GAIN Clinic improving health for seniors

James Greenhorn had been experiencing health issues since he was treated for kidney failure last Christmas. It was only after a trip to The Scarborough Hospital’s GAIN Clinic in the spring that James learned he had been taking his medication incorrectly.

“He was prescribed insulin and administering it himself, but he wasn’t shown the proper way to inject himself, and the doses were wrong for him,” explains James’ son, Ben. “The GAIN Clinic spent one-on-one time with him, and since then, he no longer has blurry vision, he’s steadier on his feet and he’s as sharp as a tack.”

James’ follow-up visits to GAIN have resulted in a significant improvement in his overall health.

The Geriatric Assessment and Intervention Network at TSH was launched in January of this year and, so far, has assessed and treated an average of eight patients a day. Part of the Central East LHIN’s ‘Aging at Home’ strategy, GAIN proactively delivers specialized geriatric care to frail seniors, enabling them to stay in the community and avoid unnecessary visits to the Emergency Department.

For James and his son Ben, the one-on-one consultations resulted in a positive outcome that allows James to continue to live independently in his home.

“He saw about eight different healthcare professionals at GAIN, and received excellent treatment,” Ben says. “GAIN is doing a great job!”

Bridget Anne Espey echoes those sentiments. She brought her husband Arthur into the GAIN Clinic with his family doctor’s referral.

“They left no stone unturned. It is good to have a place that takes an overall look at you, because you go to one doctor and they only see a particular thing about you, while another doctor sees something else,” Bridget Anne explains. “This (GAIN) is holistic, and it’s nice having someone looking over the whole picture.

“I would have no hesitation to come back to the GAIN Clinic if I needed to.”

James and Arthur share a story that is typical of the seniors who are referred to the GAIN Clinic by their primary care providers. Seniors over the age of 65 account for 23 per cent of all ED visits at TSH. That’s expected to increase as the population ages. The main goals of the GAIN Clinic are to improve outcomes for frail seniors, ensuring they receive healthcare at home or in the community while avoiding unnecessary visits to Emergency Departments.

“If a senior is already in the ED and they’re stable, we’ll try to get them out of there for an assessment at the GAIN Clinic,” explains Debbie Driver, Nurse Practitioner. “If they come directly to us, they bypass the ED completely, and that’s a bonus.”

Once in the clinic, patients get a clinical assessment from head to toe from an interprofessional geriatric team that includes nurse practitioners, social workers, occupational therapists, physical therapists pharmacists, CCAC case manager, and geriatric specialist physicians. The team is skilled at identifying other patient needs, and can link seniors with community resources.

“That’s why our CCAC case managers and Trans Care partners are so important,” Debbie says.

Since opening six months ago, the feedback from patients and their families has been overwhelmingly positive.

“I would say that 90 per cent of my assessments end with a hug,” Debbie adds. “They appreciate that we can spend time with them, listen to them and hear their story. And we can answer their questions. We try not to rush them through the assessment.”

The Central East LHIN’s Aging at Home strategy provides healthcare services tailored to meet the needs of local seniors so they can remain in the comfort and dignity of their own home, while avoiding unnecessary visits to the hospital, ultimately reducing ED wait times. TSH’s GAIN Clinic is one of four in the CE LHIN.

Submitted by Cindy Woods, Communications Officer, The Scarborough Hospital