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Complex Care Program

Our Geriatric Complex Care program is a multidisciplinary team consisting of Nurse Practitioners, a Clinical Pharmacist, and a Registered Nurse who work closely with the Primary Care physicians and our in-house Geriatrician to manage elderly patients with complex conditions.  

Types of Patients Seen

The family physician may refer a patient who:

  • has multiple medical conditions and would benefit from seeing a practitioner in one visit to address all their needs,
  • safety may be at risk due to taking numerous medications which may be dangerous in the elderly,
  • has had multiple falls and/or ER visits,
  • may benefit from community supports and whose family may require support with caring for their loved one.

Goal of the Program

The goals of the program are to provide appropriate education and resources to patients early on in disease trajectory to prevent disability when possible and to care for patients with multiple chronic and complex conditions.

Benefits for patients and families include:

  • reduced appointment burden
  • having a point of contact (in-person, phone, email)
  • improve confidence and comfort with managing their health
  • improve knowledge about community resources and how to access
  • address issues that matter to patients – caregiver stress, advanced care planning etc.

What to Expect 

During the visit we will perform a comprehensive assessment and examination. We will review your current health needs and mutually agreed upon patient centred goals. 

Please bring:

  • all of your prescription and non-prescription medications, herbal supplements and inhalers.
  • eyeglasses, contact lenses, hearing aids and any assistive devices.

We recommend that you bring a caregiver, family member or someone who knows you well, as we would like to discuss your care with them. This will help the team to develop a thorough assessment.