Geriatric Mental Health Outreach Program
Serving Halton & Northwest Mississauga

A unique and innovative program designed to provide specialized service to older adults with complex mental health needs.

Crisis Support

If you are in a mental health crisis, please contact crisis services in your area.

    Halton Crisis Outreach and Support Team (COAST)
  • Halton Crisis Line 24 hours: 1-877-825-9011 or for more information visit their website
    Mobile Crisis Peel/COAST Peel Crisis Line 24 hours: 905-278-9036 or for more information visit their website.
  • For all other emergencies call 911 or go to your nearest hospital emergency department.


The outreach service uses a trans-disciplinary approach to meet its mandates. Ideally, individual client assessments are undertaken in the person's environment. Responsibility for delivering primary health care to the older person rests with the family physician or alternative primary care provider, community agencies and long term care facilities. Our program operates within a continuum of care that includes local inpatient and outpatient services, general practitioners, long term care homes, and a range of other community services.
Client & Families and Providers & System

Client & Families

Referral Telephone Intake Assessment Monitoring Intervention Disposition Disposition Disposition

Given that HGMHOP functions under a shared-care model of service, referrals must have approval of the client's family physician. All target group seniors have equal opportunity to access and use this Ontario Ministry of Health funded HGMHOP services free from cost or any type of discrimination or barriers to access.

Referrals are received directly by the clinical office via fax to: 905-681-8628, using the standard Referral Form. Submission of an incomplete referral form can delay the service delivery process. If there are any questions about who the program serves, what we do and/or how to access the program, please contact the program office directly for assistance by calling: 905-681- 8233 or 1-866-429-7677 (toll free).

Please refer to "how to make a referral"

Telephone Intake Screen
Once a referral is received by the program a clinical staff person will contact the referred client and/or designated other by telephone to screen the referral. The purpose of screening a referral is to:

This initial point of contact follows a standard format and gathers screening information related to changes in the referred senior's: physical & mental health, functional issues, environmental issues, behavioural issues, presence of possible risk factors, family and caregiver situation, and current formal and informal supports and services. The information received by fax and over the phone will guide our service response - urgent, moderate, wait list. The case priority determines the time frame in which a case manager will see the client for an initial face-to-face assessment. Clients, designated others and/or referral sources are asked to contact the program if the situation changes or if there are any questions following the initial telephone screen.

Mental Health Assessment
All GMHOP clients who meet the criteria of the program receive a comprehensive mental health assessment by an assigned case manager during an initial home visit in their community or LTCH based residence. Through an assessment, the case manager asks a series of questions and has a conversation with the client and family (as appropriate) to hear the experience of the senior/others, inquire about the senior's/family's goals and expectations, determine possible mental health difficulties, reasons for it, possible supports and/or treatment options, and provide health teaching and support. This assessment follows a standard format, which includes a cognitive screen, mood screen, and interview. The majority of clients will meet with the case manager first and then based on priority and need the client will be assessed by the consulting geriatric psychiatrist.

We work in partnership with family physicians and others. Responsibility for delivering primary health care to the senior rests with the family physician or alternative primary care provider, community agencies and long-term care facilities. Our consulting physicians work in a shared care fashion and make recommendations to primary care physicians and others. Following the assessment and collaborative development of a plan, a clinical note is forwarded to the primary care provider and others as indicated, for consideration and implementation of the recommendations.

Monitoring and Intervention
Each active client is assigned a consistent case manager, who provides service in-person and by telephone. Outreach home visits are mutually arranged and the case manager visits the client where they reside (e.g. own home, LTC facility). Ongoing assessment and evaluation is part of the monitoring and interventions. Follow up support, interventions and monitoring are provided as needed. Interventions are client specific and may include health teaching, supportive counseling, psychotherapy, person-centered monitoring and tracking, advocacy for services and/or supports, case management and coordination, family conferencing, client-focused educational sessions for service providers in LTCH, adult day programs, supportive housing, etc.

Outreach service and intervention may also include providing education on seniors mental health to caregivers, healthcare providers and family members. Seniors with mental health and addiction difficulties often benefit greatly when they, their family members, caregivers and/or healthcare providers are well-informed about mental health, and available services, treatments and supports.

We work collaboratively with our care partners in the assessment, treatment and intervention phases of service. It is our goal to broaden and/or strengthen the client's network of support, stabilize the presenting issue and hopefully enhance the quality of life for the senior and their family/caregivers.

Individuals who are not appropriate for our service will be referred and linked to more appropriate services in order to better meet their needs.

It is our goal to stabilize the presenting issue, optimize available resources to enhance the quality of life for the senior and their family/caregivers. This may be done through a variety of approaches/interventions which may include investigations, health teaching, counseling, behavioural strategies, medications, education, and linkages to appropriate community supports. The average length of stay on the program is 8-9 months however this is very individualized.

Our program views 'discharge' as positive outcome as it reflects that through partnership, and systematic assessment and intervention, the presenting problem(s) have stabilized, resources have been optimized and the situation has been improved. Seniors, families and referral sources are reassured that if the situation changes in the future individuals can be re-referred to our program- we are just a phone call away.

Providers & System

To improve quality of care, we provide education and support to existing and future health care providers.

Education and Community Development
Through community development initiatives, in consultation and through partnerships, we strive to be a resource to front line and primary care health and social services, building community capacity to serve seniors with complex mental health and/or addiction problems.

PsychoGeriatric Resource Consultant
Complimentary to the case management staff are the services of the Psychogeriatric Resource Consultants (PRC). The Psychogeriatric Resource Consultant (PRC):