The Geriatric Assessment and Intervention Network (GAIN) Clinic provides support to Seniors living in the community who are physically or cognitively frail, increasing in frailty and/or at risk of using hospital emergency department and inpatient services. The clinic strives to strengthen the capacity for frail seniors to live at home safely and independently for as long as possible. The clinic’s goal is to help patients avoid emergency department visits, inpatient stays and alternate level of care (ALC) placements in the hospital. The GAIN clinic is part of an integrated system of care between the four largest community hospitals in the Central East Local Health Integration Network. The GAIN clinic services a large multicultural Senior population and works in collaboration with the Central East Community Care Access Centres (CE-CCAC) and community support agencies to facilitate access to care and services to its clients. Seniors are referred to the clinic from three sources: primary care providers, emergency department staff following a visit, or inpatient teams upon discharge. Each Senior undergoes a comprehensive geriatric assessment focused on cognition, mobility (including falls risk & prevention), function, medications, physical health and social/family supports. The Nurse Practitioner-led interprofessional clinic team includes a pharmacist, social worker, occupational therapist, physiotherapy expertise, and geriatrician and psycho-geriatrician consultation. Following an intensive assessment, clinicians intervene where appropriate, discuss assessment results, interventions or suggestions with the primary care provider, and provide a clear, understandable summary of the assessment and intervention plan to the patient/family, including a plan for follow-up and evaluation. The GAIN clinic has resulted in the development of sustainable methods of efficient communication between in-hospital stakeholders, primary care providers, community support agencies, CE-CCAC and regionally, between the GAIN Clinic and the 4 partnering hospitals. There has been a significant growth in the understanding of interprofessional practice. The resulting holistic, health promotion approach is appreciated by patients and their families. In terms of the impact on patient outcomes, consistently, less than 12% of clinic patients revisit the emergency department within 7 days and 30 days of an initial appointment. Patients, families, primary care providers, specialists, GEMs and ED colleagues have all commented on the benefits of the GAIN Clinic.

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