Healthy at Home supports the care of older people whose medical condition is starting to decline.
The key to staying at home is getting our assistance when you first start to decline and have difficulty managing. We hope
to maintain you in your home so you don’t need to go to hospital, although time in hospital may still be needed for some people. Healthy at Home was previously
known as the Sub-Acute Fast Track Elderly Care (SAFTE) pilot project. Our clients live in the Hornsby or Ku-ring-gai area.
 Who are we?
The Healthy at Home Team is part of the Rehabilitation and Aged Care Service at Hornsby Ku-ring-gai Health Service. Medical, nursing and allied health staff are
part of our team.
What do we do?
Healthy at Home is a rapid-response team that supports the care of older people (65 years and older or 45 years and older for the ATSI population) whose medical condition is starting to
decline. Its aim is to support older people who want to stay in their own homes, by averting further deterioration and improving their health before they become
too unwell and require hospitalisation. In the case of clients who do need to come to hospital, they may be fast-tracked to a rehabilitation ward to avoid a wait in the emergency department.
After discharge the team may then work with the patient and family to reduce the need for re-admission. The Healthy at Home program offers:
- A response within 48 hours of referral, 7 days per week
- Access to a clinical team that may include a geriatrician, a registered nurse, a physiotherapist, and an occupational therapist
- Access to a community services coordinator
The Healthy at Home team will contact clients to arrange an appointment. Clients are initially visited in their own homes by a Registered Nurse and a Community
Services Coordinator. A comprehensive assessment is undertaken of the client’s current status and requirements and a care plan is drawn up. Depending on the
circumstances, the Healthy at Home team will provide the client with:
- Clinical services such as specialist medical, nursing, physiotherapy and occupational therapy to help manage their health at home
- Fast access to blood tests and x-rays; AND/OR
- Community services (ComPacks). These may involve assistance with housework, transport, heating of prepared meals and personal care, depending on individual needs.
The Healthy at Home team works in partnership with other specialist providers, such as Aged Care Assessment Teams, dementia respite services and general practitioners, to
meet individual needs.
We have more information for health professionals on 'when to refer'.
How you can access our service
Any service provider such as a GP, community nurse, ambulance officer or volunteer worker can make a referral.
To make a referral ring 1800 152 149 and provide the relevant information to the Referral Information Centre staff member on duty.
We have a referral fact sheet available, with links to referral forms.
Where you can find us
Healthy at Home is located in Building 8 (Old Leighton Lodge), near gate 6 on the campus of Hornsby Ku-ring-gai Hospital.
What are our hours?
Office hours for Healthy at Home are Monday to Friday, 8.00am to 4.30 pm (excluding public holidays).
The Referral Information Centre takes referrals 24 hours per day, 7 days per week.
How you can contact us
Referrals can be made at any time by calling 1800 152 149.
More information
The new “Healthy at Home” project, focused on keeping people healthy and out of hospital, was trialled in 2006 at Hornsby Ku-ring-gai, St George, Queanbeyan
and Newcastle hospitals. The program was evaluated in 2007 by Wollongong University who recommended on-going funding and expansion of the program using
Hornsby Ku-ring-gai's model of care. Healthy at Home is designed for people over the age of 65 whose medical condition is starting to get worse. The aim is to
identify and treat changes in their health early so that they don’t end up in hospital.
Healthy at Home Fast Facts: results of the evaluation
- People over 65 years of age suffer from the heaviest burden of disease and disability and have the highest rates of hospital admission once they come to the Emergency Department.
- 79% of patients would have presented at the Emergency Department if not for Healthy at Home intervention
- 91% of patients had their care needs met
- 96% of carers felt their needs were addressed
- Emergency Department presentations fell by an estimated 5% in this age group
Why avoid hospital?
- most people prefer to be treated at home if possible
- treating patients in the comfort of their home helps them maintain their independence
- treating patients at home can make it easier for the team to meet the needs of family carers as well as the person they care for
- older patients may be more at risk of complications like infections when treated in a hospital setting
- familiar environments and routines are less confusing for most patients
We have a referral fact sheet available, with links to referral forms. Information about the Rehabilitation and Aged Care Service is available. Information on accessing other RACS services is available by following the links
to those services:
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