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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.

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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.

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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. 

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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.

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Learn more about the GAIN Leadership Team

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

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