[email protected] is an inpatient rehabilitation program, modelled on a GEM ward, which provides care for older people in the comfort of their own home rather than in a hospital ward.
[email protected] is designed to increase service accessibility and connection to care in the community, helping older people to achieve their care goals and best possible level of health and function. The program also aims to reduce the time spent in, and risks associated with, hospitalisation.
Patients are admitted to [email protected] for up to two weeks and receive daily visits from the multidisciplinary care team (MDT). The MDT includes medical, nursing, pharmacy, physiotherapy, occupational therapy, social work, speech pathology, dietetics, podiatry, and allied health assistant. The number and frequency of visits, and make-up of the patient's MDT, will vary according to individual patient care requirements.
Home support services (personal care, house cleaning and shopping assistance) are available and are funded by the [email protected] service whilst a patient is admitted to the program. Patients will also have access to a 24-hour clinical helpline while admitted to the program.
Patient selection / referral criteria
The [email protected] service accepts internal referrals from acute and subacute inpatient wards.
| Inclusion Criteria | Exclusion Criteria |
- Patient has complex, chronic or multiple health conditions that require treatment and management by a Geriatrician and MDT, and would otherwise be managed within a hospital inpatient ward environment
- Patient is clinically and medically stable to be at home, and is deemed able to safely manage at home +/- support from carer/family
- Patient has clear achievable care needs and goals within two to three weeks that would benefit from the program
- Patient resides within [email protected] catchment area (local government municipalities of Brimbank, Hobson's Bay, Maribyrnong)
- Home environment is assessed as suitable and safe for the patient's level of function and for staff to visit
- Patient consents to participate on the program, to receive daily visits at home, and to admission to inpatient setting if required
| - Patient is clinically/medically or mentally unstable and requires management within an inpatient hospital ward environment
- Patient care needs and goals are greater than what the program can provide, including requirement for regular monitoring of medical status more than once per week
- Patient is undergoing VCAT process for the appointment of a decision maker
- Patient resides in a residential care facility
- Patient is outside of [email protected] catchment area
- Home environment is assessed as unsafe or unsuitable for the patient to return home or for staff to visit
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How to refer
[email protected] referrals are made via completion of an order to the SNAP team using the EMR.
Key contacts
