Geriatric Evaluation and Management at Home - Services

Useful information

For referrals:

Please contact a GEM@Home coordinator PH: 9955 7544

Ambulatory care and community services referral form

Ambulatory care and community services referral form instructions

Referral information:

Hospital referrals to My Aged Care

Health professional referral to My Aged Care 

General information:

My Aged Care 

Commonwealth Home Support Program

Home Care Package Program

The Geriatric Evaluation and Management at Home (GEM@Home) program aims to ensure that frail older people with multiple and complex needs gain rapid access to specialist assessment, diagnostic and management services including care co ordination in their own home. This is in order to optimise recovery and reduce risks associated with hospitalisation. The program has a particular focus on community based referrals for clients who would otherwise require admission to an inpatient hospital setting. The program provides time limited Geriatrician, specialist nursing and allied health assessment in order to assist the client achieve their goals of care in their own home. This is done in close consultation with the client's general practitioner.

Eligibility Criteria

  • The GEM@ Home target group are predominantly, but not limited to, older people (age> 65) with complex, chronic or multiple health care conditions
  • Has medical/functional/restorative goals and requires geriatrician, nursing and allied health (occupational therapy, physiotherapy and social work) evaluation and management to achieve these
  • Consumer with a functional /cognitive decline having difficulty getting to the GP clinic / hospital
  • Living within the Eastern Health catchment area
  • Is able to be safely managed in their home environment (has a carer if consumer has cognitive impairment)
  • Close collaboration with client's general practitioner
  • Consumer/ carer consents to participation in the program
  • Not requiring acute inpatient care

Exclusion Criteria

  • Elderly clients who's primary presentation is an acute psychiatric illness indicating the need for Mental Health Services
  • Residing in Residential Aged Care.
  • Only requires Geriatrician and not allied health input.

Our Team

RN Clinical coordinator, Geriatrician, Physiotherapist, Occupational therapist, Social worker, Registered nurse.