Our Programs

The Specialized Geriatric Services (SGS) that fall under the umbrella of Seniors Care Network are focused on older adults whose complex health concerns (including frailty and dementia) threaten their independence and function. The following programs reflect the use of enhanced geriatric expertise, interprofessional teams, and organizational collaboration. Together, we are sharing this expertise and ways to deliver care that is responsive to the needs of our clients/patients and care partner, which ultimately provides the best health experience for older adults and their care partners.

Geriatric Assessment and Intervention Network (GAIN) is a network of twelve hospital and community-based interprofessional health teams providing comprehensive geriatric assessments and creating care plans with older adults and 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.

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The Geriatric Emergency Management (GEM) Nurse Program is consisted of advanced practice nurses with specialized training in gerontological nursing who deliver emergency comprehensive geriatric assessment (eCGA) and interventions to older adults with complex health conditions and their care partners in the Emergency Department in order to connect them with community services and resources that better meet their health needs when they return home.

Read more about the GEM ROI report

Program Goal

The goal of the GEM Nurse Program is to deliver emergency comprehensive geriatric assessment (eCGA) and interventions to older adults and their care partners in the Emergency Department, in order to:

connect them with community services and resources that better meet their health needs; and
enhance their independence and quality of life.

Further, GEM nurses strive to build geriatric and senior-friendly care capacity in the hospital Emergency Department and local community partners, through collaboration, knowledge transfer, and education opportunities.

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.

GEM Nurses provide targeted, emergency geriatric assessment and interventions to older adults and their care partners in the ED, and connect them with community services and supports to better meet their health needs.

There are currently nine GEM Nurses working at nine hospital locations within the Region, including:

Peterborough Regional Health Centre, Peterborough
Ross Memorial Hospital, Lindsay
Northumberland Hills Hospital, Cobourg
Lakeridge Health:
- Ajax-Pickering Campus, Ajax
- Bowmanville Campus
- Oshawa Campus
Scarborough Health Network:
- Birchmount Campus, Scarborough
- Centenary Campus, Toronto
- General Campus, Scarborough

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 Team Locations

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.

The Central East sfCare Committee is comprised of representatives from all area hospitals collaborating to promote and provide strategic direction and leadership for the sfCare strategy within the Central East Region. Additionally, an objective of the Central East Adult Day Program Committee is to promote senior friendly care/different ability friendly care throughout 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 advance this goal in the Central East Region, Seniors Care Network established the Central East Senior Friendly Care Working Group. Our membership includes representatives from each Region's hospitals, Seniors Care Network, the Regional Geriatric Program of Toronto, and Central East Home and Community Care.

The purpose of the Working Group is to provide the strategic direction and leadership for Senior Friendly Care within the Central East Region. The Working Group fosters a culture where senior friendly care, which is woven into the fabric of care organizations.

What is A Senior Friendly Hospital?

Care seniors receive while in a hospital, and the hospital experience itself, can impact their health and well-being. A Senior Friendly Hospital is one in which the environment, organizational culture, and ways of care-giving accommodate and respond to seniors’ physical and cognitive needs, promote good health (e.g. nutrition and functional activity), maximize safety (e.g. preventing adverse events like a fall in the hospital), and involve patients – along with families and caregivers – to be full participants in their care. The aim is to enable seniors to maintain optimal health while they are hospitalized so that they can return home or transition to the next level of care that best meets their needs.

Shared Goals:

Having hospital leadership and support in place to make senior friendly care an organizational priority
Providing care based on best practices for seniors care so their independence is preserved
Delivering care and service in a way that is free of ageism and respects the unique needs of patients and their caregivers
Addressing unique ethical situations in seniors care and research as they arise
Ensuring the hospital’s physical environment minimizes the vulnerabilities of frail patients

Quotes from Working Group Members

“Being part of the Seniors Care Network SFH WG has created a platform of supportive leadership. It has assisted me in my vision to build excellence of care for seniors within my hospital. Seniors Care Network has created a network of expertise that our willing to share knowledge to implement change to enhance senior friendly care.”

“Belonging to the working group has helped us re-design our focus for our Geriatrics Operations and Performance Team, encouraged use of best practice for environmental design when ordering items like new chairs, commodes etc. as we have used the Code Plus document. It allows us to share practices with our peers in other hospitals in the Region.”

Resources of Interest

For more resources, please visit the resource portion of this site.