After Hospital Home Care service
After Hospital Home Care (AHHC) is designed to support your patient as they recover at home.
The information in this page is intended for clinicians from hospitals only**
After Hospital Home Care trial service
AHHC is a 30-month trial service for eligible Medibank customers with chronic health conditions and certain accompanying risk factors to transition to and recover at home following a hospital admission, where clinically appropriate.
Support the patient at home by providing them education and information they may need to recover.
Support eligible Medibank members with chronic health conditions and accompanying risk factors that may increase their likelihood of being readmitted within 30 days of their initial admission.
Current eligibility criteria for referrals from hospitals^
We look forward to working with you to assist with identifying patients who you believe may meet the clinical and non-clinical eligibility criteria:
Clinical eligibility criteria
A patient must:
- be diagnosed with a chronic condition(s), being cardiovascular disease, respiratory diseases, musculoskeletal disorder, diabetes, neurological disorder, mental health condition, kidney and urinary disease, gastrointestinal disorder and hearing and vision disorder; and
- be assessed by the referring clinician as having at least one of the following risk factors:
- is over 75 years old;
- has had a high risk surgery;
- lives alone;
- in the referring clinician’s view, experiencing clinical deterioration based on screening questions;
- suffered a fall in hospital or since discharge;
- has had a medication change/polypharmacy (5+)/high risk medications;
- has cognitive issues;
- in the referring clinician’s view, has worries/stress
- has uncontrolled pain;
- does not have a regular doctor or access to a doctor;
- has had an emergency department visit in the last 6 months;
- poor mobility and unsteady on their feet;
- high risk home environment such as clutter, stairs, access issues, poor lighting, pets, unkempt;
- functional impairment: being unable to safely complete activities of daily living;
- psychosocial issues such as carer strain, lack of support;
- has had an emergency department visit in last 6 months;
- high-risk condition, ie., diabetes, heart failure, cardiovascular disorder, cardiac arrythmia, chronic obstructive pulmonary disease, other chest infection, sepsis, frailty, weight loss;
- has had a hospital stay of over 5 days this admission;
- has had a non-elective admission;
- has been rejected for referral to a hospital in the home or a rehabilitation in the home program.
Non-clinical eligibility criteria
A patient must:
- Be over 18, a current Medibank member paid up with residential hospital cover who has served applicable waiting periods;
- have been admitted to hospital in the last 7 days;
- have access to a telephone;
- referring clinician’s view, is that the service is suitable for the patient; and
- not be currently accepted or enrolled in a hospital in the home or a rehabilitation in the home program.
Exclusion criteria
Unfortunately, AHHC is not suitable for everyone.
Please check the exclusion criteria below:
An individual is unable to participate in the service if they:
- require highly specialised care or may also require specialised equipment, skills or constant attendant care;
- are receiving dialysis or active cancer treatment;
- are receiving palliative care treatment or services;
- are currently on or have recently been accepted into a hospital in the home or a rehabilitation in the home program.
What patients can expect from the AHHC service
- Once a patient is accepted into AHHC service, we will phone them to provide more information about the service and arrange a time for their first in-home visit. An initial home visit will be attended by a registered nurse to identify risks that may impact the patient’s recovery at home.
- Using that information, the nurse will create a care plan for the patient to agree on the approach to their ongoing recovery. The plan will then be shared with the patient.
- After the patient has agreed to their care plan, we will schedule future visits with the registered nurse and/or allied health professional, as required. At the end of the service, the patient will receive a discharge call and you will receive a discharge summary outlining the patient’s recovery.
An example patient journey is below – this is a model patient journey for illustrative purposes, a patient’s journey may vary depending on their individual circumstances:
How to refer patients
Our referral process is simple and shouldn’t delay any discharge processes you have in place now
Simply complete this form or phone us at 1800 854 300 to submit a referral.
FAQs
What does AHHC stand for?
This is our abbreviation for the service, After Hospital Home Care.
How long is AHHC offered for?
Patients will be enrolled in the service for 30 days.
Who is Amplar Health and what is its relationship with Medibank?
Amplar Health is a business of Medibank Health Solutions Pty Limited ACN 078 934 791. The service is delivered by Amplar Home Health Pty Ltd ACN 008 193 100 to Medibank customers, on behalf of Medibank.
Will I get confirmation that my patient referral has been accepted?
Yes, you will be contacted via email to confirm your referral has been accepted within 24 hours.
What happens if my referral is declined?
If we have to decline your referral, we will contact you via email outlining why we have declined your referral and any appropriate next steps if needed.
When can my patient expect to hear from you once their referral has been accepted?
Your patient will hear from the Amplar Health team within 24 hours of acceptance of referral. This may occur either before or after the patient is discharged from hospital.
Can the patient access the AHHC service if they have other service providers visiting them e.g. NDIS/My Aged Care?
Yes, provided that the patient meets all relevant eligibility criteria.
Can a patient participate in AHHC, and in either a hospital in the home program or a rehabilitation in the home program?
No. At any given time a patient can only be enrolled in one of:
- AHHC;
- a hospital in the home program; or
- a rehabilitation in the home program.
What happens if a patient is readmitted to hospital while they are participating in AHHC?
If a patient is admitted to any public or private hospital in Australia, they will be discharged from AHHC. If you deem that the patient may be suitable to be enrolled in AHHC again, you will need to complete a new referral, and the patient will need to meet the then current eligibility criteria, to be accepted into AHHC.
Do I need to complete two referrals (e.g to HITH and to AHHC)?
No. If the patient has not been accepted for HITH or RITH, and the patient consents to be referred to AHHC, a new referral form does not need to be completed.
What can the patient expect from AHHC?
Once we have accepted the referral, the patient will be contacted by a Amplar Health Case Coordinator, who will provide further information about the service and arrange their first in home visit with a registered nurse. Together with the patient the nurse will create a care plan to outline the support for them over 30 days. This care plan may include two subsequent visits from a registered nurse or allied health professional. If required, an additional visit can be arranged from an occupational therapist to conduct a home or falls risk assessment.
How is my privacy protected?
We are committed to protecting your privacy. We will handle your personal information in accordance with all applicable Australian legislation which governs the use, collection, disclosure, storage, access and disposal of personal information. For detailed information about how we handle your personal information, you can read our privacy policy here.
** While we hope you find this information helpful, please note that it is general in nature. While we have prepared the information carefully, we can’t guarantee that it is accurate, complete or up-to-date.
^This is a trial conducted by Medibank, the eligibility criteria are current as at May 2024 and may change from time to time without notice to you. Please check back here for updates.
Refer now
Amplar Health can provide healthcare and support services as part of a package of care for your clients.
Learn more
Contact us to speak to someone about our services delivered as part of After Hospital Home Care.