Geriatric Medicine (Aged and extended care services)

The CALHN (Central Adelaide Local Health Network) Transition Care Program (TCP) provides short term post-acute care for older people to assist them to recover after a hospital stay. 

Transition Care helps older people to:

• recover after a hospital stay
• regain functionality or mobility
• remain independent in their own homes
• delay entry into an aged care home for as long as possible
• avoid the need for long term care
• finalise ongoing care arrangements.

TCP team

The TCP program is delivered in collaboration with aged care service providers and general practitioners. The TCP teams are Geriatrician-led and consist of:

• nurses
• physiotherapists
• pharmacists
• social workers
• occupational therapists.

Eligibility

To be eligible for TCP, an older person must:

• be 65 years or older, or 50 years for Aboriginal and Torres Strait Islander people
• be classified as an in-patient in a public or private hospital (including hospital in the home)
• have a valid Aged Care Assessment for the TCP (within the last 28 days)
• have potential to benefit from accessing a short period of restorative care service
• be willing to adopt recommended strategies, engage with the program and interventions and have achievable re-enablement goals.

Referrals

Referrals to CALHN TCP need to be made by the treating hospital team. 

For further information contact the TCP team.

Email: PHCSCentralTCP@sa.gov.au
Phone: 8222 8864

The CALHN Falls Prevention Multi-disciplinary team includes geriatricians (TQEH and RAH), nursing and allied health.

Triggers for referral from general practitioners include:

• recent hospital admission, Emergency Department presentation or SA Ambulance Service callout for a fall  
• patient reports having had a fall, trip or slip (with or without injury) 
• patient clinical assessment reveals falls risk factors, such as:
  • history of falls
  • multiple medical conditions
  • poly pharmacy
  • psychotropic medications
  • unsteady gait, poor balance, appears unsteady
  • reduced physical activity
  • sensory loss, cognitive changes
  • incontinence, weight loss
  • unsafe footwear, home environment hazards
  • decline in function,
  • increased risk of injury e.g. fracture history, osteoporosis, anticoagulation. 

Referral to the CALHN Falls Clinic is direct via outpatient department. 

Further information on this service is being developed and will be updated soon.

• Professor Renuka Visvanathan – Head of Unit 
• A/Prof Solomon Yu – Deputy Head of Unit 
• Dr Faizal Ibrahim 
• Dr Pazhvoor Shibu 
• Dr Shailaja Nair 
• Dr Khai Tam 
• Dr Kareeann Khow
• Dr Bavand Bikdelli 
• Dr Reena Tewari 
• Dr Fin Cai 
• Dr Thanuja De Silva

• Ms Carla Smyth – Nurse Consultant Geriatric Medicine Liaison
• Ms Emma Potts – Nurse Unit Manager Ward South Ground
• Ms Kathryn Smith – Nurse Unit Manager CALHN TCP and Falls Prevention 

• Ms Maree Braithwaite
• Mr Matt Ruggari

• Ms Connie Falcone
• Ms Ernesta Smythe 
• Ms Catherine Gilbert 

GPs and other medical practitioners can make a referral to our service by faxing a referral to our department.

Mark attention to the Geriatrician, Aged and Extended Care Services, TQEH.

Fax referrals to 8222 8593.

Urgent referrals by general practitioners or other medical practitioners are to be made via our GEM Liaison Service. 

Call one of our geriatricians, GEM Liaison Registrar or GEM Liaison Nurse to discuss further.

Call the GEM team via TQEH switchboard, phone 8222 6000.

Urgent referrals by general practitioners or other medical practitioners can be made by discussing the case with the Community Geriatrician or Registrar via TQEH switchboard, phone 8222 6000.

We encourage referrals to include the following relevant information:

• patient demographics
• medical
• function
• psychosocial information.

Results from relevant investigations will be important to provide to maximise the benefits from the consultation. 

We do not accept referrals for capacity assessment.