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Geriatric Assessment Outreach Teams – Update

The Regional Geriatric Program of Eastern Ontario Specialized (RGPEO) Geriatric Services have made numerous changes to the Geriatric Assessment Outreach Teams (GAOT) to ensure patients are directed to the right service at the right time. As a result of the evidence-based review, the Outreach Team has revised their home assessment and developed a telephone assessment component for a specific patient population that would benefit from further Specialized Geriatric Services, thus reducing wait times between services.

Our purpose:

  • Provide a comprehensive multidimensional screening assessment for people over 65 years of age in their homes or by telephone to improve quality of life, promote functional independence and autonomy, and prevent or delay institutionalization unless appropriate
  • Work with other health services and community agencies in referring individuals for further assessment, information, or health and social services

When should you consider a referral to GAOT?

  • Recent changes in physical, mental, or functional abilities; falls, accidents, incontinence, impaired mobility, decreased ability for self-care, dementia, and delirium.
  • Major changes in support needs: caregiver stress, institutional placement being considered
  • Safety concerns: physical, psychological, social, and environmental.
  • Frequent use of the health care system (i.e. in the last 6 months)
    • Increasing number of visits to the family physician
    • Multiple visits to Emergency Department and/or multiple hospital admissions
    • Escalating home care needs

Referrals process:

The Outreach Teams are committed to working with the family physician and community service agencies. Referrals are made by telephone or FAX, Monday to Friday, from 8am to 4pm. If using the FAX option, the Intake form located on the RGPEO website must be completed. The information that will be required when making a referral includes:

  • Demographic data
  • Referral source (who is referring the patient)
  • Reason for referral
  • Present problem(s)
  • Patient’s knowledge of referral
  • Alternate contact person (family, friend)
  • Professional services involved

The referrals are triaged. The patient and/or contact person and referral source will be contacted to obtain more information and an appointment will be scheduled at the next available date. Please refer to the Specialized Geriatric Services wait times at for more information.

Areas Served: The teams cover the Ottawa region

West Team region: West of Bronson Ave. and the Rideau River in the South end.

  • Phone: 613-721-0041
  • FAX: 613-820-6659

East Team region: East of Bronson Ave. and the Rideau River in the South end.

  • Phone: 613-562-6362
  • FAX: 613-562-6373


AnnMarie DiMillo RN, BScN
Regional Manager, Geriatric and Community Intervention Program, RGPEO

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