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 due to:

• 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 / dementia
• delirium
• depression / mood disorder
• responsive behaviours
• falls / mobility
• incontinence
• functional decline
• substance use disorder
• malnutrition
• pain
• caregiver burden
• elder abuse

Interprofessional team includes nurse practitioner, occupational therapist, social worker, registered dietician, registered practical nurse certified in behavioural support, home support worker, Ontario Health atHome care coordinator and geriatrician or physician who specializes in geriatrics.