Geriatric Evaluation Management Program (GEM @ Home)


GEM@Home provides interdisciplinary aged care and rehabilitation services after an illness or injury. Our aim is to help our patients achieve the best level of health and function, whilst in their home. Patients are visited in their home daily whilst on the program from any member of the treating team.

The program aims to reduce the time a person spends in hospital by receiving care in their home. Research has shown that this can assist people in their recovery.
Northern Health currently has 12 GEM at Home packages


What to expect from the service?

Services Provided:
In consultation with the patient, the treating team will develop a care plan that supports a patient’s care needs and goals whilst on the program.
The care plan may include:

  • Nursing care
  • Physiotherapy
  • Dietetics
  • Podiatry
  • Occupational therapy
  • Speech pathology
  • Social work
  • Geriatrician consultancy.

Personal care could be provided on a case by case basis.

All services are available Monday to Friday with the exception of nursing care which is Monday to Sunday 0800am – 4.30pm. Time on the program will depend on patient’s individual care goals. Most people stay on the program for less than 21 days and this includes the length of stay spent on inpatient GEM Wards. Within this time, the team will work with the patient to arrange any ongoing support requirements. This could include TCP, HARP or CHSP services.


Referral email:

Completed Inpatient – Aged Care & Rehabilitation Consultation Referral form

Information required:

  • 3 points of patient identification / ward or home address
  • Reason for referral/goals
  • Clinical issues (eg. patient is on warfarin, has wound care)
  • Community referral, a GP or geriatrician summary (medical handover)
  • Eligibility Criteria
  • Chronic /complex conditions associated with ageing requiring cognitive review, treatment / management by Geriatrician / multidisciplinary team
  • Clinically/medically “stable” – acute delirium resolved or chronic
  • ‘Home’ environment is assessed as suitable / safe
  • Resides within 15km radius of a NH campus (TNH, BECC or BHS)
  • Consents to receive daily visits


Resources


Last edit: 26/03/2026

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