Geriatric Outreach Assessment Service
Who We Are
The Outreach Service works with the older person and their caregivers to assess and provide recommendations for the most helpful and available rehabilitative and supportive patient and family services. The team consists of a Geriatrician, Occupational Therapist (OT), Physiotherapist (PT), Registered Nurse (RN) and Social Worker (SW).
What Do We Offer
Comprehensive, multidimensional assessment and recommendations are made for older persons with complex health problems and recent or unexpected changes in functional abilities.
The assessment reviews the reasons for unexpected health changes and determines the potential for health and functional improvement. This begins with completion of a multidimensional assessment (approximately 2 hours in duration) where the person lives, i.e. at home, a retirement residence, long term care or community hospital in Southeastern Ontario.
In most instances, the initial multidimensional assessment is completed by a Registered Nurse. The assessment might also be arranged in collaboration with another health care professional, e.g. CCAC Case Manger or Geriatric Psychiatry clinician.
Areas that are assessed include:
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Recent changes in health
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Client and caregiver’s perceptions and goals
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Review of health history, recent hospitalizations, Emergency Department admissions, consultations, investigations
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Formal and informal social supports including family relationships, professional and community based services, and access to meaningful leisure opportunities
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Health data including hearing, vision, speech, nutrition, skin, cardio-respiratory, bladder, bowel, joints, pain, movement
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Cognitive function/mood – memory, sleep, losses, screening tools such as the Folstein MMSE and Geriatric Depression Scale (GDS)
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Functional data – mobility, ADLs, IADLs
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Medication history
Eligibility
Seniors with complex health problems – at home, in community hospital or in another residence in the Regional Geriatric Program catchment area are eligible.
How to Refer
Referrals should be directed to the RGP Intake Secretary at 613-544-7797 or 1-800-214-5848 or by FAX at 613-544-4017. Physicians should complete a Physician Referral Form (see PDF attached) and fax to the Intake Secretary at 613-544-4017.
Post Referral Process
At the conclusion of the home visit, the Outreach Service team member will complete a brief client letter that summarizes the areas discussed and any agreed upon next steps. This information is left with the client and/or family member to encourage their active participation in care planning.
After a home visit a Multidisciplinary Conference (MDC) with the Geriatrician and other team members is held for a clinical review of initial findings from home visit and formulation of team recommendations. Such recommendations may include:
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Strategies to optimize health, improve quality of life, enhance functional independence.
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Referrals to community services or resources
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Desirability for further assessment and treatment including : discipline specific assessment within Outreach Service, Geriatric Medicine Outpatient Clinic, Geriatric Inpatient Service, Day Hospital
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Referral to Geriatric Psychiatry or other specialist services
Following the MDC, the client and/or family as appropriate is contacted to share assessment results and recommendations. The multidimensional assessment report is forwarded to the family physician and other active service providers in the “circle of care”.