Supportive Geriatric Outreach Program

North York General Hospital

6th Floor North, Rm 601

4001 Leslie Street

Toronto, Ontario, M2K 1E1

Telephone: 416-756-6232

Email: SupportiveGeriatricOutreach@nygh.on.ca

The Supportive Geriatric Outreach Program is a nurse practitioner (NP) & physician-led initiative to provide supportive, palliative and end-of-life care in the home for those living with a progressive, life-limiting, non-cancer illness. This service is an added layer of support for you, your family, and your health care team, to help you receive the care you need to stay at home.

What is palliative care?

  • Palliative care is an approach that aims to improve quality of life, assist with symptom management and reduce suffering for people living with a serious illness. 

  • Serious illnesses can include diseases such as dementia, motor–neuron disease, end-stage kidney or lung disease, heart disease, stroke and cancer.

  • Palliative care can be provided along with other treatment plans and can be offered in a range of settings, including one’s home, a care facility, a hospital, hospice, or outpatient centre, depending on a person’s needs.

  • When a person approaches end of life, palliative care becomes increasingly important to ensure quality, coordinated care and symptom management.

 

Reproduced with permission from the BC Centre for Palliative Care. https://bc-cpc.ca/cpc/all-resources/individuals/understanding-palliative-care/ 

What does the Supportive Geriatric Outreach Program provide?

Our program has a wide variety of services available not only to you, but also to your family and loved ones:

  • Seamless and coordinated palliative and end-of-life care in collaboration with your healthcare team

  • Management of physical and psychological symptoms and practical issues to improve your quality of life at home

  • An individualized plan of care based on your values and goals

  • Connecting you and your family to community resources

  • Grief and bereavement support if required

How does the Supportive Outreach Program work?

  1. You can be referred to the Supportive Geriatric Outreach service by your doctor or nurse practitioner.

  2. Our team will contact you within 14 days of receiving the referral and schedule an initial consultation at your home.  Telephone or video visits may be arranged with mutual agreement.  

  3. After our first visit, we will work with you and your health care team to develop a care plan.  This may include adjusting medications, identifying additional services such as nursing support, physiotherapy, home safety assessment, and personal support.  We will connect with your home healthcare team to coordinate referrals to other community support services.

  4. We will follow up with you regularly, based on your unique needs, and continue to partner with your healthcare team to care for you at home.

 

How do we care for you?

We support and care for you in different ways so you have what you need to stay at home safely, including:

  • Conduct in-home, phone or video visits

  • Collaborate with your family and your existing healthcare team to provide care for you at home

  • Connect you and your family with any additional support you might need

There is also a phone number you can call if you have any questions or concerns.

 

Who are the team members?

  • Palliative care nurse practitioners and doctors

  • Your family doctor

  • Professionals from community support agencies and/or the Local Health Integration Network (LHIN), which could include, depending on your unique needs: Personal support workers (PSWs), nurses, physiotherapists, occupational therapists, etc.

The team has expert knowledge in treating symptoms associated with serious illness. We will work with family and friends involved in your care to provide the best possible care that is consistent with your wishes. 

Who might benefit from Supportive Geriatric Outreach?

  • Persons who are homebound and are experiencing difficulties attending clinic appointments

  • Persons with symptoms related to progressive, life-limiting, non-cancer illness, such as shortness of breath, swelling, anxiety and depression

  • Persons living within the following geographic boundaries: Steeles to the North, Victoria Park to the East, Lawrence to the South, and Bathurst to the West

Steeles Ave.

Bathurst Ave.

Victoria Park Ave.

Lawrence Ave. 

For how long can a patient receive services?

Patients can receive ongoing support through the Outreach service for as long as their wishes and preferences are consistent with a palliative approach to care, while they are living at home.

What happens if I am hospitalized?

If your medical condition changes and you are admitted to hospital, the services you are receiving through the Supportive Geriatric Outreach Program will continue once you return home. Your Outreach team will work with your homecare team to follow-up with you once you return home.

 

Contact us

For all enquiries, please call us at 416-756-6232 or email us at SupportiveGeriatricOutreach@nygh.on.ca

 

Referrals

Please have your doctor or nurse practitioner complete and fax this Palliative Care Common Referral Form to 416-756-6024

©2019 by North York Toronto Health Partners.