Care at HomeÂ
Post-Acute Care
Short-term care at home after hospital discharge
A variety of care at home services can be arranged such as:
- nursing
- showering assistance
- domestic assistance (e.g. home cleaning)
- in-home respite
- occupational therapy
- physiotherapy.
A Post-Acute Care Coordinator will assess, arrange and monitor a personalised care plan for you that considers your individual and clinical requirements.Â
Any services you were receiving prior to hospital admission are expected to continue upon discharge.Â
Program length is typically up to four weeks.Â
Your Post-Acute Care Coordinator will liaise with agencies that can provide longer-term services (e.g. local council) and make referrals to other agencies if needed.
All Post-Acute Care services are free of charge.Â
Complex Care/HARP
Care at home for people with chronic and complex health issues
Complex Care (previously known as HARP) supports people with chronic disease, those who are aged and/or have complex needs (including psychiatric disability or mental health issues) and people who frequently use hospitals or are at risk of unplanned hospitalisation.
Key objectives are to:
- improve patient outcomes
- provide integrated, seamless care within and across hospital and community sectors
- reduce avoidable hospital admissions and emergency department presentations
- ensure equitable access to healthcare
The service is staffed by community nurses and social workers, who work closely with other allied health staff to provide patient-centred care coordination, education and self-management support.
This service is free. However, our team may recommend programs, services and equipment that may attract a fee. There is no obligation to accept any of these recommended programs.
Residential In Reach
Hospital care in the comfort of your aged care residence
Residential In Reach brings free specialised clinical care right to your residential aged care facility. Our goal is to enhance your comfort and well-being without the need for travel to hospitals or emergency departments.
This short-term service works alongside your regular care team. It’s not a replacement for the care you receive from your aged care home or your usual GP.
To benefit from Residential In Reach, you’ll need to provide consent, along with your GP’s approval. Your GP or aged care facility can request this service on your behalf.
While you receive this extra care, the dedicated staff at your facility will continue to support you as usual. An @Home coordinator, a Registered Nurse, will collaborate with your GP and care team to ensure you get the additional support you need. With your permission, your family or carer will also be kept informed about your care.
District Nursing Service
Nursing care at home
Our District Nursing service is staffed by experienced and professional registered nurses who coordinate care with your local GP and allied health professionals to provide comprehensive and compassionate nursing care at home. This service is available for anyone living in the Mount Alexander Shire.
This service provides advice, education and support to encourage self-management and independence. Our focus is helping maintain independence while delivering the best clinical care to suit your needs.
A nursing assessment will be conducted to identify your needs and the ability of the district nursing team to meet those needs. With your consent, our nurses will help connect you to services you may require to address more specific issues.
Our service is available to any community member of any age who requires nursing assistance to manage their healthcare needs. We also deliver services to National Disability Insurance Scheme (NDIS) participants, Home Care Package holders, Transport Accident Commission (TAC) and the Department of Veterans Affairs (DVA).
Anyone can be referred to our District Nursing Services, and self-referrals, including those from carers, are welcome. Alternatively, your GP, medical practitioner, treating hospital, or allied health professional can refer you to the District Nursing Service.
We will contact you once your referral is received to organise an appointment. Anyone over 65 years or for ATSI must have a My Aged Care active client record. You can access Australian aged care information and services at My Aged Care. The Charter of Aged Care Rights applies to District Nursing clients who are funded under the Commonwealth Home Support Programme. We acknowledge the support of the Australian and Victorian Governments.
Please note that referrals are prioritised, and visits are scheduled according to urgency and client needs. You must agree to any referral on your behalf. Please let us know as soon as possible if you need to change or cancel a scheduled appointment. A GP or specialist doctor’s health summary should be provided with the referral and emailed to District Nursing.Â
Please phone our office on +613 5471 3555 if you have any questions about eligibility for our service.
Hospital at Home
Hospital care in the comfort of your home
Hospital in the Home offers free, hospital-level care in your own home, eliminating the need for an inpatient stay.
Receiving care at home helps reduce the risk of hospital-acquired infections and complications. You can spend more time with family and loved ones, and recover better in a familiar environment.
You can be admitted directly by your GP, urgent care, acute ward or another health service. You’ll need a GP with admitting rights to Dhelkaya Health and access to a carer. You’ll also need a family member or support person.
Once admitted, you’ll get details about your condition and treatment plan. Registered nurses will visit you as needed, and allied health professionals (like physiotherapists or dietitians) may also provide services.
Regular check-ups with your GP will occur at your home, your GP’s clinic or at Dhelkaya Health. Even at home, you’ll be a registered inpatient of Dhelkaya Health.
GEM@Home
Short-term treatment for older people with age-related conditions
GEM@Home is a free service for older people with age-related conditions, cognitive impairments, or long-term illnesses.
It is delivered to you in the comfort of your home by a care team that includes a geriatrician, your GP, nurses and allied health clinicians.
GEM@Home programs typically last between 1 and 4 weeks and may start in hospital before moving to home care. If you’re a hospital patient, your care team can refer you into GEM@Home. Your GP can also refer you to the program.
On admission, the GEM@Home team will comprehensively assess you. They might ask for input from your family or carer to help them understand what matters most to you. The team will then set treatment goals, create a discharge plan, and schedule regular visits based on your needs.
You’ll have access to a wide range of health professionals as part of your treatment.
To be eligible, you’ll need to be medically stable, mobile and able to care for yourself, and have someone living with you who can assist you. Your home also needs to be suitable for daily visits.
