June 13, 2025
By Provincial Geriatrics Leadership Ontario
In a compelling example of the power of specialized geriatric care, a frail elderly woman living alone in a rural area successfully transitioned from a state of crisis to a life of safety, dignity, and support—thanks to the collaborative efforts of the Geriatric Outreach Team (GOT) and the Couchiching Family Health Team (CFHT) System Navigation Team.
In a success story shared by the team, a patient, referred for cognitive impairment and frequent falls, was found living in hazardous conditions: a cluttered and unsanitary home, signs of malnutrition, unmanaged medications, and profound social isolation. With no stable support system and declining physical and cognitive health, she was at significant risk.
Enter the Geriatric Outreach Team—comprising an occupational therapist, registered nurse, and social services worker—who conducted a comprehensive in-home assessment. Their findings painted a stark picture of a vulnerable individual in urgent need of intervention. But rather than a one-size-fits-all approach, the team employed a deeply personalized, patient-centered strategy.
A Model of Collaborative Care
Through persistent outreach, trust-building, and interprofessional collaboration, the team coordinated a wide range of supports:
- Medical and Cognitive Support: A geriatrician was brought in for further assessment, and medication management was streamlined with the help of the patient’s pharmacy.
- Home and Personal Safety: Equipment such as a rollator walker and personal alarm were provided, and home safety modifications were recommended.
- Social and Financial Stability: The System Navigation Team helped the patient file years of back taxes, apply for entitled benefits, and arrange housekeeping and meal services.
- Emotional and Social Well-being: Regular visits and personal worker support not only improved hygiene and nutrition but also reduced isolation and rekindled the patient’s sense of self.
Despite initial resistance, the team’s respectful persistence led to the involvement of a family member, further strengthening the support network. Ultimately, the patient transitioned into a retirement home—a safer, more supportive environment where she could thrive. Noted Dr. Amanda Gardhouse, a geriatrician involved with the team, “the caregiver was instrumental in helping us tackle an action plan. Without him it would not have been possible to ensure safety. It always takes a team!”
A Life Reclaimed
The impact was profound. The patient’s quality of life improved dramatically, her personality re-emerged, and her sense of humor returned. “I’m so happy you came to see me,” she told one team member. Another was warmly invited to “come back anytime.”
A team member summed it up best: “What a success story!”
Why Specialized Geriatric Services and Seniors’ Mental Health Programs Matter
This story underscores the critical importance of specialized geriatric services in addressing the complex needs of older adults. “Across Ontario, roughly 350 specialized geriatric and seniors’ mental health teams work each day to support patients’ just like this one to optimize their health and improve their quality of life” says Dr. Kelly Kay, Executive Director of Provincial Geriatrics Leadership Ontario (PGLO), an organization working to coordinate clinical services that support Ontario’s most vulnerable older adults. “This story highlights how a coordinated, compassionate, and multidisciplinary approach can not only stabilize but truly transform lives” emphasized Kay.
As our population ages, the need for such services will only grow. At the regional level, coordination and clinical support for Ontario’s system of specialized geriatric services is facilitated by Regional Geriatric Programs (RGPs) and Regional Specialized Geriatric Services (RSGS), entities that keep critical clinical services for older adults humming along.
RGPs and RSGS entities form the backbone of Ontario’s clinical geriatric care system. These regional bodies provide strategic and operational leadership to ensure older adults receive integrated, high-quality, and specialized care across the province. Key functions of RGPs and RSGS entities include:
- Integrated Care Leadership: Collaboration with Ontario Health Teams and community partners to advance coordinated care for older adults.
- Specialized Service Delivery: Oversight and support for services such as geriatric medicine, seniors’ mental health, and interprofessional geriatric teams.
- Knowledge Translation: Development and sharing of clinical tools, research, and best practices with clinicians, caregivers, and policymakers.
- Capacity Building: Delivering education, mentorship, and training through academic and community partnerships.
- Performance & Policy Support: Contributing to evaluation, indicator development, and implementation of provincial guidelines and policies.
- System Coordination: Facilitation of communication and initiatives across local, regional, and provincial levels.
- Resource Linkage: Connecting care providers with tools and resources to enhance support and patient outcomes.
- Health Human Resource Planning: Analysis and planning support for geriatric care workforce needs.
Together, RGPs and RSGS entities, along with Seniors’ Mental Health Programs, ensure that older Ontarians receive support for aging with dignity and independence.
This story, similar to many others playing out around the province, is a powerful reminder of what’s possible when we invest in the right care, at the right time, for the right people.