Toronto Rehab
550 University Avenue
Toronto, ON M5G 2A2
Tel: (416) 597-3422 x3065
Fax: (416) 597-7066
www.uhn.ca
Geriatric Outpatient Services – Toronto Rehab
Service
Criteria for referral
 Outpatient rehab for patients over the age of 65 requiring two or more of the following services: nursing,
Geriatric Day
Hospital




physiotherapy, occupational therapy, social work, speech-language pathology, therapeutic recreation
12-week duration, 2 sessions per week
Appropriate for patients with complex physical/psychosocial concerns
Program is individualized to each patient
Medical management overseen by a geriatrician
Exclusion Criteria:
 Require more than 1 person assistance for transfers/ambulation
 Cognitive difficulties preventing patient participation
Falls Prevention
Program
Geriatric Medicine
Clinic
Geriatric
Psychiatry Clinic




Interprofessional assessment by geriatrician, physiotherapist and nurse
12-week duration, 1 session per week including educational lecture and group exercise class
Appropriate for patients over the age of 65 at risk for falls
Patient must be able to participate in group exercises and learn new information
Exclusion Criteria:
 Cognitive or medical issues that would impair participation in group exercise
 Requires assistance or supervision with transfers or ambulation
 Comprehensive assessment by a geriatrician (nursing and social work available as needed)
 Common reasons for referral include:
 Cognitive impairment
 Complex medical problems and polypharmacy
 Functional decline or falls


Consultation by a geriatric psychiatrist
Common reasons for referral include:
 Depression, Anxiety
 Agitation, Aggression
 Delusions, Hallucinations

Independence at
Home (IAH)
Community
Outreach Team
Multi-disciplinary assessment, care plan development and coordination ( team members may include RN,
OT, PT, Pharmacy, SW, MD based on patient’s needs)
 Appropriate for medically and socially complex, community dwelling seniors who have experienced recent
functional decline and have potential to regain function or may be struggling for other reasons to remain
in the community – i.e. poor connections to community services. Ideal for more home-bound seniors.
 May include an in-home assessment based on patient’s needs
 The team will create a comprehensive care plan and connect patients to appropriate rehabilitation services
(e.g., in-home therapy, community exercise programs, specialized geriatric rehab programs such as FALLS
Prevention Program, Geriatric Day Hospital, Inpatient Geriatric Rehab, or Convalescent Care) as well as
other home and community supports that can help maintain their independence.
Catchment: South of St Clair Avenue and O’Conner Drive., West of Greenwood Ave., and East of Dufferin Ave
Please fax referral and related consultation notes, current medication list and recent investigations to (416) 597-7066.
For questions or concerns regarding the IAH Community Outreach Team please contact (416) 597-3422 x3830. For questions or concerns
regarding any other Geriatric Outpatient Service please contact (416) 597-3422 x3065.
** Toronto Rehab/UHN is a teaching hospital. Trainees may be involved in your care.*
[Type text]
Please fax the completed referral and accompanying documentation to (416) 597-7066
Toronto Rehab
550 University Avenue
Toronto, ON M5G 2A2
Referral Form
Tel: (416) 597-3422 x3065
Fax: (416) 597-7066
www.uhn.ca
Geriatric Outpatient Services - Toronto Rehab
Please indicate to which service the patient is being referred. Please note that during the referral review process, patients may be
redirected to another of the listed Geriatric Outpatient services if more appropriate.
(please refer to p. 1 for service descriptions)
Geriatric Day Hospital
Falls Prevention Program
IAH Community Outreach Team
Name of Patient:
_______________________________________
Geriatric Medicine Clinic
Geriatric Psychiatry Clinic
_____________________________________
Last Name
First Name
DOB:
_____________
dd/mm/yyyy
M
F
Address: ________________________________________________
City:__________________________________ Postal Code: ________________
Phone: __________________________________________ Health Card
#:____________________________________
Version: ____________________
Emergency Contact: ________________________________________
Contact to Arrange Appointment:
Client
Relationship: ________________________
Alternate Contact Does client speak English?
Has the patient/family been informed of this referral? Yes
Yes
No
Tel: ________________________
If No, indicate language: _________________
No Has the patient been seen by a Geriatrician? Yes
Has the patient provided consent to liaise with/contact family/caregiver(s)?
Yes
No
Transfers:
Independent
Assistance
Not sure
Ambulation:
Independent
No Name:____________________
Assistance Mobility Aid: _____________________
Reasons for Referral:
Main Concern(s) to be Addressed
Has diagnosis been discussed with patient?
Medical History / Medication List
Yes
No
Documentation Attached
Please attach the following documentation:
Brain imaging (if available)
Bone Mineral Density (if available)
Relevant consultation reports (e.g., cardiology, neurology, geriatrics, etc.)
Blood work
Medical
Complex comorbidity
Functional
decline
Medication
management
Other:_________________________
Pain management
Sleep
Constipation
Incontinence
Swallowing
Weight loss/nutrition
Cognitive/Behavioural
Cognitive impairment
Depression
Verbal/physical aggression
Delusions/hallucinations
Psychosocial
Caregiver issues
Social isolation
Elder abuse
Functional decline
Mobility/falls
Speech difficulties
Other: ______________________
Family MD:_______________________________________ Billing #: _________________ Phone:_________________________ Fax:__________________
Referring MD/NP:__________________________________ Billing #: _________________ Phone:_________________________ Fax:_________________
Signature of Referring MD/NP:____________________________________________________________ Date:____________________________________
[Type text]
Please fax the completed referral and accompanying documentation to (416) 597-7066
INDEPENDENCE AT HOME
COMMUNITY OUTREACH TEAM
Dear Colleagues,
We are excited to share with you that we are introducing a new Geriatric Community Outreach
Service to our growing portfolio of Geriatric Community and Outpatient Programs available in Central
Toronto.
With funding from the TC LHIN, The Independence at Home (IAH) Community Outreach Team
has been established as an exciting new multi-organization partnership including team members
from the Toronto-Central CCAC, Circle of Care and Woodgreen Community Support Services, the
Sinai Health System, and University Health Network Hospitals. We are hoping this new resource will
fill in an important care gap for the older patients and their families and care providers in Toronto.
The focus of this team is to connect community dwelling frail older adults with most appropriate
rehabilitation and home and community support services through the development of comprehensive
care plans by a Geriatrician-led Interprofessional team based out of Toronto Rehab.
Through this program individuals may be connected to one or more of the following services home
care and community support services:

