Concurrent Sessions

D3-a – Geriatric Care Outreach Team- Improving Care for At Risk Seniors in Our Community

Theme 3. Expanding your reach

Presentation Details

  • Date: Thursday October 25, 2018
  • Concurrent Session D
  • Time: 9:45-10:30am
  • Room: Harbour C
  • Style: Presentation (information provided to audience, with opportunity for audience to ask question)
  • Focus: Balance between both (e.g. Presentation of a best-practice guideline that combines research evidence, policy issues and practical steps for implementation)
  • Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Representatives of stakeholder/partner organizations

Learning Objectives

Participants will learn about how to provide excellent specialized geriatric care to their community in a team based format.  The composition of a Geriatric Care Outreach Team will be discussed as well as ways to provide services in various locations in the community including in patients’ homes, retirement homes, and community hospital.  We will discuss the benefit of a Geriatric Nurse Assessment with each patient and patient navigation and connection with other community supports.  We will discuss how Nurse Practitioners can play an essential role in the team to diagnose geriatric conditions as well as prescribe appropriate medications and deprescribe inappropriate medications.


Our Geriatric Care Team, an outreach team in Huntsville, aims to help optimize the health, independence, and quality of life for frail seniors in our community and in our hospital.  We would like to show the benefits of our model of care and give other FHTs ideas regarding how they can model teams within their FHT and/or community after our team. We provide specialized geriatric care to at risk seniors in our community, particularly to those with cognitive impairment, dementia, mood issues, and frequent falls.  This program is an extremely effective way to provide specialized geriatric services to those that need it. It is consistent with Simcoe Muskoka LHIN’s plans for Local Specialized Geriatric Services which maintain or improve frailty, improve management and assessment of responsive behaviours, reduce caregiver burden, and increase patient/caregiver satisfaction with services and outcomes (SGS, 2016). Our team’s work is also consistent with Health Quality Ontario’s Quality Statement regarding Dementia Care for People Living in the Community (Health Quality Ontario, 2018) as well as their standard on Behavioural Symptoms of Dementia (HQO, 2018). Our Registered Nurses complete comprehensive geriatric assessments & assistance to our patients and their caregivers in making decisions related to care.  The Nurse Practitioner diagnoses and prescribes treatment or suggests treatment to the patient’s primary care provider or MRP at the hospital.  We work closely with primary care providers as well as in-hospital physicians, regional specialists, and community programs including Home & Community Care in order to optimize the health of our patients. Our team helps our patients navigate the health care system and acts as an access point for our patients and their caregivers.


  • Melissa Kilpatrick, MN, NP-PHC, NP with Geriatric Care Team, Employee of Algonquin Family Health Team
  • Judith Braun, RN, Lead RN with Geriatric Care Team, Employee of Algonquin Family Health Team