What GAIN Does
The Geriatric Assessment and Intervention Network (GAIN) is comprised of eleven hospital- and community-based interprofessional teams providing Comprehensive Geriatric Assessments (CGAs), creating goal-based care plans with older adults and care partners. GAIN clinicians also provide time-limited interventions to help optimize function, independence, and overall quality of life.
Our Goals
Help older adults live safely and comfortably at home for as long as possible.
Reduce avoidable emergency department visits and hospital admissions.
Prevent early or unnecessary transitions into long-term care.
Our Team
GAIN interprofessional teams are Nurse Practitioner (NP) led and supported by:
Pharmacists
Occupational Therapists/Physiotherapists
Social Workers
Registered Nurses/Registered Practical Nurses
Behavioural Support Clinicians
Dietitians
GAIN teams are also supported by Physicians (Geriatricians and/or Care of the Elderly). There is variation in the size and composition of the team.
Proven Program Impact & Benefits
Our specialized, team-based approach delivers measurable health outcomes and significant value to the healthcare system. According to our recent GAIN Return on Investment (ROI) Report:
The program generated an estimated +150% ROI, delivering over $23 million in annual health system benefits.
Read the Full GAIN Return on Investment Report
 | 66% of clients maintained or improved their frailty status. |
 | 68% of clients stabilized or improved their dementia staging scores. |
 | 69% of clients experienced a reduction in falls or fall risk following their initial assessment. |
 | 1 in 3 clients reduced their emergency department utilization. |
*Source: Seniors Care Network GAIN ROI Evaluation (2025)
Referral Process & Criteria
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
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 care partner burden/stress due to caregiving responsibilities, etc.
Who Can Refer?
We welcome referrals from:
Physicians and Specialists
Healthcare Professionals (Pharmacists, Community Paramedics, etc)
Community Agencies (Ontario Health at Home, Community Care Organizations, Alzheimer Societies, etc)
Family Members, Care Partners, or Self-Referrals
How to Submit a Referral
Locate a Team: Review the interactive map below to find the GAIN team serving your local area.
Submit: Click on your preferred location pin on the map to access direct Ocean e-Referral links, or download our fax referral form.
Confirmation & Next Steps: Once a referral is submitted and reviewed, our team will contact the client, care partner, or referring provider.
Note on Service Duration: GAIN is a time-limited, goal-directed service. We work in close partnership with primary care providers and community organizations. Once goals are met, clients are discharged back to the primary care team or appropriate community services. Repeat referrals are welcome at any time should new needs arise.
Interactive Team Locations Map
Click a pinned location on the map to view team details and launch the Ocean e-Referral portal.
What Patients & Care Partners Say
"The staff were so kind, very knowledgeable, very comprehensive exam, very thorough." — GAIN Client
' Visits went very well. The GAIN team was very thorough with their assessments and the doctor explained things in a simple but very understandable way." — GAIN Client
' Staff always listened and respected me as caregiver. Share their expertise and offered programs that would clearly make a difference in our lives. Provided handouts were extremely helpful." — Care Partner
Learn more about the dedicated professionals guiding our network. Meet the GAIN Leadership Team.