Geriatric Assessment and Intervention Network

As part of a regional network of Specialized Geriatric Services, the Haliburton GAIN clinic provides Comprehensive Geriatric Assessments for frail seniors living at home (not Long Term Care), usually 65 years of age or older, whose health, dignity, and independence are at risk.

Referrals to the GAIN Clinic

It is ideal if referrals to GAIN are signed by a Physician or Nurse Practitioner (MD/NP) and supportive information is included (ie. medications or therapies attempted or in place). Self-referrals are also accepted. Completed referral forms (which can be downloaded at the bottom of this page) can be faxed directly to the Haliburton Highlands GAIN at 705-286-0720.

Risk Factors

Multiple complex medical and psycho-social problems;

A recent unexplained decline in health and/or level of function;

Loss of capacity for independent living.

GAIN patients require the support of an interprofessional team to address challenges associated with aging manifested in multiple conditions that negatively impact function and independence, such as:

cognitive change / impairment / demential

delirium

depression / mood disorder

responsive behaviours

falls / mobility

incontinence

functional decline

substance misuse

malnutrition

pain

caregiver burden

elder abuse

Objectives of Haliburton Highlands GAIN

The GAIN team will work with seniors, caregivers, Primary Care Practitioners, and other service providers to:

Improve the senior’s safety and ability to live independently and successfully in their own home

Improve the quality of life experienced by the senior and their caregivers and family while living in their home

Reduce the frequency of preventable visits to local Emergency Departments

Reduce the frequency of preventable admissions and re-admissions to hospital

Shorten lengths of stay in hospital

Delay admission to Long-Term Care Homes as long as safely possible

What patients can expect

Seniors will be assessed and treated at home or in our clinic as needed. Recommendations and treatment plans will be created and shared with the senior, their caregiver and primary care provider. It is important for seniors to be prepared for their appointment. The initial visit may be split into two visits to best meet the needs of the senior. The senior and their family or caregiver will meet with two or three team members during their initial visit(s).

Please ensure the following items are either readily available for the home visit or brought to the clinic:

walking aids

eye glasses (both reading and distance)

hearing aids

ALL medications, including over-the-counter products (please bring all medication containers, bottles, eye drops, vitamins, creams, etc). Keep all original labels on the containers or packages.

a light lunch/snack - the assessment may take 2 to 3 hours, if tolerated.

The team at the Haliburton Highlands GAIN includes:

Nurse Practitioner

Occupational Therapist

Social Worker

Registered Dietitian

Registered Practical Nurse, certified in behavioral support

Home Support Worker

CE CCAC Intensive Case Manager

Administrative Assistant

Geriatrician or physician who specializes in geriatrics available for consultation when required.

Access to GAIN:

The team works collaboratively with the physicians and nurses in our Emergency Departments (ED) to identify appropriate seniors who will benefit from the services provided by the Haliburton Highlands GAIN.

Other seniors who may benefit from the GAIN services could be identified during hospitalization and would be referred to the clinic in advance of or on discharge from hospital

Primary Care Providers (Physicians and Nurse Practitioners) will also identify seniors who could benefit from the specialized clinic services and potentially avoid a visit to the Emergency Department

Other community partners who provide services to seniors in our region are welcome to obtain consent from a senior and forward a referral to the GAIN

Self-Referral or referrals from caregivers are welcomed

GAIN brochure

Download (341.71 KB)

Gain Referral Form

Download (368.9 KB)