Northern Adelaide Geriatric Service (NAGS)

Service information

The GEM Unit is a hospital-based 24 bed unit, which provides specialist geriatric services with a focus on restorative therapy and medical optimisation to enable a patient to safely return home. This includes comprehensive and responsive assessment and care planning in consultation with the older person, their family, carer, and current community services involved in their care. GEM promotes an interdisciplinary approach to care, based on principles of best practice management of older people.

Referral information

Essential criteria

• aged 65 years or older (or 50 years or older for Aboriginal or Torres Strait Islander people)
• lives within the NALHN service area
• patient or Substitute Decision Maker (SDM) consents to the referral and transfer if accepted
• person is not on a maintenance care type

Inclusion criteria

• Clinical Frailty Score of 4 to 7
• patient has specific and readily recognised cause for recent change in functional or cognitive status (e.g. recent surgery, fracture, acute illness)
• patient with existing BPSD will be only accepted if there has been a recent change in their behaviour care requirements
• planned discharge destination is to the person’s own home within two weeks

Exclusion criteria

• bariatric weight exceeding 150kg
• requires a three-person assist or sling lifter or lacks sitting balance
• end of life care of palliative diagnosis
• requires frequent monitoring exceeding four-hourly observations
• requires ongoing sub-specialty input (including specialist nursing) that cannot be provided onsite
• experienced a MET, Code Blue, or Code Black in the last 48 hours
• requires 1:1 guard
• undifferentiated presentations that have resulted in an acute drop in mobility or function that require further diagnostic clarification
• admitted under a maintenance care type

Referral is made via the VIVA platform. Referrals are screened and accepted by the SPOC (Single Point of Coordination) Team and added to the GEM VIVA watchlist.

Please contact the GEM Unit team to discuss your individual needs.

Contact details

Phone: (08) 8161 2172

Service information

The Geriatric Inpatient Rehabilitation (Geri IPR) Unit is a 20-bed specialised service designed to support older people recovering from illness, surgery, injury, or functional decline. The service focuses on restoring independence, improving mobility, enhancing quality of life, and supporting safe discharge back to the community or residential care.

Geri IPR aims to improve functional outcomes, increase patient independence, reduce falls risk, optimise chronic disease management and provide safe transition to home or appropriate care setting. This is a two-week goal-oriented program.

Referral information

Inclusion criteria

• aged 65 years or older (or 50 years or older for Aboriginal or Torres Strait Islander people)
• referrals are to be completed by a clinician via the VIVA platform and assessed by SPOC
• patient must be medically stable and willing to participate in daily therapy (minimum of two hours per day)

Reasons for referral may include:

• falls and fractures
• orthopaedic surgery
• deconditioning after acute illness
• mobility decline
• frailty syndromes
• complex medical conditions impacting function

Exclusion criteria:

• 1:1 nursing is required 48 hours prior to referral
• post acute stroke
• no home or not confirmed discharge destination post program
• complex medical issues requiring specialist review

Please contact the Geri IPR team to discuss your individual needs.

Contact details

Phone: (08) 8161 2117

Service information

GITH is a 35-bed hospital substitution service which provides in home services for the older person requiring urgent health-related review, treatment, and investigations. The service delivers in-patient, multi-disciplinary care and treatment to older people within their home environment, including in Residential Aged Care Homes.

GITH aims to reduce the need for presentation to the Emergency Department and support early discharge from inpatient hospital units. Patients are admitted to GITH by a geriatrician and receive visits up to twice per day by medical, nursing and allied health clinicians, with telehealth provided as indicated.

Referral information

GITH admits patients who:

• are aged 65 years or older (or 55 years or older for Aboriginal or Torres Strait Islander people)
• present with geriatric syndromes
• require geriatrician input and at least one other discipline to achieve their restorative goals

Service exclusion criteria includes patients who:

• are admitted under a maintenance care type
• require one or two person assistance with mobility and Activities of Daily Living (ADL) that cannot be facilitated by family or an external provider within their home
• require more than twice daily medication management that cannot be facilitated by family or an external provider within their home
• are discharging against medical advice
• require the administration of blood products

Reasons for referral can include:

• recommendation or an assessment for cognition, mobility, ADL and equipment needs
• chronic illness management
• physical exercise programs
• medication review and management
• wound care
• blood monitoring including anticoagulation
• pain management
• falls risk assessment and prevention strategies

Contact details

To discuss entry into this service, please contact:
Northern Adelaide Geriatric Service Administration
Phone: (08) 7321 4014 (Monday to Friday)

Service information

CGEM is a community-based service providing comprehensive multidisciplinary assessment and recommendations to older people within their homes. The team; which consists of geriatricians, nurses, physiotherapists, occupational therapists, social workers and dieticians, works in partnership with the patient, their families, General Practitioners (GP’s) and other service providers to provide a holistic, coordinated, multidisciplinary approach to form a long-term plan of care.

