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Geriatric Assessment Clinic

The “Primary Care-Geriatric Assessment Clinic” model is founded on the integration of an experienced Geriatric Assessor working together with a primary care practice to support the assessment, diagnosis, and management of patients at risk for, or living with, undiagnosed cognitive impairment. The model involves a comprehensive geriatric assessment approach coupled with the use of standardized tools and best practices and is supported by case conferencing with a geriatrician.

To support local primary care group practices in addressing some of the identified barriers related to assessment, diagnosis and management of Mild Cognitive Impairment (MCI) and dementia the Geriatric Assessment Outreach Team has partnered with Family Health Organizations to pilot a shared care, in-house “Geriatric Assessment Clinic`` focused on cognition. In this model, an experienced Geriatric Assessor hosts a monthly clinic in the primary care setting, collaborating with the physicians and nurses in the primary care practice setting. The clinic supports the practice by completing a comprehensive geriatric assessment, and providing appropriate treatment and ongoing care management recommendations to the primary care physician and nurses. The model involves the use of standardized assessment tools and is supported by a geriatrician through case conferencing with the Geriatric Assessor.

An algorithm, developed for the pilot, outlines the flow as well as the commitments of the primary care practice and the geriatric assessor within the clinic. The “Geriatric Assessment Clinic” provides the primary care practice with increased capacity to offer geriatric assessments focused on cognition while supporting capacity building in the form of knowledge translation and system navigation of geriatric and community resources. To date, the model has been successfully implemented  in five primary care practices in the Ottawa Area.