​​Photo caption: BSO Registered Nurse Lindsay Kluke, Geriatric Assessor Maddie Thoma

By: Cory Rose, Medical Affairs and Communications Lead and the GICS Team, St. Joseph’s General Hospital Elliot Lake​.

With about 40 to 42 per cent of the population aged 65 or older, Elliot Lake has one of the highest older adult populations in Canada. St. Joseph’s General Hospital in Elliot Lake (SJGHEL) has launched an innovative geriatric care program that is redefining how older adults receive support in Northern Ontario. Built on evidence-based practices and guided by a commitment to person-centred care, the program is already showing measurable improvements in patient outcomes, quality of life and system efficiency.

In its first year, the Geriatric Inpatient Consult Service (GICS) received 115 referrals between​​ April 2024 and April 2025. These numbers highlight both the growing need for specialized geriatric support and the critical role of early, individualized intervention.

At its core, the program offers individualized care plans for every patient, ensuring that each care plan is personalized. The plan extends beyond clinical needs to consider the personhood of each patient asking the questions, who they were? what they value? and how they can remain engaged and connected?

The addition of seven new personal support workers and one recreational therapy aid dedicated to this initiative has been a game-changer. These team members work alongside nurses, physicians, physiotherapists, a social worker, and dietician to bring care plans to life through daily interactions, therapeutic interventions, activation activities, and behavioural support. It is a model that does not just treat symptoms. It restores dignity, purpose, and independence with a goal of maintaining or improving the individual’s pre-admission baseline.

A Collaborative and Evidence-Based Approach

The program was developed through provincial funding in partnership with the Ministry of Health and the Northeast Specialized Geriatric Centre. It reflects the best practices recommended by research and implementation experts across Ontario, including Health Sciences North’s collaborative geriatric subgroups.

The goals are ambitious yet clear:

• Reduce alternate level of care days by supporting transitions from hospital to home or long-term care.
• Collaborate with community partners for best discharge care plans.
• Decrease readmission rates through proactive planning.
  
• Enhance quality of life by addressing social frailty and preventing functional decline.

To achieve this, GICS operates as a team. Physicians refer patients for a Comprehensive Geriatric Assessment (CGA), an evidence-based, holistic review carried out by the GA. The GA then consults with the patient’s family or caregiver to ensure accurate baseline information. With those referrals, the BSO RN develops a behaviour and personhood profile.

Daily interdisciplinary rounds adjust the care plan in real time based on progress and reassessments.

From Hospital Bed to Hiking Trails: Real Stories of Impact

One of the most compelling aspects of the program is how it restores meaning to patients’ lives. Maddie recalls working with a patient who had a long history of outdoor activities. Hospitalized for an acute illness, the patient faced significant decline and was placed on a locked unit for safety.

Rather than let the decline continue, the GICS team designed a plan that included daily outdoor walks, drawing on his passion for nature and independence. Lindsay was able to walk with him, providing valued care that resulted in an outcome medication alone could never achieve.

“It is just as important as his medication,” Maddie says. “By personalizing care, we give patients something to look forward to, which is vital to their mental and physical well-being.”

Behavioural Care with Compassion

Lindsay emphasizes that success in geriatric care means seeing the person, not just the diagnosis. Her role involves developing individualized strategies for managing responsive behaviours through approaches grounded in empathy, history, and collaboration with families.

“No two care plans are alike,” she says. “We look at who the patient was before hospitalization and what brings them comfort or joy. That might mean a certain type of music, an activity they love or involving family in daily routines. These are small things that make a big difference.”

A Vision for the Future

Program manager Randal Bertrand sees this as the beginning of a larger cultural shift in geriatric care. “Our goal is sustainability,” she explains. "We have built a team of passionate individuals who understand the purpose and importance of their roles. Although it has only been a year, we are already seeing the positive impact it has on our patients and their families, as well as our staff."

Metrics such as functional gains, length of stay and readmission rates will guide ongoing evaluation. Early data already suggests positive trends, but for Randal, the most compelling evidence comes from patient stories and family feedback.

Changing Health Care in Northern Ontario

This initiative reflects what happens when innovation meets compassion. By combining evidence-based strategies, interdisciplinary teamwork, and a respect for individuality, the geriatric program at SJGHEL is setting a new standard for rural health care.

As the population ages and demand for geriatric services grows, programs like this offer a blueprint for how to deliver care that truly matters, care that not only extends life but enriches it.