Geriatric Assessment and Intervention Network (GAIN) 

What is GAIN?

Geriatric Assessment and Intervention Network (GAIN) operates clinics in each of the four largest hospitals in the Central East LHIN: Lakeridge Health (Oshawa), Peterborough Regional Health Centre, The Rouge Valley Health System (Centenary Site) and The Scarborough Hospital (General Campus) and now includes eight community-based teams in Scarborough (Carefirst Seniors and Community Services Association and St. Paul’s L’Amoreaux Centre), Durham Region (Carea Community Health Centre), and the North East (Community Care City of Kawartha Lakes, Peterborough Regional Health Centre, Port Hope Community Health Centre, Haliburton Highlands Health Services and Trent Hills Community Team).

GAIN teams serve seniors, typically aged 75+, living at home or in retirement residences who are frail and require comprehensive assessment and intervention. This may include people experiencing:
  • Multiple complex medical, functional, mental health and psycho-social problems
  • Recent functional or cognitive decline
  • Frequent falls, or those at risk of falling

GAIN teams provide inter-professional comprehensive geriatric assessment, working with older people and their families to develop personalized care plans that assist seniors to remain safely in their homes for as long as possible. GAIN teams collaborate with patients/families, primary care providers, and other services in the implementation of care plans. GAIN teams include:

  • Nurse Practitioners
  • Community Care Access Centre (CCAC) – GAIN Nurse Care Coordinators
  • Physiotherapists
  • Occupational Therapists
  • Social Workers
  • Pharmacists
  • Geriatrician and physician support
  • Administrative team  members
GAIN teams accept referrals directly from:
  • Emergency Departments
  • Family Physician or Nurse Practitioner in the community
  • Inpatient hospital units for follow-up after discharge from hospital
  • Individuals/family members

To obtain a copy of the GAIN referral form, please click HERE.

Note to Primary Care Providers:  You will received a comprehensive consult note from the GAIN team following the client's visit.  The GAIN team welcomes the opportunity to collaborate with referrers, primary care providers, clients and families around the development of an effective senior care plan. 

Background

  • GAIN is a regional program managed centrally at Lakeridge Health through the leadership of the Seniors Care Network
  • GAIN teams are helping to reduce the impact on Alternate level of Care/Emergency Department Wait Times by:
    • Providing an alternative destination for avoidable Emergency Department visits (referrals from community)
    • Shortening Emergency Department visits that do happen (referrals from ED/GEM)
    • Preventing avoidable admissions
    • Providing specialized care for this population

Building Geriatric Knowledge

GAIN, as a Regional Program of Seniors Care Network, is committed to development and sharing of geriatric knowledge. GAIN clinicians participate in multiple initiatives aimed at building geriatric expertise and capacity. We are currently engaged with Seniors Care Network and provincial colleagues in the development and validation of a Competency Framework for Inter-professional Geriatric Assessors. Teams have also contributed to the research base for geriatrics through a project entitled, “A Systemic Approach to Team Based Reflective Practice in GAIN Teams”.

Our clinicians present locally, nationally and internationally sharing knowledge and scholarly work.  Please click HERE for more information.

Frequently Asked Questions - FAQs

Who will be seen in GAIN Geriatric Clinics?
GAIN Geriatric Clinics are designed to care for high risk seniors (generally aged 75+) who are living at home or in a retirement residence; have multiple complex medical, functional and psychosocial problems impacting their level of independence; a recent unexplained loss of functional independence or recent health or functional decline or are at risk for falling or multiple/frequent falls.

How are patients referred to the clinics?
Patients may be referred to the clinics either directly through the Emergency Departments, inpatient units or through referral forms completed by a patient's Family Physician, Nurse Practitioner or other community care provider. These are not a Walk-In clinics.   In the hospital clinics, patients will be assessed and treated by the GAIN Geriatric Team and if they are non-acute and stable they will be safely discharged home thereby avoiding hospital admission. Patients who are assessed as acute or unstable will be transferred from the clinic to a hospital's inpatient geriatric service.