Geriatric Evaluation Management Program (GEM @ Home)

For Patients and Visitors

What is the Service?

The Geriatric Evaluation Management Program (GEM @ Home) provides aged care rehabilitation services to people residing within Northern Health’s catchment area following an illness or injury. Our aim is to support recovery, help patients achieve the best possible level of health and function and reduce the time spent in hospital.

What can I expect from the service?

The program is up to 3 weeks duration and will provide you with daily visits from members of the team based upon the plan that you and your family set with the team. The multidisciplinary team includes nursing, physiotherapy, occupational therapy, social work, speech pathology, allied health assistant, dietetics and geriatrician consultancy. If required, the program can also arrange a personal care assistant to support this care requirement during your time on the program.

How much does it cost?

There are no fees associated with the GEM @ Home program and all medication and necessary medical or physical equipment are provided to you for the duration of the program.

Contact us

While in hospital, you can talk to your treating team or ask for the Discharge Support Team. They can answer any questions and see if the GEM @ Home program can meet your needs.

For all other GEM@ Home program enquiries, contact us during business hours (Monday to Friday) on 9495 3101


For Health Professionals

Service Overview

GEM@Home is a GEM-Bed substitution program and provides interdisciplinary aged care and rehabilitation services to patients in their homes after an illness or injury. The aim of the program is to reduce the time spent in hospital and help patients achieve the best level of health and function whilst recovering in their own home.

Inclusion criteria:

· Chronic or complex conditions associated with ageing requiring treatment and management by a Geriatrician and multidisciplinary team.

  • Patient is clinically and medically stable to be at home.
  • Patient resides within 15 km radius of Northern Health inpatient sites.
  • Patient consents to receive daily visits at home from a member of the GEM@Home team.
  • The patient’s home environment is assessed as suitable/safe for the patient’s level of function and for any staff visiting the home.
  • The patient has achievable goals that would benefit from the GEM@ Home program.

Exclusion criteria:

· Patient resides in residential care.

  • Patient is medically/clinically unstable.
  • Undergoing VCAT process for potential appointment of a guardian.
  • Patients care needs and goals are greater than what the program can provide (I.e. requires twice daily nursing support).
  • Home environment is unsafe or unsuitable for the patient to return home or staff to visit.
  • Patient is outside of Northern Health catchment area.
  • Length of stay is greater than 30 days inclusive of GEM admission. Patient requires care coordination.

How to Refer:

  • Acute – OARS form following ACAT assessment
  • Subacute – Gem@ Home e-referral form
  • Community – GEM@ Home e-referral form and a GP or Geriatrician summary

All referrals to be emailed to NHS – GEM at Home Referrals

Referral must include:

All referrals must include:

  • Documentation of the patient’s verbal consent,
  • Goals applicable to two or more disciplines\summary of medical and functional status,
  • ISBAR compliance
  • Referrals from within Northern Health require a long-term drug chart, goals of patient care and a medication management plan to be completed and sent home with the patient.

Alternative service options:

  • Hospital in the Home (HITH) – if the patient requires intravenous medication, any intravenous products or VAC therapy
  • Home based transition Care
  • Private Geriatrician


For all GEM@ Home program enquiries, please contact the office during business hours (Monday to Friday) via 9495 3101 or via

The Clinical Coordinator is also available on 0428 599 694 to discuss any referrals.