A new, innovative trial has safely supported the acute and long-term care needs of older people in Metro North who have complex and chronic health conditions associated with ageing. 

Community and Oral Health Transition Care Team Leader Leanne Carroll said across Metro North we have seen an increased demand on community services to provide healthcare at home that supports healthy ageing and the care needs of the elderly. 

The Community Transition Care Program’s GEM@Home trial was highly commended in the integrated care category of the Community and Oral Health Staff Excellence Awards.

“The Metro North Geriatric Evaluation and Management at Home (GEM@Home) was a short three month trial which provided a community-based, geriatrician-led service, which aimed to minimise hospital stay and support the ongoing care needs of the older person in their own home,” she said. 

“The GEM@Home trial supported early transfer of older patients from hospital and built clear pathways for the ongoing management of age-related conditions and reduced hospital readmissions. 

“We saw a four to five-day reduction in length of stay in hospital for the trial cohort, plus a decrease in unplanned readmissions.” 

As part of GEM@HOME, 26 patients from The Prince Charles Hospital who had an average age of 85 years, safely left hospital early and received care at home. 

“Persons admitted to the trial mainly included those that had a fall, or needed mobility support, personal care, nutrition, medication management, pressure injury care or other medical requirements,” Leanne said. 

“We also saw a significant cost in the reduction per episode of care with an estimated 2:1 cost ratio difference between hospital care compared to safe care in the home.”   

The trial saw five additional Hospital in the Home places dedicated to older patients, following their stay in The Prince Charles Hospital. 

Leanne said patients received home access to a multidisciplinary team, including a dedicated geriatrician, nurses, physiotherapists, occupational therapists, dieticians, social workers, pharmacists and speech therapists. 

“The TPCH service continues with the view of developing a broader service to support elderly people at home across Metro North,” she said. 

GEM@HOME was led by Metro North Health staff from the Community Transition Care Program, and Innovation and Research Centre, as well as The Prince Charles Hospital.