The At Home initiative has enhanced care for older people across Frankston and the Mornington Peninsula, by introducing comprehensive services directly into the community.
Peninsula Health is now strengthened with a specialised geriatrician as part of the At Home Clinical Response Service, significantly improving the quality of care for older residents. This service supports people to manage complex health needs, dementia, and other age-related conditions, which have traditionally required numerous hospital visits.
For those older people with circumstances that prevent them from accessing existing Peninsula Health Geriatrician Outpatient Clinics, the At Home Clinical Response Service ensures they can receive dedicated consultation and care. This can occur within the comfort of their aged care facility or home, reducing hospital admissions and improving overall health outcomes. Understanding someone’s unique needs is at the core of the new geriatrician service. The team is dedicated to delivering person-centred care plans that cater to individual health requirements and foster a supportive and compassionate care environment. Key features of the service are:
Proactive Care for older adults
Introducing a geriatrician to the team marks a shift from a reactive to a proactive care service. Previously the service was tasked with responding to urgent calls from nursing homes as well as supporting patients and facilities after time in hospital.
With the enhanced service, patients now receive comprehensive medical assessments and tailored care plans in their residential settings. This is done in consultation with them, their families, General Practitioners (GPs) and other care givers. The service liaises with Emergency Departments and inpatient hospital ward teams, and, if needed, staff in residential facilities regarding ongoing care for patients about to be discharged. This proactive approach helps to:
- manage health conditions before they escalate,
- guarantees discharge plans are reviewed and remain appropriate,
- and ensures continuous, high-quality, person-centred care.
Multidisciplinary Team Support
The multidisciplinary team, which includes GPs and Emergency Department Consultants, now benefits from the added expertise of a Geriatrician.
This specialist knowledge allows for more team collaboration, information-sharing among team members, and encourages depth in handling complexity. This enhancement ensures patients and clinicians are linked to specialised advice and support and improves the overall quality of care provided to patients.
Community and Beyond
While the primary focus is patients in residential aged care, the geriatrician service also extends to older people living independently with complex needs. This approach is particularly beneficial for patients who face challenges in accessing traditional clinic-based care due to unique circumstances.
With the addition of a geriatrician to the At Home Clinical Response Service, which combines proactive care and multidisciplinary support, there is a new benchmark for comprehensive care for older people in the community.
For further information, please contact:
Glenn Mathieson, Head of Unit, Community Health (including Hospital in the Home), Acute, Medicine, Sub-Acute & Integrated Care GMathieson@phcn.vic.gov.au
or
Fergus McGee, Clinical Director, Integrated & Ambulatory Care, Acute, Medicine, Sub-Acute & Integrated Care FMcGee@phcn.vic.gov.au
At Home is a Peninsula Health initiative to improve care for the local community by keeping people out of hospital.
At Home moves additional medical care into the home and community environment;
allowing patients to access experienced clinicians, nurses, and allied health professionals.
Peninsula Health’s At Home vision is to treat people at home, making home
the first preference for care
*Home is defined as = aged care facilities, community residential settings & private homes