CGEM has a role in providing specialised, comprehensive assessment and care coordination for older people with high physical, cognitive and social complexities and attempts to link them into longer term supports via the My Aged Care system. It is targeted at those who would be unable to make the link into mainstream services independently. CGEM is a non-urgent service, and patients typically remain on the program for four to six weeks.

Referral information - Psychosocial stream

Inclusion criteria:

• aged 65 years or older (or 55 years or older for Aboriginal or Torres Strait Islander people)
• older people who are socially isolated or vulnerable and safety concerns are held

AND one of the following:

• multiple presentations to hospital in the past 12 months
• present with geriatric syndromes
• history of falling with no support systems in place and cannot access falls intervention through alternate public or private pathways

The psychosocial stream primarily works with highly vulnerable older people who are at risk in the community. Concerns may include, but are not limited to elder abuse, exploitation, hoarding/squalor, and loneliness/isolation with limited supports.

Referral information - Falls stream

Referrers utilise CGEM to access in home falls assessments and to triage referrals forwarded on to the Falls Geriatrics Clinic. This stream consists of two focuses: providing targeted intervention and/or therapy with a focus on reconditioning if the person can participate or to assess and provide targeted interventions with a functional/cognitive focus with the aim of promoting independence and reducing the risk of falls, then referring onwards to external services.

Inclusion criteria:

• aged 65 years or older (or 55 years or older for Aboriginal or Torres Strait Islander people)
• have experienced more than two falls in the past 12 months, or one fall resulting in injury
• have no support systems in place and cannot access falls intervention through alternate public or private pathways

*CGEM does not accept referrals to solely link older people in with supports through the My Aged Care system. Referrals are received through the Virtual In-home Virtual Assist system (VIVA) but are also accepted via email or fax.

Contact details

Email: nalhncommunitygem@sa.gov.au
Phone: (08) 7321 4044
Fax: 1300 467 567

Service information

TCP supports older people after a hospital stay by providing short-term care, therapy, and support to help them regain independence and improve their health outcomes. The program also helps people plan for any longer-term care or support they may need after completing the program. TCP is a short-term program, with a maximum duration of 12 weeks.

Care is tailored to each person’s goals and needs and may be provided:

• in the person’s own home, or
• in a Residential Aged Care Home

TCP services may include:

• nursing care
• physiotherapy
• occupational therapy
• speech therapy
• social work
• dietary advice
• personal care and support

The program is jointly funded by the Australian Government and the South Australian Government. The TCP works in partnership with community service providers, who deliver care and therapy services during the program.

Referral information

To be eligible for TCP, the individual must be a patient in a public or private hospital and be ready for discharge.

An Aged Care Assessment Service (ACAS) will be required to confirm eligibility for TCP. A NALHN TCP Coordinator will then meet with the person to discuss current care needs, explain the program and support them to complete the TCP Service Agreement.

NALHN TCP eligibility criteria:

• aged 65 years or older (or 55 years or older for Aboriginal or Torres Strait Islander people)
• lives within the NALHN service area
• willing and agrees to the program
• medically stable and is prepared for hospital discharge

Community TCP criteria:

• participates consistently in daily care needs and therapy for three consecutive days
• has achievable functional goals
• is safe at home and overnight with (support of own carer if needed)
• can self-manage or has existing supports in place to manage:
  • daily medications
  • basic mobility
  • continence and toileting
  • meals

Please contact the team to discuss your individual needs and available options for accessing the TCP.

Contact details

Email: healthphcsnortherntcp@sa.gov.au
Phone: (08) 7117 8341

Service information

TCP supports older people after a hospital stay by providing short-term care, therapy, and support to help them regain independence and improve their health outcomes. The program also helps people plan for any longer-term care or support they may need after completing the program. TCP is a short-term program, with a maximum duration of 12 weeks.

