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Geriatric Services at The Ottawa Hospital

The Inpatient Geriatric Medicine Unit

This post-acute care unit accepts patients in transfer from other units at the Ottawa Hospital. Appropriate patients for transfer are those who present with an acute or sub-acute functional and/or cognitive decline due to a medical illness, with a high probability of recovery from this decline. They may also have complex and interacting geriatric conditions requiring the intervention of a Multi-Disciplinary Team. These conditions may include:

  • Decreased mobility/falls
  • Changes in cognition due to dementia/delirium/depression
  • Problems with Activities of Daily Living (ADLs) and/or Instrumental Activities of Daily Living (IADLs)
  • Unexplained physical decline/weight loss/failure to thrive
  • Concurrent medical conditions: CHF /Diabetes /Hypertension /Osteoporosis/ Parkinson’s Disease/ Postural hypotension that require optimization prior to patients returning home or prior to them going to another program, such as Geriatric Rehabilitation or Convalescent Care

The Geriatric Medicine Ambulatory Services and Day Hospital

The Geriatric Medicine Ambulatory Services and Day Hospital provide care to older adults with complex medical issues who are experiencing a change in function, mobility, memory, or mood. This multidisciplinary team provides assessment, intervention, treatment and follow-up to over 1200 patients each year, with an emphasis on support and education for patients and their caregivers as well as future planning. The team also works in partnership with community organizations and services to allow patients to remain in their homes and communities for as long as possible.

The Geriatrics Enhanced Consult Service

This service assists referring services in the assessment and management of their patients, and offers recommendations regarding the following:

  • Recent changes in cognition due to delirium, dementia or depression
  • Mobility changes/ impairments complicating recovery and discharge
  • Medication management (reviewing of medication profiles based on the geriatric principles)
  • Management of multiple or complex medical problems impacting discharge
  • Assessment of falls etiology and implementation of strategies for fall risk reduction
  • Maintenance/ recovery of overall function

In 2014, the Enhanced Geriatric Consultation Team expanded, in partnership with Geriatric Psychiatry, to include Clinical Nurse Specialists in behavior management, in order to develop a Behavior Management and Support Consultation Service for elderly patients. This new service focuses on hospitalized older patients who have agitated behaviors, in order to help improve patient outcomes and facilitate discharge. External funding from the Champlain LHIN made this program possible and was the result of an intense lobbying effort by the Regional Geriatric Program and Geriatric Psychiatry.

Geriatric Emergency Management

Geriatric Emergency Management (GEM) is a program aimed at identifying seniors at risk who will be discharged home from the emergency department (ED) in order to initiate early referral to community and specialized geriatric services. Patients are identified by a 2 stage screening process. Identified high-risk patients receive a targeted geriatric assessment by an emergency nurse with specialized training in geriatrics.

The role of GEM nurses in the ED is summarized below:

  • Complete a geriatric assessment during their ED visit
    • Advocate for age appropriate ED care
  • Improve the quality & sustainability of ED discharges
  • Develop a plan of care that will support the capacity for older adults to remain in their own home
    • Initiate early referral to specialized geriatric services
    • Referral for community support services
  • Promote communication between primary care provider, community & acute care services
  • Provide consultation & education to the ED team regarding geriatric issues
  • Promote research & evidence based practice to build a Senior Friendly ED environment

GEM nurses are available at both The Ottawa Hospital emergency departments 7 days a week to support the assessment and management of high-risk older adults.