Patient 1: A 78-year-old woman arrives at the hospital by ambulance at 10 a.m. While making tea this morning, she fell on the kitchen floor. She couldn’t get up and was found two hours later.
Patient 2: An 82-year-old man woke up this morning and didn’t recognize his wife. He was fine the night before. He becomes agitated and falls. His wife calls 911 and he is brought to the emergency department.
Patient 3: A family physician and nurse practitioner see a 75-year-old patient for his regular quarterly office visit. They notice he has bruises, has lost 10 pounds and is not as well-groomed as usual. His wife died recently and his adult children are involved in his life but are very busy.
These are the kinds of patients who are now benefiting from the new Geriatric Assessment and Intervention Network (GAIN) clinic, located at The Scarborough Hospital, General campus, that provides a comprehensive assessment for frail seniors.“We don’t only look at the patient’s primary complaint or concern, we look at the entire picture. We want to help seniors live independently, with dignity and safely,” explains Debbie Driver, Nurse Practitioner, GAIN geriatric clinic. “This is a one-stop shop. Our patients meet with an inter-professional geriatric team – a specialized geriatric nurse, a pharmacist, social worker, physiotherapist – that work collaboratively to assess the patient.” Patients must be referred by their primary health-care provider or an emergency department physician. “We want to help seniors stay at home and healthy. The reality is that seniors, once admitted to hospital, have longer stays. And that means a longer recovery,” explains Debbie. The clinic – which is expected to see about 2,000 patients annually – opened in January and is part of the Central East Local Health Integration Network’s Aging at Home strategy, aimed at providing tailored health-care services that meet the needs of seniors so they can remain in the comfort of their home while avoiding unnecessary visits to the hospital and ultimately reduce emergency department wait times. For Debbie, the clinic is an exciting opportunity to help seniors stay well longer, identify health concerns earlier and prevent people from unnecessarily entering nursing homes. “With the right supports in place, not everyone needs to go to a nursing home. GAIN’s team approach allows us to identify and assist with multiple complex health issues,” says Debbie. “Many seniors are unaware of the resources that are available in the community and we can assist them with connecting to the right resources.” The clinic accepts referrals for patients generally 75 and older, who live at home or a retirement residence and have multiple complex medical, functional and psychosocial problems, multiple or frequent falls and have experienced recent functional decline.