Aims: There is increasing need to deliver proactive ‘home-first’ assessment and management of older people at risk of preventable hospitalisation. As part of the Strengthening Medicare measures, Bendigo Health was the regional health service selected to design and operationalise a non-admitted multidisciplinary geriatric outreach Older Person's Care Hub (OPCH) in a three year pilot.
Methods: Program design and implementation planning included multidisciplinary workforce recruitment, service and workflow integration, digital enablement, establishment of governance structures and referral pathways, stakeholder engagement, and development of the care delivery model. These elements were integrated with existing Better at Home, Residential InReach, and emergency department consultation services to avoid duplication and support system flow. A structured evaluation framework was developed alongside service planning.
Results: The OPCH is scheduled to commence in 2026, targeting 80 rapid-response episodes of multidisciplinary geriatric assessments and care in older people's homes in the first year, scaling to 110-120 episodes annually across the broader health service network. Early reflections from the planning phase highlight key enablers. Including clinical leadership and integrated governance, and anticipated challenges such as workforce alignment and digital interoperability.
Conclusions: Proactive, home-based geriatric assessment and linkage to appropriate services remain inconsistently embedded across health systems. As demand from rom an ageing population increases within constrained service and workforce environments, structured, integrated models of non-admitted geriatric care will become increasingly important, particularly in rural and regional settings. Early dissemination of implementation insights from pilots such as this may support the development of sustainable, scalable solutions for older Australians.