Patients over the age of 65, more specifically patients who are at risk or demonstrate signs of frailty. Frailty is defined as age related deficits in normal function and involve several body systems. It often involves the presence of two or more chronic conditions such as cancer, arthritis, heart disease, diabetes, COPD etc. Medically fragile seniors, especially those who are homebound or whose mobility or medical conditions impede their ease of access to clinic appointments. While this program by no means replaces clinic appointments it does provide another means of assessing seniors and sharing these findings with the patient’s Doctor or NP. Seniors or persons who have been diagnosed with cognitive impairment or caregivers who support those with cognitive impairment.
The Geriatric Navigation and Support program is led by a Registered Nurse and a Nurse Practitioner. Nurses will make visits to local retirement homes and in some instances patient’s home to assess patients using various assessment tools and communicate the findings of these assessments with the patient’s primary care provider. The goal of these visits is to provide timely care that will prevent ER visits, hospital admissions and assist the elderly in accessing healthcare. As well, the nurse provides support to retirement home staff through knowledge sharing and system navigation to connect patients to resources such as Home and Community Care, the Alzheimer society, and other community agencies that support clients to stay in their home as long as possible.
If you are a rostered patient and in need of mental health/counselling supports please speak to your health care provider about a referral, or you may request this service on your own by calling in to the clinic.