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Geriatric Assessment and Intervention Network (GAIN) are specialized teams who provide interprofessional comprehensive geriatric assessments (CGA) and interventions with older adults and their care partners to optimize function and independence and keep older adults living at home.

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 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 older adults living with frailty.

 

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

Referrals

Referrals to GAIN are accepted from primary care providers, hospitals, community organizations, older adults, and their care partners.

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