Monash at Home – Aged and Rehabilitation Care opens a new site to deliver care to people in the south-east of our Monash Health community.
Every day, 1 in 10 patients in hospital could be receiving their care at home. [1]
Public health demand is ever-increasing. The population and care needs of the Monash Heath community will only continue to grow. Already Monash Health is under pressure to meet current inpatient demand, and the forecast is for more presentations and increased case complexity.
We know the safest place for a patient is often in their own home, particularly for older people.
Monash Health is looking to a future where more care is delivered to our patients in their homes or communities
Monash Health’s Excellence in Timely Care initiative is about ensuring patients receive the right care, in the right place, at the right time.
It looks to a future where hospital care is provided only when people cannot receive care in their community. As a health service, we are expanding our capacity to bring hospital care to the patient, as we adapt more to an at-home-first mindset.
Monash Health already provides a vast network of services for care delivered in people’s homes. We have established, committed teams in this space that we can build on.
Monash at Home – Aged and Rehabilitation Care brings healthcare to patients in the comfort of home.
Monash Health is currently expanding its Monash at Home – Aged and Rehab service, with the commissioning of a hub site in Cranbourne. Once fully operational next month, we will have doubled the capacity of the Monash at Home – Aged and Rehab service.
What is Monash at Home – Aged and Rehabilitation Care?
Monash at Home – Aged and Rehabilitation Care (building on the GEM at Home service) provides home-based care for individuals with complex medical, functional, and often cognitive issues, who require comprehensive, medically-led, multidisciplinary assessment and optimisation.
As an alternative to hospital-based subacute care, the service is designed to facilitate an earlier discharge from acute care and/or avoid a subacute hospital stay entirely.
Patients in the service receive at least daily visits from a member of the multidisciplinary team (in person or by telehealth) and access to 24-hour telephone support. (Patients with more complex medical or care needs, requiring greater than twice daily visits and/or more intensive medical care will continue to receive their care within the hospital setting.) Patients may also access brokered services to assist with activities of daily living where there is no other support available.
Who we are
The Monash at Home – Aged and Rehab service is a medically-led multidisciplinary team and includes:
- Geriatricians
- Rehabilitation physicians
- Nurses
- Pharmacists
- Allied health including podiatry, physiotherapy, occupational therapy, social work, dietetics, and speech pathology
- Neuropsychologists
Who do we care for?
Monash at Home – Aged and Rehab supports patients, ideally directly from the community or acute care setting, who:
- Require short-term, medically led, multidisciplinary care to optimise function and establish ongoing support
- Have completed their inpatient (hospital-based/emergency room-based) medical care (i.e. clinically stable – do not require more than twice daily clinical input, frequent blood tests, emergent investigations, specialist consultations and/or enteral nutrition)
- Have clinical care needs that can be met in twice daily visits (e.g. wound management, medication monitoring, glucose management, IDC/stoma care)
- Have a community risk assessment (OHS) that determines their home (discharge) environment is not a risk to staff safety and/or any identified risks can be mitigated
- Accept and understand any identified clinical risks for discharge (dignity of risk) and that these can be mitigated to an acceptable level
Why the expansion?
Demand for hospital-based services will continue to surpass capacity.
Each day over 40 Monash Health patients are waiting in acute to receive their aged and rehabilitation care, equating to an estimated >25,000 acute bed days spent waiting.
In the lead up to the expansion, the team completed a feasibility audit. It identified 18% of subacute inpatients as suitable candidates for a home-based alternative.
Further (retrospective) data analysis estimates >3,000 bed days could be provided at home each year for patients with a length of stay <14 days and high functional independence measure (FIM).
What is changing?
Until now, Monash at Home – Aged and Rehab has operated from the Kingston Centre, to a patient cohort covering the north-west of the Monash Health community, including suburbs in the Monash, Kingston, Greater Dandenong and Bayside local government areas (LGAs).
On 9 October, a new Monash at Home – Aged and Rehab hub site opened in Cranbourne. Following the conversion of a site on Mundaring Drive, extensive planning, and orientation of the workforce for the new site, a 15-bed capacity went live.
The expansion will extend access to patients in the Casey and Cardinia areas and mean the Monash at Home – Aged and Rehab service is available to the whole Monash Health community.
How has it gone so far?
Demand for the service has been high since adding more capacity.
Monash at Home – Aged and Rehab has seen increasing acute/ED referrals from a baseline of 2 to a median of 10 referrals per week, since the revised referral pathways (ARAS) were implemented.
The increased choice for patients to receive their care at home has been well received, with 98% occupancy (35 beds), exceeding the (per annum) forecast of 600+ patients.
We have seen an increase in bed days provided at home, with an estimated 940 occupied bed days provided at home in August 2023.
The service continues to receive positive feedback from consumers of the service, with an average rating of 9 out of 10.
“The nurses were well informed and handed over patient updates seamlessly from day to day. I felt confident no stone was left unturned and I was provided with updates on my mother’s care needs – particularly important as she not only has cognitive decline but also has a language barrier to deal with.”
– Daughter of a patient
“Feeling secure that they were coming every day to check on my health.”
– Patient
“Care was still provided by doctors, nurses, etc. We saw an improvement with mum’s recovery being at home surrounded by family and the comfort of her own home.”
– Daughter of patient
“Doctors, nurses and OT were very professional, friendly, kind, patient and timely. Having medicines and wound care provided was excellent, respectful and helpful.”
– Patient
“They always rang and let us know when they were coming and did their work real professionally. Keep up the good work that you all do.”
– Wife of a patient
“Helpful information was received from the dietitian of how to improve increasing weight by suggestion of drinks and food. Plus nurses calling beforehand to let us know when they are coming. Very helpful and assisted us well as all this has been new to the family.”
– Daughter of patient
What’s next?
The third phase of the Monash at Home – Aged and Rehab expansion will open an additional five beds on Monday 6 November, bringing the total capacity across both Kingston and Cranbourne sites to 40 beds.
How to refer
Referral pathways and more information is available on the Aged and Rehabilitation intranet page.
DCO of the Aged Care Stream Neil Gunn spoke to the Employee Forum on Tuesday 24 October about the Monash at Home – Aged and Rehab expansion. Take a look here.
Approved by Stuart Cavill, Interim Deputy Chief Operating Officer Kingston, Aged and Rehabilitation and Allied Health Adult Inpatient Care
1 Lim , S. (2021). Home First! Identification of hospitalisation patient for home-based care. JAMDA.