Older Persons Care Hub (OPCH)

What we do

Our goal is to stabilise health concerns and help people remain safely at home.

We aim to see patients within 24-48 hours of referral. Our team provides assessment and treatment in the home when it is safe to do so. We work closely with the patient’s GP and referrers to ensure clear communication and continuity of care.

Our Older Persons Care Hub provides short-term care in the patient’s home. This may include:

• A comprehensive health assessment
• Medical review by a geriatrician
• Medication review and optimisation
• Support after a fall or sudden change in health
• Help with mobility and daily activities
• Care planning
• Referral to community services if needed
• Written communication and handover to the patient’s GP

We step in early to help sort out health concerns before they become serious enough to need a hospital or Emergency Department visit.

Who we care for

The Older Persons Care Hub supports older people living in our catchment who are:

• Aged 65 years and over, or
• Aged 50 years and over for Aboriginal and Torres Strait Islander people

Patients may be experiencing an immediate health concern that could otherwise lead to a hospital visit but can be safely managed at home. This may include:

• Falls
• Sudden decline in strength or daily function
• Confusion or delirium (with supports in place)
• Medication-related concerns
• Early worsening of a chronic medical condition
• Other acute health issues requiring rapid assessment

If emergency care is required, call 000

What we are not

• Not a long-term service
• Not a replacement for general practice or usual community care
• Our Older Persons Care Hub provides short-term support (usually up to two weeks) and works alongside the patient’s GP and existing healthcare providers

What to expect

If a patient is accepted into the Older Persons Care Hub:

• The team will contact the patient and/or referrer
• A home visit will be arranged
• Multiple clinicians may see the patient depending on their needs
• A care plan will be developed
• A summary and recommendations will be provided to the GP

What to Prepare

Once your referral has been accepted, please prepare before your home visit:

• A list of current medications (or medication containers)
• GP details
• Recent hospital discharge summaries or relevant medical information

Our Team

• Geriatricians (doctors specialising in older people’s health)
• Nurse
• Physiotherapist
• Occupational Therapist
• Social Worker
• Pharmacist

How to Access the Service (Referral Information)

All referrals within our catchment map are made via phone.

Anyone is welcome to make a new referral. Please call: 0409 051 905

If you are unsure whether our Older Persons Care Hub is suitable, please call to discuss.