Our Programs

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.

The Geriatric Assessment and Intervention Network (GAIN) comprises of twelve hospital and community-based interprofessional teams providing comprehensive geriatric assessments (CGA), and creating care plans with older adults and care partners to optimize function and independence. GAIN’s primary goal is to help older adults live safely at home for as long as possible, to reduce hospital admissions/early admission to long-term care, and to improve their overall quality of life.

GAIN is a specialized geriatric service serving individuals, typically aged 65 and above, living with multiple, complex conditions (also referred to as frailty). Common reasons for referral include:

Cognitive decline (Memory changes)
Functional decline (e.g., recent/worsening difficulty with carrying out common daily tasks, e.g., meal preparation, shopping, maintaining hygiene, etc. new challenges with medications, financial mismanagement, etc.)
Recent falls or mobility changes
Increased caregiver burden/stress due to the caregiving responsibilities, etc.

The interprofessional teams comprise of Nurse Practitioners, Pharmacists, Occupational Therapists/Physiotherapists, Social Workers, Registered Nurses/Registered Practical Nurses, Behavioral Support Clinicians and/or Dieticians. GAIN teams are also supported by Physicians (Geriatricians and/or the Care of the Elderly). There is variation in the size and composition of the team.

Referrals are accepted from various sources including, physicians, any health professional – including pharmacists, Community Paramedicine, community partners (Ontario health at Home, Community Care organizations, Alzheimer Societies, etc.), and family members. GAIN also accept self-referrals.

GAIN is a time-limited service. Teams work in partnership with primary care and other clinical and community programs & services to best support the client. When appropriate, clients are discharged from GAIN with transfer of care to an appropriate clinician/service. Repeat referrals can be made at any time.

Learn more about the GAIN Leadership Team

Please see the map below for team locations and team specific e-referral links

The Geriatric Emergency Management (GEM) Nurse Program consists of advanced practice nurses with training in geriatric assessment. They are Registered Nurses (RN) with specialist training in gerontological nursing (GNC(c)) and/or Nurse Practitioners (NP-Adult) who deliver emergency comprehensive geriatric assessment (eCGA) and interventions to older adults living complex health conditions and their care partners in the Emergency Department.

Program Goals

deliver eCGA in the Emergency Department to older adults living with frailty;

connect older adults living with frailty and their care partners with community services and resources that better meet their health needs; and

build geriatric and senior-friendly care capacity in the hospital Emergency Department;

collaborate with local community partners to facilitate care, knowledge transfer, and education.

Meet the Need

Older adults represent as many as 30% of the patients seen in hospital Emergency Departments, more than any other age group. Health complexity and risks for rapid functional decline during a hospital visit can make Emergency Department visits a life changing experience for older adults and their care partners. By providing specialized geriatric services from a GEM Nurse in the Emergency Department, decline and loss of independence can often be prevented.

Our recent GEM Return on Investment (ROI) evaluation demonstrated an impressive monetary return of 354.27%—a clear testament to the value of these specialized geriatric services.

Read more about the GEM Return on Investment Report

The Nurse Practitioners who make up the Central East's NPSTAT team provide direct clinical care to the residents of Ontario Health East's long-term care homes (LTCH) by responding to acute and episodic changes in the residents’ condition to reduce unscheduled transfers to a hospital. In addition, NPSTAT Nurse Practitioners work with LTCH caregivers to support the sharing of geriatric expertise and to increase caregiver ability to support the increasingly complex clinical needs of LTCH residents.

Responding to the health risks that come with transferring frail seniors to hospital Emergency Departments, NPSTAT Nurse Practitioners are on-call to LTCH across the LHIN. Hospital or acute care settings have a focus on stabilizing and discharging the patient, a strategy that is not always consistent with the needs of long-term care residents.

NPSTAT works with homes and hospitals to enhance the emergency experience for frail seniors or to avoid a visit to the emergency department entirely where possible. Reducing avoidable hospital visits and admissions improves the health profile and health care experience of long-term care home residents, while maintaining or reducing the cost of providing appropriate care for those residents.

When LTCH residents are hospitalized, NPSTAT helps coordinate transitions back to the LTCHs which can decrease hospital length of stay, enhance continuity of care and communication between acute and long-term care facilities, and provide support and resources to LTCH staff to help manage returning LTCH residents with increasingly complex medical needs.

NPSTAT focuses on being both an outstanding care partner and system partner in supporting key LHIN program deliverables, while delivering the right care in the right place at the right time.

NPSTAT is active across the Region, triaging and responding to long-term care homes in the Scarborough, Durham, and Northeast clusters.

MINT Memory Clinics are interprofessional teams of family doctors, nurses, social workers, pharmacists, and others who are specially trained in caring for people living with dementia, and other memory difficulties. The team provides assessment, early diagnosis and ongoing care in a primary care setting.

The team also works closely with your own family doctor, with members of community groups like the Alzheimer Society, and specialist physicians to ensure
your care needs are met.

We are conveniently located in Scarborough, Durham, and Northumberland. For more information on these clinics, please click the appropriate link:

To learn more about MINT Memory Clinics, or to find other locations, please click here.

Launched in 2013, the Central East sfCare Committee is comprised of representatives from all area hospitals and the Regional Geriatrics Program of Toronto. The members collaborate to promote and provide strategic direction and leadership for the sfCare strategy within the Central East Region.

The goal of Senior Friendly Care (sfCare) is for healthcare providers in all sectors to work collaboratively with each other and with older adults and their caregivers to achieve the best possible outcomes for older adults. The sfCare Framework serves as the foundation for what senior friendly care should look like, and the sfCare Getting Started Toolkit provides a self-assessment tool and report card, implementation resources, and training modules.

To learn more about sfCare, visit the RGP of Toronto Website.

Our Programs

Trained health professionals and programming helping older adults with challenging behaviours resulting from complex mental health, addictions, dementia and other neurodegenerative issues. Click here to learn more.

Funded by: