Our Services

<- previous page

INTRODUCTION
The East and West Geriatric Assessment Outreach Teams are community components of the
Regional Geriatric Assessment Program operating in the Ottawa Carleton Region.

The teams are made up of the following members:

• Geriatrician
• Nurse
• Occupational Therapist
• Physiotherapist
• Social Worker
• Secretary/ Intake

GOALS
1. To provide a comprehensive multidimensional screening assessment for people over 65 years
of age in their homes.
2. To work with other health services and community agencies in referring individuals for further appropriate assessment, information, or health
and social services in order to:

• Improve quality of life
• Promote functional independence
  and autonomy
• Prevent or delay institutionalisation,
  unless appropriate
  

WHEN TO CONSIDER A REFERRAL
TO OUTREACH TEAMS
Recent sudden changes in physical, mental, or functional abilities: falls, accidents, incontinence, impaired mobility, decreased ability for self- care, dementia, delirium.

Major changes in support needs –
caregiver stress, institutional placement
being considered.
Safety concerns – physical, psychological,
social, environmental.
Frequent use of the health care system
(i. e. in the last 6 months):

• increasing number of visits to
  the family physician
• multiple hospital admissions
• multiple visits to EmergencyDepartments
• escalating home care needs

The primary function of the Geriatric Assessment Outreach Team is to provide multidimensional assessment in order to identify appropriate treatment and support for seniors with complex health problems. Rather than providing emergency treatment or ongoing community care, our teams work with clients, their doctors, and caregivers to
optimise seniors’ independence and quality of life.

AREAS SERVED
The teams cover the region of Ottawa-Carleton.

West region – West of Bronson Ave. and
the Rideau River in the south end

East region – East of Bronson Ave. and
the Rideau River in the south end

REFERRAL MECHANISM
Referrals to the Outreach Team will be accepted from:

• prospective clients
• health care workers
• family members
• family physician

The Outreach Teams are committed to working with the family physician and community service agencies. The family physician must be contacted before a referral will be accepted by the Outreach Team.

Referrals are made by contacting the secretary of the appropriate team so that intake information can be
obtained and an appointment scheduled.

Intake Information Requested:

• Client's knowledge of referral
• Family physician's knowledge of the referral
• Demographic data
• Referral source
• Referral diagnoses
• Present problem( s)
• Reasons for referral
• Contact person
• Professional services involved

WHAT TO EXPECT FROM THE VISIT
One Geriatric Assessor (nurse, occupational therapist, physiotherapist, social worker) completes an initial multi-dimensional screening assessment
incorporating aspects of physical, cognitive and psychosocial status, functional abilities, and environmental factors.

The visit may last 1½ to 2½ hours. Collaboration with the elderly person (and family/ caregiver where
applicable) helps to identify needs and determine appropriate action.

Based on consultation with the geriatrician and other team members, further action may consist of:

– More in- depth assessment/ treatment at one of the components of the Regional Geriatric Assessment Program (see next page).

– Referral to other health agencies or
community resources for further
assessment, treatment, rehabilitation,
or other services.

The assessment summary and recommendations will be forwarded to the family physician and health care
professionals/ agencies involved.

REGIONAL GERIATRIC ASSESSMENT PROGRAM (RGAP)
The Regional Geriatric Assessment Program
is comprised of:

Outpatient Clinics

• Queensway- Carleton Hospital
• Ottawa Hospital, General Campus
• Bronson Pavilion, SCO Health Service
• Saint- Vincent Hospital, SCO Health Service
• Almonte General Hospital
• Pembroke Marian Hill Villa
• Kemptville General Hospital
• Cornwall Hotel Dieu Hospital
• Winchester District Memorial Hospital

Geriatric Assessment Units

• The Ottawa Hospital, Civic Campus
• Queensway- Carleton Hospital

Day Hospitals

• Élisabeth Bruyère Health Centre, SCO
  Health Service
• Saint- Vincent Hospital, SCO Health Service

Geriatric Rehabilitation Units

• Saint Vincent Hospital, SCO Health Service

Geriatric Assessment Outreach Teams

• Queensway- Carleton Hospital
• Élisabeth Bruyère Health Centre,
  SCO Health Service

HOW TO REACH US
Referrals may be made by telephone Monday to Friday, from 8:30 to 16:30, or by mail.

COST
Services are funded by the Ontario Ministry of Health.

GERIATRIC ASSESSMENT OUTREACH TEAMS

East Team

Élisabeth- Bruyère Health Centre
43 Bruyère Street
Ottawa, Ontario
K1N 5C8
PHONE: 562- 6362
FAX: 562- 6373

West Team

Queensway- Carleton Hospital
3045 Baseline Road
Nepean, Ontario
K2H 8P4
PHONE: 721- 0041
FAX: 820- 6659

<- previous page