The Geriatric Evaluation and Management at HOME (GEM@HOME) program aims to ensure that frail older people with multiple and complex needs gain access to specialist assessment, diagnostic and management services including care coordination in their own homes.

This is in order to reduce long hospital stays, optimise recovery and reduce risks associated with hospitalisation.

  • Patients below premorbid level of function resulting from recent or complex conditions associated with ageing and/or chronic illness
  • Medically stable enough to be treated at home
  • Consenting to participate in daily home visits and therapy
  • Within the Eastern Health Catchment Zone
  • Requiring treatment by a Geriatrician and daily multidisciplinary intervention
  • Able to actively and meaningfully participate in therapy programs and has achievable goals and realistic goals.
  • Home environment suitable and safe for patients level of function and home visits
  • Can safely manage basic needs such as toileting, mobility, medications on their own or with family/carer or established support system.

  • Patient has unstable acute care needs that are unable to be supported in the home setting
  • Complex social needs unable to be resolved and will affect care, ie awaiting VCAT to ascertain need for decision maker
  • Patient is homeless
  • Home environment is unsafe or unsuitable for the patient to return home or for staff to visit.

If you have a patient that you wish to refer and are unsure if they meet the inclusion criteria and want to discuss, please do not hesitate to call 0439 688 028

  1. Phone our clinical nursing coordinator and discuss your client, we will confirm acceptance of your referral within 24 hours.
  2. Complete a Referral Form (PDF, 530KB)
  3. Provide relevant information concerning your client such as
    • Health Summary
    • Result/s of recent investigations
    • Relevant correspondent from other specialists providers
    • Infection status, recent weight, allergies, adverse drug reactions and any other alerts


Ph: 0439 688 028

Ph: (03) 9955 1255

Fax: (03) 9955 7582

E: [email protected]