June 26, 2025Northern Health’s Geriatric Evaluation and Management at Home (GEM@Home) program has recently marked its 10-year milestone, celebrating a decade of delivering innovative, hospital-level care to older patients in the comfort of their own homes.
The program was established to ensure frail older people with multiple and complex needs have access to specialist assessment, diagnostic and management services, including care coordination – without needing to leave home.
The idea was born from a shared vision to reimagine subacute care. “We brought together the key services traditionally delivered in a hospital bed and trained our staff to provide the same level of care in the home,” said Dr Sandra Brown, Divisional Director of Subacute Services and Hospital Without Walls.
Each day, nurses visit patients in their homes, with doctors and allied health professionals working collaboratively to support recovery. The Allied Health team includes physiotherapists, occupational therapists, social workers, speech pathologists, dietitians and a podiatrist. Allied Health Assistants then support patients in working towards their personalised therapy goals.
“GEM@Home is designed to increase access to care and strengthen connections within the community,” added Johanna Hayes, also Divisional Director of Subacute Services and Hospital Without Walls. “Our aim is to help older people reach their care goals and achieve the best possible level of health and function.”
Many staff members have been with GEM@Home since its inception. One of them is Nurse Grisel Jose, who transitioned from ward nursing to home-based care. “I’ve seen so many positive changes over the years,” said Grisel. “I used to work on the wards, but the benefits I saw in patients being supported at home really inspired me.”
Over time, the service has evolved with advancements in technology. “We now complete all of our clinical documentation using electronic medical records,” said Grisel. “It gives the team clear visibility of a patient’s care, even when delivered remotely.”
Research has highlighted the value of home-based programs like GEM@Home, particularly in promoting incidental physical activity in the home – an important factor in improving health outcomes for frail older adults. The program has proven effective in reducing lengthy hospital stays, enhancing recovery, and minimising the risks associated with hospitalisation.
Reflecting on the journey, GEM@Home Program Manager, Mathew Wood, said, “I’ve had the pleasure of leading the team for the past six years. It’s a privilege to work alongside such a dedicated group of professionals who are deeply invested in both the program and our patients.”
From all of us at Northern Health, congratulations on this milestone!
Pictured in featured image: The GEM@Home team
