Specialized Geriatric Services (SGS) are one part of the broader network of care available to older adults across North Simcoe Muskoka. Seniors may receive care through family doctors, home care, long-term care, adult day programs and other community services.

SGS provides specialized, short-term support for frail older adults with more complex needs, particularly when care involves multiple health care professionals.

The service includes expertise in geriatric medicine and geriatric mental health. A Comprehensive Geriatric Assessment (CGA) looks at an individual’s medical needs, physical and cognitive abilities, daily activities, social supports and living environment. This helps identify the supports and services needed and develop an individualized plan of care.

Specialized Geriatric Services are linked with better outcomes for frail older adults and their caregivers, as well as the health system, including:

• Fewer avoidable emergency department visits and hospital admissions.
• An increase in aging at home and a decrease in premature placement in long-term care.
• Less avoidable decline among high-risk individuals with complex medical and psychosocial problems.
• An increase in functional ability, independence and quality of life for older adults and their caregivers
• Increases in the skills and knowledge of health care providers regarding the care of frail older adults.

NSM Specialized Geriatric Services Central Intake provides a single point of access to SGS programs for older adults with complex or frailty-related needs.

Central Intake can connect individuals to the appropriate service based on their needs, including:

• Geriatric Medicine
• Geriatric Mental Health
• GeriMedRisk
• NSM Seniors CARE Exercise Program

A single referral form is used to access SGS services. Referrals should be submitted through the NSM SGS online referral system or through an Ocean e-referral account.

Note: For Allied Health Professionals, please choose “other” for Clinician Type so you will not be required to submit your professional ID.

The team supports older adults and their care partners who:

• Have a serious mental illness and need consultation about treatment or care.
• Are experiencing responsive behaviours related to dementia, mental illness, addictions or other neurological conditions.

Responsive behaviours can include hitting, resistance to care, wandering, exit-seeking, rummaging or other actions in response to a person’s environment or experience.

The team can provide:

• Comprehensive geriatric assessment (CGA) Comprehensive geriatric assessment (CGA) A CGA examines an older adult’s medical situation, functional abilities (i.e. walking, bathing, memory, etc.), psychosocial situation and environment to develop a plan of care to meet the individual’s specific needs , person-centred assessments.
• Mental health and behaviour support recommendations.
• Collaborative care planning with the individual, care partners and care providers.
• Behaviour care plans, when appropriate.
• Non-medication approaches to support mental health and responsive behaviours.
• Coaching and education for care partners and care providers.
• Geriatric psychiatry consultation and treatment recommendations.

Geriatric psychiatrists provide recommendations and do not prescribe or write medication orders. A physician or nurse practitioner referral is required for a geriatric psychiatry consultation.

Health care providers can follow the SGS Referral process. Members of the public should speak with their family physician.

Referrals to Waypoint’s Horizon Inpatient Unit are made through Waypoint Central Intake.

NSM SGS is also a partner in Behaviour Supports Ontario, a provincial initiative supporting older adults experiencing responsive behaviours.

NSM Specialized Geriatric Services is a partner site of the provincial GeriMedRisk program, a virtual service that helps health care providers optimize medications and manage complex health conditions in older adults.

GeriMedRisk connects physicians, nurse practitioners and pharmacists with specialists in geriatric medicine, geriatric psychiatry and clinical pharmacology.

• Reviewing and optimizing medications, including deprescribing.
• Identifying drug interactions and medication-related problems.
• Providing advice about medication side effects.
• Supporting medication management for complex physical and mental health conditions.

A patient-specific consultation and educational resources are typically provided within five business days once all required information is received.

GeriMedRisk can be accessed through SGS Central Intake, OTNhub eConsult, or by calling 1-855-261-0508.

Seniors CARE (Collaboration, Activity, Rehabilitation, Education) is a group rehabilitation program for older adults living with frailty. Classes are offered twice a week for up to 12 weeks, either in person or virtually, in Barrie, Couchiching, North Simcoe and South Georgian Bay.

The program focuses on strength, balance, coordination, mobility, cognitive stimulation and health education, and is led by Registered Kinesiologists with support from an SGS physiotherapist when needed.

The program is intended for frail older adults who meet the following criteria and can be classified as a 4-6 on the Frailty Scale (see below):

• Have recently experienced a decline in physical function or ability to manage daily activities, including decline in one or more ADLs or IADLs related to a medical condition or life event.
• Are at high risk of hospitalization or admission to long-term care.
• Have the potential to regain some lost function through rehabilitation (restorative potential).
• Have the cognitive ability to participate/follow instructions; the tolerance to participate; AND the willingness/ability to attend classes in the available locations or virtually by Zoom Healthcare.
• Have medical clearance to participate.

Complex Case Resolution (CCR) helps care providers find solutions for older adults with cognitive impairment and responsive behaviours. It supports collaboration and smoother transitions through the health system.

• Level 1: One-on-one consultation with a provider to explore possible solutions.
• Level 2: A team-based case review for more complex situations when other options have been tried.

No referral form is required. To request a CCR consultation, contact your NSM Psychogeriatric Resource Consultant (PRC). PRCs also provide education and case consultation to organizations.

eConsult connects North Simcoe Muskoka physicians and nurse practitioners with geriatricians and geriatric psychiatrists for secure advice on specific clinical questions.

Submit referrals through OTNhub eConsult and select “North Simcoe Muskoka Specialized Geriatric Services.” Referrals are triaged through SGS Central Intake.

eConsult is not intended for urgent referrals, comprehensive assessments or complex cases. Some referrals may be declined or redirected to a full assessment.

Algonquin Family Health Team 

Barrie Community Family Health Team 

Barrie Community Health Centre’s Aging Well Clinic 

Cottage Country Family Health Team’s Specialized Geriatric Services programs 

Couchiching Family Health Teams Geriatric Outreach Team 

North Simcoe Family Health Team’s Community Seniors Care Program 

Orillia Soldiers’ Memorial Hospital’s Specialized Geriatric Services programs 

Royal Victoria Regional Health Centre’s Specialized Geriatric Services clinics and programs 

South Georgian Bay Ontario Health Team’s Health Aging Team 

Wendat Community Programs