About Connect@Home

Connect@Home is a short-term, multidisciplinary transition support service for adults returning home from an inpatient stay at Eastern Health. The team comprises a medical officer (general physician oversight), a registered nurse and a pharmacist. We provide short-term follow-up, medication review, care coordination and linkage with Care@Home services and community supports, with the aim of improving follow up care and reducing avoidable re-presentation during the transition home.

  • Adults (age > 18) being discharged from an Eastern Health hospital or service.
  • Benefit anticipated from short-term multidisciplinary transition support, medication review or care coordination.
  • Clients are able and willing to engage with telephone contact and home-based follow-up.

  • Acute deterioration requiring emergency assessment — direct to ED, VVED or 000.
  • Acute mental health crisis or primary substance use concerns — please refer to Eastern Health Mental Health Triage or an appropriate specialist service.
  • Clients requiring ongoing daily home nursing (consider HITH, YVDNS or Post Acute Care).
  • Clients already under another similar follow up program such as Health Independence Program or Care@Home program — discuss with current team first.

  • Internal referrers: via the Connect@Home referral form in the EMR.
  • External referrers (GP, community): contact the service directly during operating hours on 9955 7799 or via connectathome@easternhealth.org.au using secure attachment.
  • Referrals should include presenting issue, discharge summary or reason for concern, current medications, and identified risks or goals of care.

  1. Referral is triaged, usually within one business day.
  2. Initial contact with the client within 24–72 hours of discharge.
  3. Multidisciplinary assessment and care plan, in collaboration with the client’s GP.
  4. Short-term follow-up with warm handover to GP and other services as appropriate.
  5. Communication back to referrer at key points and on discharge from the program.

  • For acutely unwell clients — direct to ED, ambulance, or Victorian Virtual ED.
  • Clients requiring urgent same-day medical review — consider Residential Inreach for RACF clients, HITH, or primary care.
  • Clients needing intensive daily input — consider HITH, Rehab@Home or GEM@Home.

  • Clinical deterioration identified during follow-up is escalated as per Eastern Health clinical deterioration protocols.
  • Clients and carers are advised to contact 000, VVED or their GP outside Connect@Home operating hours.
  • Ambulance Victoria referral criteria are followed where clinically indicated.

Monday to Friday 0800-1700

Connect@Home Program
Operating Hours – Monday to Friday 0800-1700 and selected public holidays.
Phone – 9955 7799
Email – Connectathome@easternhealth.org.au

Connect@Home is the new name for the Talk To You Tomorrow (TTYT) program. The service, referral process, catchment and team are unchanged. Any existing referral pathways you use will continue to work during a transition period; please update local forms and pathway information when you are able.