Overview
Initiative type
Service Improvement
Status
Deliver
Published
June 2025
Summary
Until recently, geriatric patients who required a higher level of less acute clinical support, had to stay in the hospital setting. Now they have a choice to have hospital level care at home under Geriatric Evaluation and Management - Hospital-in-the-Home (GEM-HITH).
Dates: January 2024 - December 2024
Implementation sites: Queensland statewide
Partnerships: N/A
Aim
To have a positive impact on aged and frail patients at risk of functional decline in hospital, by early discharge home and assessment in the community.
Outcomes
- Reassurance to worried families that their aged family member is supported as they transition home from an acute medical episode. Right care in right place at right time.
- Assessment and hospital avoidance of the sub-acute patient in their home environment with a multidisciplinary approach.
- Supporting seamless care across the continuum from Hospital to Community
Background
Service mapping and gap analysis were previously performed and identified a need for Geriatric Care in the community to support early discharge and prevent readmission.
Methods
Rapid implementation through Plan-Do-Study-Act (PDSA) cycles and an agile improvement methodology was used to break the project down into phases with rapid feedback processes through the GEM-HITH working group to allow for adjustments.
Discussion
The success of the project was dependant on integration, collaboration and cooperation of existing services and processes to work together. This project focused on leveraging what resources and processes that were already in place: sub-acute services, medical discharge teams, GERI service in ED, rapid access Allied Health, HITH and Hospital Avoidance services.
One of the early outcomes of the GEM-HITH trial, was patient Leo. A frail elderly gentleman who is the main carer for his wife who has dementia. He lives at home with her and his faithful dog and does not want to spend any time in a hospital setting. Leo had had a number of falls and an ambulance was called. He was found to have a significant postural drop and needed to be assessed medically. He unfortunately spent five days in the emergency department short stay unit until the GEM-HITH service stepped in to assist getting Leo home. His family was trying to navigate increasing the aged care package and change providers to give Leo and his wife more support at home. Leo also needed some reconditioning from Allied health to increase is function at home. The multidisciplinary GEM-HITH team was able to support Leo to titrate his antihypertensives and reduce his falls risk, avoid a readmission and be that hospital level support at home for Leo and his family. By the end of his GEM-HITH admission, Leo was caught mowing his lawn.
References
Central Queensland HHS Clinical Services Plan
Australian Institute of Health and Welfare - Older Australians in Hospital.
Key contact
Louise Kime
NUM Community Acute and Non-Acute Services, Rockhampton Hospital
Central Queensland HHS