Geriatric Assessment and Intervention Network

 

GAIN teams provide interprofessional comprehensive geriatric assessment (CGA) and specialized geriatric care to support frail seniors living at home or in retirement residences, who have multiple complex conditions and frailty. Through the interprofessional CGA, teams assess the following:

  • Reason for Referral/Area of Concern
  • Medical and Surgical History
  • Medications
  • Continence
  • Social History
  • History of Falls
  • Functional Abilities
  • Cognition
  • Nutrition
  • Physical Health
  • Pain
  • Mood and Mental Health
  • Sleep

Older adults with complex health concerns including frailty, may experience changes in support needs, safety concerns, psychosocial and mental health concerns or frequent health service usage. These individuals will benefit from the services offered by their local GAIN team. Depending on the needs of a particular individual, interprofessional GAIN teams were created to provide the required support, and to increase their capacity 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 Nurse Care Coordinators, dedicated Behavioural Supports Ontario (BSO) clinicians, and other interprofessional team members. Our GAIN Team members have completed additional training as Geriatric Assessors, and are skilled in goal-based care planning and interventions for frail older adults.

Interprofessional 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 collaborate with geriatric specialist physicians (i.e. Geriatric Medicine, Geriatric Psychiatry, and Care of the Elderly) and other physician specialists.

Referrals to GAIN are accepted from primary care providers, hospitals, community organizations and seniors and their family/friend care partners.

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