What GAIN Does
The Geriatric Assessment and Intervention Network (GAIN) is a network of 11 hospital- and community-based interprofessional teams. We provide Comprehensive Geriatric Assessments (CGAs) and partner with older adults and their care partners to create personalized care plans that 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
Each GAIN team is an interprofessional group supported by may include:
Nurse Practitioners & Registered Nurses/Registered Practical Nurses
Pharmacists
Occupational Therapists & Physiotherapists
Social Workers
Behavioural Support Clinicians
Registered Dietitians
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.
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 provides time-limited, specialized geriatric services primarily tailored for individuals aged 65 and older who are experiencing complex health conditions (also referred as Frailty), cognitive changes, or frailty.
Common Reasons for Referral
Cognitive Changes: Memory loss, confusion, or decline in cognitive function.
Functional Decline: Increasing difficulty with daily activities (e.g., preparing meals, personal hygiene, managing finances, or taking medications safely).
Mobility & Safety: Unsteadiness, changes in mobility, or recent falls.
Caregiver Stress: Heightened strain or burnout experienced by family members or care partners.
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, Caregivers, 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 to confirm appointment details.
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 & Caregivers 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 Giver
Learn more about the dedicated professionals guiding our network. Meet the GAIN Leadership Team.