Specialized geriatric consultation

Community exercise falls prevention programs

In-home therapy

Geriatric day hospital

Inpatient geriatric rehabilitation

Convalescent care services

Caregiver support programs
The IAH Community Outreach Team has the ability to conduct in-home or clinic-based assessments
depending upon an individuals’ specific needs. The Independence at Home Community Outreach
Team consists of a Nurse, Social Worker, Physiotherapist and Occupational Therapist, Pharmacist,
CCAC Coordinator, and a Geriatrician.
You can refer patients to this program through the same common referral form used for our other
Geriatric Outpatient Services at Toronto Rehab (please see attached). Please review the referral
form for details of our other Geriatric Outpatient Services.
If you are unsure of which service to refer your patient, please refer your patient to the IAH
Community Outreach Team, and they will assist with linking your patient with the most appropriate
services.
The eligibility criteria for the Independence at Home (IAH) Community Outreach Team is as follows:
•
Have experienced a recent functional decline and have potential to regain function.
•
Would benefit from increased supports at home or in the community to remain independent.
•
•
Are homebound and would benefit from an in-home specialized geriatrics assessment
Reside in our Service Area for in-home services : South of St Clair Avenue and O’Conner
Drive., West of Greenwood Ave., and East of Dufferin Ave (See Map for Details)
In addition to our referral form, we are enclosing a fact sheet and map that can be a future resource
for you and your team when considering our service.
Please contact us if you have any questions (416) 597-3422 ext. 3830.
Yours Sincerely,
Dr. Samir K. Sinha, MD, DPhil, FRCPC
Director of Geriatrics, Sinai Health System and the University Health Network Hospitals
on behalf of Independence at Home (IAH) Community Outreach Team
P: 416-597-3422 x 3830