The Geriatric Evaluation and Management (GEM)@Home service at SALHN functions with a ‘home first’ principle by providing sub-acute hospital level care, goal directed therapy, and support to older people in the comfort of their own environment.

Delivered by a specialist team of geriatricians, nurses and Allied Health geriatric specialists based at the Repat Health Precinct, the service has an in reach (intensive program) and an outreach (community program) component designed for older consumers with complex medical, function and/or psychosocial needs.

The inreach service will provide daily care for people (including on weekends) for up to 14 days. The outreach service will provide care and community service planning for up to 12 weeks.

GEM@Home uses the latest digital enhancements in health care to allow for better visibility and greater understanding of patient’s health care needs. The new technology includes biometric kits for clinicians to be able to monitor vital signs and devices that can be installed within the home to minimise harm and prevent incidents such as falls.

Patients who are 65 years and older (50 years or older for Aboriginal people), or less than 65 years with a formal diagnosis of young onset neurocognitive disorder, can be referred to this service.

For more information about the GEM@Home service, please view our frequently asked questions (PDF 144KB).

GEM@Home Inreach (Intensive Program) Admission criteria

  • Patient is over 65 years old (50 years for patients identifying as Aboriginal or Torres Strait Islander), or less than 65 years with a formal diagnosis of young onset neurocognitive disorder and lives in the southern catchment area.
  • Medically suitable to be transferred to GEM@Home.
  • Suitable community location has been identified for patient to receive service (eg own home; stay with family; in a RACF) and method of communication identified. Home access must be considered if mobility level is different to premorbid level.
  • Functional goals of care with a restorative focus have been identified and agreed with patient/carer. 
  • Care needs can be appropriately and safely met by a community program - ability to mobilise and transfer independently or with standby if carer present who can assist; continence needs can be managed at home independently or carer present who can assist; not requiring more than twice a day nursing. Complex nursing interventions should be discussed with GEM@Home Triage.
  • GEM@Home has been discussed with client and /or carer and are agreeable.

GEM@Home Inreach (Intensive Program) Exclusion Criteria

  • Further medical investigations indicated that need to be completed in hospital.
  • 1:1 nursing or 24/7 support.
  • Behaviours of concern or wandering that cannot be safely managed at home.
  • If delirium is present, it is not resolving.
  • Patient requires nursing care more than 2x/day. 
  • VAC dressings.

GEM@Home Outreach (Community Program) Admission criteria

  • People 65+ or 50+ years of age for Aboriginal and Torres Strait islander people, with complex care needs.
  • People under 65 years of age with an age-related illness such as early onset dementia.
  • People who have had a deterioration in their level of functioning due to age related health issues such as cognitive decline or frailty who may require input from a geriatrician.

And at least one of the below:

  • Risk factors identified that must include 2 or more of the following: living alone with cognitive impairment and minimal support (formal/informal), poor personal hygiene, poor nutrition, high falls risk, concerns regarding driving abilities, financial mismanagement, medication mismanagement, changed behaviours, cognitive decline, wandering, safety concerns, suspicion of elder abuse, carer stress.
  • Environmental issues including hoarding and squalor with cognitive impairment.
  • Imminent risk of hospital admission or residential care with poor access to primary health care.
  • Unwilling or unable to attend memory clinic appointments.

Please note: Referrals will be reviewed on a case by case basis and not limited to those criteria listed above.

GEM@Home Outreach (Community Program) Exclusion Criteria

  • People who can attend the outpatient memory clinic for assessment and have no other identified needs (No need for simultaneous referral to memory clinic and GEM@Home).
  • People with acute mental health diagnoses as their primary issue- should be referred to Older Persons Mental Health Services (OPMHS).
  • People with hoarding as primary issue without cognitive impairment.
  • People with substance abuse as primary issue without cognitive impairment.
  • People with adequate formal or informal supports in place.


Referrals to GEM@Home will be triaged based on clinical need and service availability.

Please complete the referral form (PDF 160KB) and send via email or fax as detailed below.

Referrals to the inreach service (Intensive Program) will be accepted from SALHN Inpatient areas only. Referrals to the outreach service (Community Program) will be accepted from a range of pathways such as Residential Aged Care Facilities and GPs in the southern area.

Contact details

Phone: (08) 7425 0346
Fax: (08) 8124 1435