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
Community Paramedicine Frailty Pathway
Community paramedics are uniquely positioned to support coordinated care through early frailty identification, risk stratification, targeted interventions, and proactive service connections. The decision-tree outlines an innovative Community Paramedicine Frailty Pathway that uses a standardized, stepwise approach to integrate frailty into chronic disease management and ongoing patient monitoring. By facilitating timely referrals to Specialized Geriatric Services, rehabilitation programs, community supports, and other healthcare resources, the pathway promotes proactive frailty management. This approach can improve patient outcomes, reduce avoidable emergency department utilization, and help delay or prevent permanent institutionalization, supporting older adults to remain safely and independently in their communities for longer.
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 (SGS), it provides a structured approach to screening and referral decision-making by incorporating both cognitive and frailty considerations.
The focus of the Pathway is not on directing clinical management. Rather, it supports consistent referral practices, service navigation, and transitions across the continuum. Tested through a regional pilot evaluation, the approach demonstrated potential for alignment between patient needs and SGS connections. Thereby, 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.