All GEMS members have access to an Alternative to Hospitalisation benefit which can be used if you need medical care but do not require admission to an acute hospital, or if you have been in hospital and the remainder of your care no longer warrants being admitted in an acute facility. This benefit is paid from your overall annual limit and will not impact your day-to-day benefit.
A number of different services are covered from this benefit and these are listed below. If you need any of the care mentioned, please ask your doctor to email a clinical assessment referral letter with the request for the specific outpatient care required to homebasedcare@medscheme.co.za. GEMS will review the request and provide an authorisation number if it is approved. The healthcare provider that will provide the care is required to have a valid practice number to complete the authorisation
It is important to remember that GEMS does not cover frail care.
1. Hospital at Home
Hospital at Home is similar to being in hospital in that you have continuous, hospital-grade monitoring, but this happens at home and not in a hospital facility. Vital signs are captured via digital systems and closely monitored by a team of healthcare professionals in a 24-hour medical command centre.
In addition to continuous monitoring, the following services are also covered:
Benefit management and rapid response protocols are followed. If your condition should deteriorate during treatment, the clinical team will identify these changes and make the necessary arrangements. This could be an increase in visits, early review by the treating doctor, or transfer to hospital if required.
Members who would ordinarily require admission in a hospital general ward are eligible, as this service brings hospital-level care to the home. Consent from both the member and treating doctor is required.
Hospital at home could also include the different services provided by a nurse in the home environment. Stoma care, the care of long-term ventilated patients, neonatal care, and assistance with mobilisation following a long-term illness are examples of these services
2. Home oxygen
3. Wound care
4. Palliative end-of-life care, such as pain management, is available for terminally ill members and this can be provided in a hospice or at home. There is also a separate value-based GEMS Palliative Care Programme where GEMS partners with any willing provider to deliver quality of life outcomes.
5. Physical rehabilitation, is the care that may be required to recover as fully as possible after an acute traumatic episode (e.g. post-surgery, physical trauma or amputation), or medical episode (e.g. after a stroke). Please note that there is a physiotherapy benefit available after hip, knee or shoulder replacement.
6. Stepdown/Sub-acute care
7. Other Medical care can also be funded from this benefit if appropriate. This includes:
Contact the GEMS Call Centre on 0860 436 777 or email hospitalauths@gems.gov.za if you require more information.
At GEMS we believe that every one of our members matter. That is why we have prepared the member newsletter to focus on your specific needs.