The team with the Geriatric Assessment & Intervention Network provides Comprehensive Geriatric Assessments for frail seniors living at home or in a Retirement Home (not Long Term Nursing Care Home) whose health, dignity, and independence are at risk. Seniors will be assessed and treated at home or in our clinic as needed.

With the client and family members, the GAIN will:

• Complete a comprehensive assessment
• Develop a personalized care plan
• Provide follow-up in the home
  
  

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 in their own home

• Improve the quality of life experienced by the senior, their caregivers and family while living in their home
• Reduce the frequency of preventable visits to local Emergency Departments and hospital admissions/re-admissions
• Shorten lengths of stay in hospital
• Delay admission to Long-Term Care Homes as long as safely possible

The GAIN team members include: behavioral support nurse, care coordinator, client services worker, community health worker, nurse practitioner, occupational therapist, office support, pharmacist, physiotherapist and a social worker.

• Are living at home or in a Retirement Home (not Long Term Nursing Care Home)
  
• Have multiple complex health problems or medication issues
  
• Have experienced a functional decline, are at risk for falling or present with safety concerns
  
• Have experienced a cognitive decline, psychosocial issues, and/or have difficulty coping