The Geriatric Assessment and Intervention Network (GAIN) Clinic is a network of coordinated health care services that provide clinical care and education to ensure the best care for frail older adults and their families. An interprofessional team of health care professionals works collaboratively with patients and families and their primary care providers to strengthen supports and capacity for older adults whose health concerns threaten their ability to live independently at home (including retirement residences). GAIN teams draw upon the expertise of nurse practitioners, physiotherapists, occupational therapists, social workers, pharmacists, personal support workers, dedicated GAIN/Community Care Access Centre Care Coordinators, collaborating geriaticians, and other specialists.
The program is a regional collaboration between TSH, Rouge Valley Health System – Centenary, Lakeridge Health and Peterborough Regional Health Centre, as well as the Community Care Access Centre (CCAC) and the Central East Local Health Integration Network. TSH has formally partnered with community agencies, including Carefirst Seniors and Community Services Association and St. Paul’s L’Amoreaux to provide additional geriatric services to support our patients’ overall well-being.
GAIN Clinic also works closely with many other organizations including the Alzheimer Society of Ontario, Transcare Community Support Services and Scarborough Centre for Healthy Communities to support our patients and their families.
Staff at the GAIN clinic at TSH begin your care with a geriatric assessment, which is an outpatient appointment and usually takes about two hours. In addition to identifying and treating illnesses, the team looks at many other aspects that may be affecting a senior’s life such as self-care, brain function, physical ability, as well as education and support for care givers.
Services provided by the GAIN clinic include:
Comprehensive geriatric assessment
- Assessment of memory and thinking
- Balance, mobility and falls risk
- Medication (and supplement) assessment
- General health, as well as chronic disease assessment
- Mood and mental health
- Education regarding chronic disease self-management
- Teaching about dementia and behavioural care
- Advance care planning
- Referral to community supports such as adult day programs, transportation services and Meals on Wheels
- Access to personal support and home safety assessments, where appropriate
- De-prescribing and medication adjustment
- Initiation of treatment for dementia
GAIN supports older adults living at home or in retirement residences with multiple complex medical problems including:
- Cognitive impairment
- Decreased function
- Falls or risk of falls
- Impaired mobility
- Multiple medications
If you or your family member are experiencing these changes above and changes in support needs, safety concerns, psychosocial and mental health concerns and frequent health service usage – then consider contacting your nearest GAIN Team.
Please ask a family member or someone who knows your health care history to accompany you to your appointment.
Please bring any aids such as eye glasses, hearing aids and all medications, including over the counter products in their original containers (all containers, bottles, eye drops, creams) to your appointment.
We work with our patients and families to identify any concerns and create an appropriate plan that addresses your needs and goals.
We provide a complete report to your primary care provider (family doctor or nurse practitioner) and referring agency that describes the plan, the changes we made to your care, and any needed follow-up. We are always happy to talk to and work with your primary care provider.