Inside Queensland’s flagship Hospital in the Home (HITH) programs

Older Australians in Queensland are avoiding protracted hospital stays and getting better treatment outcomes, thanks to two flagship home care initiatives, being rolled out across the state.

The Geriatric Evaluation Management in the Home (GEMITH) program, and its rehabilitative sibling (GEMRITH), led by a central project team within the Healthcare Improvement Unit, target older and vulnerable consumers, who are more at risk of complications from lengthy hospital visits.

As well as sending patients home earlier, the programs altogether divert eligible patients from the bricks and mortar hospital setting.

In addition to taking referrals directly from inpatient wards, they support direct referrals from Emergency Departments, Queensland Ambulance Service and General Practice, providing alternate care pathways for those bypassing inpatient services.

“The focus was on reducing in-hospital length of stay and preventing avoidable admissions for patients 65 years or above, or 50 years and above for Aboriginal and Torres Strait Islander people with age related physical, functional and/or cognitive decline associated with frailty. Our goal was to improve patient well-being, autonomy, satisfaction and achieve the best possible health outcomes,” said Dr Fiona Baker, Medical Clinical lead for the GEMHITH Project, said.

To achieve this, the programs include daily visits from members of a multidisciplinary care team. Depending on the patient’s needs, they may be seen by nurses, physiotherapists, occupational-therapists, speech pathologists, allied health assistants, dietetics or geriatrician or rehabilitation consultants.

Celebrating success

Since their launch, an estimated 70+ new beds have been opened, allowing people, who would otherwise have been admitted to a hospital bed, to be treated at home.

Dr Baker says data gathered from published research and already established services in Queensland hospitals has justified the model’s expansion.

“The model has been around for a while and has research published on its clinical outcomes. So, we know it’s effective for reducing in-hospital length of stay for older people, improving patient outcomes, reducing hospital acquired complications, as well as delivering geriatric and rehabilitation care in the community,” she said.

Data from consumer surveys has also nodded to the model’s success, with the initiative well-received by the majority of those treated.

“We’ve had great feedback and know that people generally prefer staying at home to receive their care. It’s more comfortable, and they don’t face the same risk, like hospital acquired infection or delirium, as they do from extended hospital stay.”

Staff also find more value in their work when they see patients getting better outcomes.

“A ward rehab physician recently said, it’s “absolutely marvellous” being able to transition someone out of the rehab ward when they’re ready to get home. So, it’s a win-win situation all round.”

Designing the model

The initiative was led by a central project team, which included medical nursing clinical leads, and project support. “They worked collaboratively with health services to develop and implement the models of care,” Dr Baker said.

To ensure model integrity across the state, they follow Queensland Health guidelines around Hospital in the Home (HITH). At the same time, however, health services have autonomy to develop the service as appropriate.

“Broadly, we are all meeting the core principles of the model, such as ensuring access to a 0.5 FTE senior medical officer (as a minimum). geriatricians and rehabilitation physicians as part of a multidisciplinary team, align the visiting discipline of care practitioner to patient needs, via daily assessment or intervention.

“Then, providing these criteria are met, we feel flexibility to adapt the model to various contexts is important.”

The flexibility component has seen sites adopt varying services and referral pathways. Some have linked their services to dedicated teams within their emergency departments, who refer eligible subacute and rehab level patients for at-home treatment. Others have linked their service to the Queensland Ambulance Service falls co-responder team, to help flag and refer people who recurrently fall– or those with a high falling risk – into the hospital system.

“It’s incredibly varied what they can take onto this service. If it’s a surgical patient, you could be looking at deconditioning or rehabilitation post theatre. If it’s a medical patient, you could be looking at delirium management post-acute illness, a recurrent faller program to improve everyday functioning or a ‘trial at home’ patient who has a high risk of readmission but are supported by family and / or services to trial transition to home. Providing the care type meets GEM or Rehabilitation care types, the possibilities to support patients are endless.”

Navigating setbacks

The programs have already been implemented in seven new sites and expanded in six more, since a submission to grow the initiative was approved by the Commonwealth in July 2024.

While the rollout is going well, Dr Baker says it has been afflicted by several challenges.

“Recruitment been a big problem, particularly in regional Queensland. It’s not just the senior medical officers, geriatricians and rehab physicians health services have struggled to recruit to. It’s also allied health and nursing professionals.

“Of course, we always knew this would be a challenge in the current climate, but it’s more so than we anticipated, particularly in regional areas.”
Adverse weather setbacks like flooding, storms and cyclones have also kept health services on their toes.

“We’ve had our fair share of logistical setbacks. Being an at-home service, with people driving on the road, access to cars and safe driving conditions has been an important consideration.”

Further insight

Sharing more details of the rollout, Dr Fiona Baker will present at the upcoming Hospital in the Home Conference, as part of Connect Virtual Care on 31st March to 1st April 2026.

One pass to Connect Virtual Care gives you access to three conferences:

– National Telehealth
– AI in Health Regulation, Policy and Standards
– Hospital in the Home

Learn more and register your tickets here.