describes a framework that incorporates trauma-informed approaches and evaluates structural barriers such as medication access, nutrition, and hygiene. Implementing this adapted CGA allows interprofessional teams to distinguish medical conditions from social contributors to decline, supporting realistic, client-driven care plans that improve diagnostic clarity and reduce avoidable acute care utilization.
Integrating Frailty into Chronic Disease Management: Enhancing Care for Older Adults living with Complexity
Unrecognized or unmanaged frailty can impact the achievement of desired outcomes for individuals living with chronic conditions such as Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), Diabetes Mellitus (DM), etc. The Guidance Document details a practical, 4-step approach for integrating frailty-informed care into Chronic Disease Management for older adults. Frailty is a dynamic condition that influences clinical outcomes, self-management capacity, and risk of harm. Identifying and addressing frailty early allows primary care providers and specialty care teams to tailor care plans, mobilize appropriate supports, and improve quality of life.