Hospital to Home: Key Points

  • Planning starts at admission, not on discharge day. A 48-hour head start on discharge planning makes the difference between a safe transition and a crisis.
  • The hospital social worker or discharge planner is the key contact. Find them within the first day or two and introduce yourself.
  • The first two weeks home carry the highest risk of readmission. Medications, falls, missed appointments, and poor nutrition are the main risk areas.
  • NDIS participants can access Core Supports immediately after discharge. Aged care participants on Support at Home can direct that funding to post-discharge needs.
  • A written discharge plan, medication list, and follow-up appointment schedule are the minimum documents to have in hand before leaving the hospital.

Why the First 14 Days Matter Most

Hospital readmission within 30 days of discharge is one of the most watched metrics in Australian health care. Readmission is not just a statistic. It represents a person who went home and, within a month, ended up back in an emergency department or ward.

The causes of early readmission are well understood: medication errors, falls, inadequate support, missed follow-up appointments, and poor recognition of deterioration at home. Most of these are preventable with structured planning and active monitoring.

This guide gives families a practical framework for the 14 days from discharge. Not every item will apply in every situation. But the structure helps families ask the right questions at the right time.

Before Discharge: Days Minus 3 to 0

Make contact with the discharge planner

The hospital social worker or discharge planner is responsible for coordinating the discharge process. Their role includes identifying what support a person needs at home and making referrals to community services.

Find this person early. In a large hospital they may be juggling dozens of cases. Families who introduce themselves, communicate clearly what support is available at home, and ask specific questions about what the hospital is arranging will receive more attention and more thorough planning.

Questions to ask the discharge planner:

  • When is the expected discharge date?
  • What level of care will the person need at home?
  • What referrals are being made to community services?
  • Is there an occupational therapist assessment happening before discharge?
  • Will there be nursing or allied health follow-up in the first week?
  • Is there a written discharge plan we can take home?

Get the medication list

Medication changes during hospitalisation are a major source of post-discharge risk. People often go home on different medications, different doses, or with new prescriptions added alongside existing ones, without anyone reviewing the full list for interactions or duplications.

Before discharge, request a complete medication list including:

  • Every medication the person is taking, including what is new and what has been changed.
  • The dose and frequency for each medication.
  • Which medications from before admission have been stopped, and why.
  • Any medications that need to be filled from a pharmacy before going home.

Ask the treating doctor or pharmacist to explain any new medications in plain language. Request a written summary. If the person uses a dose administration aid (Webster pack or blister pack), arrange for their regular pharmacy to update it before or immediately after discharge.

Request an occupational therapist assessment

If the hospitalisation has resulted in reduced mobility, balance issues, or changed functional capacity, an OT assessment before discharge can identify whether home modifications are needed and provide equipment to reduce fall risk.

Common items identified in a pre-discharge OT assessment include:

  • Grab rails for the bathroom or toilet.
  • A shower chair or bath board.
  • A raised toilet seat.
  • A hospital-style bed or pressure mattress.
  • Walking aids appropriate to the current level of mobility.

Some items can be arranged quickly. Others take days or weeks. Starting the OT assessment before discharge maximises the chance that the home is ready when the person arrives.

Confirm home supports are in place

If the person receives NDIS or aged care funding, contact the provider before discharge to:

  • Inform them of the discharge date and the person’s current condition.
  • Discuss whether the current service schedule is adequate for the post-discharge period.
  • Arrange additional visits in the first week if needed and if funding allows.
  • Brief the provider on any changes to care needs, medication, or mobility.

If new home support is needed and the person is not yet receiving funded care, the discharge planner can make referrals. Allow time for this. New services cannot always be arranged on discharge day.

Days 1 and 2: Arrival Home

The home environment

Before or immediately after arriving home, walk through the key areas of the home with the safety risks in mind:

  • Is the path from the car to the front door safe? Remove loose mats or obstacles.
  • Is the bathroom accessible? Is the shower safe with current mobility?
  • Is the bedroom arranged so the person can get in and out of bed safely?
  • Are medications stored accessibly, correctly labelled, and separate from any medications that have been discontinued?
  • Is there food available that the person can eat given any dietary changes since admission?

If the OT assessment identified modifications needed, check whether they have been installed.

First medication administration

The first time medications are taken at home is a high-risk moment. Follow the new medication list from the hospital. Do not assume that the pre-admission routine continues unchanged.

If there is any uncertainty about which medications to take, call the discharging hospital or the person’s GP rather than guessing.

Confirm the follow-up appointment

Most people are discharged with a follow-up appointment scheduled with their GP or specialist. Confirm this appointment is in the diary. If the person cannot travel without assistance, arrange that assistance now.

