Geriatric Outreach Teams

Home visits

During a home visit, a Geriatric Assessor—such as a nurse, occupational therapist, physiotherapist or social worker—completes a detailed screening. This includes looking at physical health, memory and thinking, emotional well-being, daily function and the home environment.

Visits usually last between 90 to 150 minutes. The assessor works closely with the patient and, when appropriate, their family or caregiver to understand needs and determine on next steps.

Based on input from the geriatrician and other team members, follow-up may include:

• A more in-depth assessment or treatment at another part of the Regional Geriatric Program.
• Referral to health or community services for further care, rehabilitation or support.

With the patient’s consent, a summary of the assessment and recommendations is shared with their family physician and other health professionals involved in their care. 

Referrals

Referrals to the Geriatric Outreach Teams can be made by:

• Family physicians
• Health-care providers
• Family members
• Prospective patients

Before a referral is accepted, the Outreach Team must confirm that the patient’s family physician is aware of and involved in the referral process. The teams work closely with physicians and community agencies to ensure coordinated care.

To make a referral, contact the secretary of the appropriate team. They will collect intake information and schedule an appointment. 

Information requested during intake

• Whether the patient and family physician are aware of the referral.
• The patient’s contact and demographic details.
• The reason for referral and current concerns.
• Diagnoses and referral source.
• Contact person.
• Health professionals or services currently involved.