Geriatric Assessment and Intervention Network (GAIN) - updated November 4, 2013

What is GAIN?

Geriatric Assessment and Intervention Network (GAIN) operates clinics in each of the four largest hospitals in the Central East LHIN including Lakeridge Health (Oshawa), Peterborough Regional Health Centre, The Rouge Valley Health System (Centenary Site) and The Scarborough Hospital (General Campus).GAIN - physician and patient

GAIN teams serve seniors, typically aged 75+, living at home or in retirement residences who are frail and require comprehensive assessment. This may include people experiencing:

  • Multiple complex medical, functional, mental health and psychosocial problems
  • Recent functional or cognitive decline
  • Frequent falls, or those at risk of falling

GAIN teams provide comprehensive, inter-professional geriatric assessments and work with older people and their families to develop personalized senior care plans to assist seniors to remain in their homes. GAIN teams collaborate with primary care providers and other services in the implementation of care plans.

GAIN teams include:

  • Nurse Practitioners
  • Community Care Access Centre Case Managers
  • Physiotherapists
  • Occupational Therapists
  • Social Workers
  • Pharmacists
  • Geriatrician and physician support
  • Administrative team  members

GAIN teams accept referrals directly from:

  • Emergency Departments, for urgent  assessment  (immediate, 24-48 hours, follow up)
  • Family Physician or Nurse Practitioner in the community
  • Inpatient hospital units for follow-up after discharge from hospital

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

Note to Primary Care Providers: You will receive our comprehensive consult note following the client’s visit and we welcome the opportunity to collaborate with referrers, primary care providers, clients and families around the development of an effective senior care plan.

BackgroundGAIN - grandpa

  • GAIN is a regional program managed centrally by Lakeridge Health
  • Hospitals are supporting the clinic investment by establishing geriatric services that will enable direct access to in-patient programs for frail seniors
  • Use of GAIN is expected to impact 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)
    • Preventing avoidable admissions
    • Providing specialized care for this population

GAIN Education Day - posted November 4, 2013

On October 31, 2013, the Geriatric Assessment and Intervention Network convened its annual Planning and Education Day, which was attended by more than 100 participants representing 23 organizations or groups serving seniors across the Central East LHIN. The goal of the day was to exchange knowledge and experiences to foster collaboration.  To download copies of the presentations made at the event, please click on the links below: 

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. This is not a Walk-In clinic. Once at the clinic, 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.