Days 3 to 7: The First Week

Daily monitoring points

In the first week, the person should be monitored daily. Family members who do not live with the person should call or visit every day. The things to monitor include:

  • Are medications being taken correctly and at the right times?
  • Is the person eating and drinking adequately?
  • Is the pain level manageable? Is there any new or worsening pain?
  • Is the wound, if any, healing without signs of infection?
  • Is the person able to move around the home safely?
  • Is the person sleeping?
  • Is the person’s mood stable, or are they anxious, confused, or withdrawn?

Any significant change from the previous day is worth investigating. Deterioration in the first week often develops quickly.

First GP visit

A GP appointment in the first week of discharge is valuable, particularly for complex hospitalisations, medication changes, or any ongoing clinical needs. The GP may not have received a complete discharge summary yet. Bring the written discharge plan and medication list to this appointment.

Allied health follow-up

If the hospital arranged physiotherapy, occupational therapy, or other allied health follow-up in the community, confirm these appointments are scheduled and accessible.

Support worker briefing

If a support worker is visiting during the first week, brief them specifically on:

  • What changed during the hospitalisation.
  • The current mobility and functional level.
  • Any signs of deterioration to watch for and report.
  • The follow-up appointment schedule.
  • What the person is and is not able to do independently right now.

A support worker who understands the post-discharge context is far more useful than one arriving without that information.

Days 8 to 14: Consolidating the Transition

Review the plan

By the end of the first week, the family has real information about how the transition is going. Use this information to review the plan:

  • Is the current support schedule working, or are there gaps?
  • Are medications being managed without errors?
  • Has the person had any falls or near-falls?
  • Are they sleeping, eating, and moving?
  • Have they attended follow-up appointments?

If anything is not working, address it now rather than hoping it settles.

Functional recovery trajectory

For many hospitalisations, the first two weeks represent the steepest recovery period. A person who was very limited in the first few days may be considerably more capable by day 14.

Equally, some people plateau or decline during this period. The trajectory should inform decisions about ongoing care support. If recovery is progressing well, the intensive support of the first week may taper. If the person is not recovering as expected, escalate to the GP or specialist.

Medication review

A formal medication review by a GP or pharmacist within the first two weeks is good practice for anyone who had significant medication changes during hospitalisation. Home Medicines Review (HMR), which is a pharmacist-led review conducted in the home and funded through Medicare, is specifically designed for this purpose.

To access HMR, the GP makes a referral to an accredited pharmacist. The pharmacist visits the home, reviews all medications, and produces a report for the GP. This review often identifies problems that were not apparent at discharge.

Plan the ongoing care arrangement

By day 14, the acute transition period is ending. The ongoing care arrangement should now be settled:

  • Are funded supports at the right level?
  • Are there needs that are not currently funded that warrant a plan review or reassessment?
  • Does the home need modifications that have not yet been actioned?
  • Are there therapy goals (rehabilitation, mobility, independence) that should be built into an ongoing plan?

This is also a good moment to discuss with the GP and any relevant specialists what the longer-term prognosis and care trajectory looks like.

Emergency Signs to Act On Immediately

During the 14-day transition, contact the GP urgently or call 000 if the person experiences:

  • Chest pain, difficulty breathing, or new confusion.
  • A fall with any injury.
  • A temperature above 38 degrees Celsius.
  • Significant increase in pain.
  • Wound signs: increasing redness, warmth, swelling, discharge, or smell.
  • Inability to keep fluids down.
  • A sudden change in behaviour, cognition, or responsiveness.

Do not wait and see with these symptoms. The recovery period is a vulnerable time, and early intervention prevents serious deterioration.

Key External Resources

Carevo connects families with home care providers experienced in post-discharge support. Find a provider who understands the hospital-to-home transition and can coordinate care from day one.

Frequently Asked Questions

How soon should families start planning for discharge? Within 24 to 48 hours of admission for any hospitalisation likely to result in changed care needs. Waiting until discharge day is one of the main causes of unsafe transitions.

What is a hospital discharge plan? A document summarising the medical situation at discharge, care needs, medication changes, follow-up appointments, and community referrals. Request one explicitly if it is not offered.

Can NDIS fund support after hospital discharge? Yes. Existing Core Supports can be used immediately. If needs have increased beyond the current plan, an unscheduled plan review can be requested.

What does aged care funding cover during the transition? Support at Home funding covers personal care, nursing, domestic assistance, and other daily supports. If the person is not yet receiving aged care funding, the hospital team can refer to My Aged Care for an urgent assessment.

What are the biggest risks in the first two weeks home? Medication errors, falls, missed follow-up appointments, poor nutrition and hydration, and delayed recognition of deterioration. Structured daily monitoring reduces all of these.

Who is responsible for arranging home support after discharge? The hospital has a duty to plan for discharge, but families should not assume everything will be arranged. Proactive engagement with the discharge planner and home care provider is the safest approach.