Monash at Home – Aged and Rehabilitation Care provides a safe, home-based alternative to hospital-based aged and rehabilitation (also known as subacute) care.
Our service helps people recover at home by either reducing the length of a hospital stay or preventing the need for hospital admission altogether.
Who we are
Our multidisciplinary team works together to provide comprehensive, coordinated care tailored to each patient’s needs. The team includes:
- Medical specialists: geriatricians and rehabilitation physicians
- Nurses
- Pharmacists
- Allied health professionals: occupational therapists, physiotherapists, social workers, speech pathologists, dietitians, podiatrists, allied health assistants
- Neuropsychologists
Who we care for
We support patients who:
- Live within the Monash Health primary catchment
- Have rehabilitation or aged care goals requiring input from a multidisciplinary team
- Have a home environment that is safe for both patient and staff
Eligibility criteria for access to the service
Patients must meet all of the following:
- Experiencing a decline in functional status compared to the level before the onset of recent or complex conditions related to ageing and/or chronic illness
- Medically stable and suitable for care in a home setting, with medical needs that can be managed via once- or twice-daily visits
- Provides informed consent to participate in daily home visits and therapy sessions
- Clinically and medically stable, and assessed as being able to safely remain at home, with or without support from a carer or family member
- Resides within the Monash Health catchment area (available on request)
- Requires care from a Geriatrician or Rehabilitation Consultant, and would benefit from multidisciplinary intervention
- Home environment is assessed as safe and appropriate for the patient’s level of function and for staff home visits
- Able to safely manage basic needs (e.g. toileting, mobility, medications) independently or with support from carers, family, or a pre-established support system
- When alone without supports, the patient is assessed as safe to remain at home
- Has clear and achievable care goals that can be addressed within approximately two weeks
- Consents to the program by signing the Service Agreement (available on request), including agreement to inpatient admission if necessary
Exclusion criteria
Patients will not be eligible if any of the following apply:
- Unstable acute medical needs that cannot be safely managed at home
- Unresolved complex social issues that impact care delivery (e.g., awaiting VCAT decision on legal decision-making)
- Currently homeless or without a fixed, suitable residence
- Home environment assessed as unsafe or unsuitable for the patient and/or staff
- Clinically, medically, or mentally unstable, requiring inpatient hospital management
- Requires sliding-scale insulin therapy
- Care needs or rehabilitation goals exceed the scope or resources of the Monash at Home – Aged and Rehabilitation Care program
- Resides in a residential aged care facility (RACF)
- Lives outside the Monash Health catchment area
What patients can expect
Patients and families can expect goal-directed, medically-led care, provided by a coordinated team of health professionals. Our service includes:
- Daily nursing visits (7 days a week), supported by an on-call service
- Allied health and psychology input, as clinically required
- We can support you in various ways – in person, by telehealth, and phone support
- Brokered services when needed, such as assistance with activities of daily living
Operating hours
Our team operates 7 days a week, between 7:30 am and 8:30 pm.
Nurse visits take place Monday to Sunday, between 8:30 am and 7 pm
Medical visits take place Monday to Friday, between 8 am and 4:30 pm (some telehealth appointments take place on Saturday mornings, subject to availability)
Allied health visits take place Monday to Friday, between 8 am and 4:30 pm
Monash at Home – Aged and Rehabilitation Care is based at:
- Kingston Centre, Heatherton
- Mundaring Drive, Cranbourne
How to refer
From GPs and health providers outside Monash Health
Email the completed referral request along with the patient’s medical history to: monashathomearc@monashhealth.org
Phone: 9265 1318
Internal referral from providers within Monash Health
- Acute inpatient to Monash at Home – Aged and Rehabilitation Care: via EMR order Aged and Rehabilitation Access Service – ARAS (Initial)
- Emergency department to Monash at Home – Aged and Rehabilitation Care: via the ED geriatrician (in hours), on-call geriatrician (out of hours), or the Care Coordinator
- Aged and rehab bed-based (subacute) to Monash at Home – Aged and Rehabilitation Care: via EMR PowerForm Aged and Rehabilitation Access Service – ARAS
For Intake enquiries, please contact:
Email: monashathomearc@monashhealth.org
Phone: 9265 1318
Intake hours: Monday to Friday, 7:45 am to 4:15 pm