Care is tailored to each person’s goals and needs and may be provided:

• in the person’s own home, or
• in a Residential Aged Care Home

TCP services may include:

• nursing care
• physiotherapy
• occupational therapy
• speech therapy
• social work
• dietary advice
• personal care and support

The program is jointly funded by the Australian Government and the South Australian Government. The TCP works in partnership with community service providers, who deliver care and therapy services during the program.

Referral information

To be eligible for TCP, the individual must be a patient in a public or private hospital and be ready for discharge.

An Aged Care Assessment Service (ACAS) will be required to confirm eligibility for TCP. A NALHN TCP Coordinator will then meet with the person to discuss current care needs, explain the program and support them to complete the TCP Service Agreement.

NALHN TCP eligibility criteria:

• aged 65 years or older (or 55 years or older for Aboriginal or Torres Strait Islander people)
• lives within the NALHN service area
• willing and agrees to the program
• medically stable and is prepared for hospital discharge

Residential TCP criteria:

• participates consistently in daily care needs and therapy for three consecutive days
• has achievable functional goals
• needs no more than one person support for transfers, mobility and personal care
• has a suitable post-program living arrangement already identified

Please contact the team to discuss your individual needs and available options for accessing the TCP.

Contact details

Email: healthphcsnortherntcp@sa.gov.au
Phone: (08) 7117 8341

Service information

The Care Awaiting Placement (CAP) service provides short-term care for older people waiting for a placement in a Residential Aged Care Home. Delivered in partnership with Helping Hand Residential Aged Care at their Parafield Gardens site, the program uses a brokered, interdisciplinary approach focused on person centred care, supported discharge planning and clinical oversight.

CAP operates within a 12-bed unit featuring single rooms and 24/7 nursing and carer support provided by a GP via twice weekly rounds. The CAP Program improves NALHN inpatient flow by freeing up hospital beds for those who require acute or sub-acute medical care.

Referral information

Inclusion criteria:

• aged 65 years or older (or 50 years or older for Aboriginal or Torres Strait Islander people)
• lives within the NALHN service area
• is medically stable and no longer requires hospital care, while awaiting residential aged care home placement
• weight is under 120kg
• has a suitable post-program living arrangement already identified
• pending SACAT hearing with documentation provided
• requires only basic wound care

Service specific exclusion criteria:

• bariatric weight over 120kg or requirement for specialist equipment
• active smoker
• dependent on PEG feed or flushes
• prone to intrusive wandering
• medically unstable
• unknown discharge destination
• experience a Code Black or MET call within the last 48 hours

Referral is made via the VIVA platform. Referrals are screened and accepted by the Single Point of Coordination (SPOC) Team and added to the CAP VIVA watchlist. The CAP clinical nurse is responsible for coordinating patient flow within CAP.

Please contact the CAP team to discuss your individual needs.

Contact details

Email: Health.NALHNCAP@sa.gov.au

Service information

The NRICH service is delivered in partnership with ACH Group, at the HEALTHIA Residential Aged Care Home in Elizabeth Vale.

Together, the ACH Group and NALHN, provide specialist multidisciplinary aged care support for NRICH patients across 24 hours a day, seven days per week. The team provide medical oversight, planning and an individualised reablement program to optimise functional independence in a home-based setting to support safe discharge to home.

Referral information

Inclusion criteria

• experiencing deconditioning and/or functional decline following an acute illness
• able to participate in an average of 1.5 to 2 hours of therapy per day
• unable to return home immediately from hospital (to a community setting or RACH) and is still requiring overnight care but with a clear aim to return home
• has a defined and suitable discharge destination arranged on completion of the NRICH admission with any necessary community support already organised
• requires a maximum of one-person assistance and does not require a lifting device

Exclusion criteria

• active delirium, severe confusion, agitation or Behavioural and Psychological Symptoms of Dementia (BPSD) requiring 1:1 nursing support
• experienced a code black within the past 72 hours
• no established discharge destination
• acute requirement for IV therapy or oxygen therapy (long term home oxygen prescriptions are acceptable)
• active smoker

Please contact the NRICH team to discuss your individual needs.

Contact details

Email: Health.NALHNNRICH@sa.gov.au