Geriatric Evaluation and Management (GEM) services provides care in which the primary clinical purpose or treatment goal is improving the functioning of a person with multidimensional needs. These needs are associated with medical conditions related to ageing. They include falls, incontinence, reduced mobility, delirium and depression.
The person may have complex psychosocial problems and is usually (but not always) an older person. GEM is always managed by a clinician with special expertise in GEM.
GEM incorporates an individualised multidisciplinary management plan that is documented in the person’s medical record. The plan includes negotiated goals within indicative timeframes and documented assessment of functional ability.
The GEM patient
GEM patients are generally older and frailer people. They tend to have multi-morbidity that needs to be considered when developing their treatment regime.
Younger patients can be cared for in GEM, especially where there are clinical issues generally associated with ageing or disabilities. There may be complex social issues that require a multidisciplinary approach to assessment and planning.
GEM patients present with a diverse range of primary diagnoses. However, orthopaedic and neurological conditions account for around 30 per cent of all GEM admissions. A further 30 per cent present with general medical conditions, cardiac or pulmonary diseases.
A review of diagnostic related groups identifies a wide range of conditions, the more prevalent being:
- dementia and delirium
- injuries (commonly related to falls)
- infections (especially of the genitor-urinary tract and respiratory-related)
- cardio-pulmonary failure and unstable angina
- disorders of the nervous system disease
- other factors influencing health
- chronic obstructive airways disease
- gastro-intestinal disorders.
Elements of the service model
The GEM service model provides specialist assessment and management by an interdisciplinary team comprising medical, nursing and allied health. Direct care and all assessment and planning occurs within GEM.
Key members of the health team conduct initial assessments. Their expertise includes medical, nursing, physiotherapy, social work and occupational therapy. Other allied health professionals are referred in when specific issues are identified. Given the complexity of the cohort, access to the full range of allied health is generally required, including psychology and neuropsychology.
A formal assessment of functional ability, both on admission and discharge, is required. The Functional Independence MeasureTM (FIM) is currently mandated by the department for assessment of all GEM episodes.
All GEM patients’ cognition should be assessed on admission and whenever there is evidence of change during the admission.
Comprehensive geriatric assessment
The GEM patient group is made up of people who have complex and multiple medical, functional, and often cognitive, conditions requiring a comprehensive geriatric assessment (CGA).
A CGA will identify pre-hospital function and issues such as malnutrition, depression, cognition and ability to manage daily living activities in addition to current level of functioning.
The aim of a CGA is to maintain or restore function, minimise risks associated with impaired function, manage common geriatric conditions (such as falls and immobility, incontinence and cognitive impairment) and optimise community living arrangements.
A CGA always acknowledges the older person’s personal preferences and engages with family and carers when developing the care plan. Determining pre-morbid function is essential in the planning of care to identify early any issues around the discharge destination.
The plan of care needs to be routinely reviewed by the treatment team to determine the patient’s progress against the set goals.
Key features of a CGA
The key features of a comprehensive geriatric assessment are:
- team-based interdisciplinary assessment and planning
- geriatric medical input
- focus on the older person’s medical, psychological, functional and social capabilities
- coordinated and integrated treatment plan and longer term care planning
- focus on restoration of function or compensation for lost function
- person-centred and goal-orientated approach.
Setting of service
Geriatric evaluation and management can be provided in a variety of settings. These include dedicated inpatient beds, the community, the patient’s own home or in another setting such as residential care.
Consideration should always be given to providing care for the vulnerable older person in the least restrictive setting that will promote independence and reduce the risk of functional decline and adverse events often associated with admission to hospital. For appropriate patients, this means getting them home earlier supported by a GEM service model, including from an emergency department, acute ward or short stay unit.
The physical environment
The environment in which geriatric evaluation and management operates should be one that is designed to encourage independence and promote an interdisciplinary team approach. It should also take into consideration:
- the older person’s needs - their strengths and abilities should be fostered while they are also protected against harm
- the need for interactions between family and carers to be enhanced - private spaces and communal areas should be available
- how the environment supports people with cognitive impairment - Improving Care for older people: A policy for health services (2003) and Improving the environment for older people in health services: An audit tool (2006) provide the policy framework and a practical tool for developing an environment that is safe and functional for both patients and staff providing care.
Geriatric evaluation management also has a significant focus on rehabilitation. People need to actively participate in their therapy program and be encouraged to become as physically active as they can.
The ward environment needs to be set up to promote independence, with communal areas for dining and leisure. Patients are expected to be dressed and remain as active as possible during the day. Access to outdoor spaces may be considered therapeutic especially for patients with cognitive impairment.
Location of services
GEM is to be provided at all metropolitan, regional and sub-regional health services. In Planning the future of Victoria’s subacute service system: a capability and access planning framework (2012), a service capability framework defines the scope of practice and expectations for Levels 3, 4 and 5 services that are designated to report GEM or rehabilitation programs.
Geriatric evaluation and management (GEM) services are located across Victoria at the following health services.
- Alfred Health
- Austin Health
- Eastern Health
- Melbourne Health
- Mercy Public Hospitals Inc (Werribee)
- Monash Health
- Northern Health
- Peninsula Health
- St. Vincent's Health
- Western Health.
Barwon - South Western Region:
- Barwon Health
- South West Healthcare
- Western District Health Service.
- Latrobe Regional Hospital
- Bass Coast Health
- Bairnsdale Regional Health Service
- Central Gippsland Health Service
- West Gippsland Healthcare Group.
- Ballarat Health Services
- Wimmera Health Care Group.
- Albury Wodonga Health
- Goulburn Valley Health
- Northeast Health Wangaratta.
Loddon Mallee Region:
- Bendigo Health
- Castlemaine Health
- Echuca Regional Health
- Mildura Base Hospital.