Going home is an important part of recovery, but it can also be a vulnerable point in a person's care.
Discharge planning connects hospital treatment with the care the person will need after leaving. Good planning should consider medication, wound care, follow-up appointments, mobility, equipment, community services and whether the person will have adequate assistance at home. Health Direct
For older people or people with complex health needs, early planning for home-based support can help create a more coordinated transition.
Consider the person's situation at home
Before discharge, it can be useful to establish:
Does the person live alone?
Who will be available to assist them?
Can they safely shower, dress and toilet?
Can they prepare meals and drinks?
Can they move around the home safely?
Have their mobility needs changed?
Can they manage their medications?
Is wound or other nursing care required?
Are continence or catheter needs adequately managed?
Is equipment required before they return home?
Can they attend GP, specialist and allied-health appointments?
Is the family/carer able to provide the expected level of support?
Are existing services sufficient for the person's needs after discharge?
These considerations align with discharge-planning guidance, which highlights home circumstances, mobility, medicines, wound care, follow-up treatment, and equipment as key components of planning the transition home. Health Direct
Information that helps us coordinate care
Where available and relevant, include the discharge summary, current medication list, diagnosis and relevant medical history, wound or treatment plans, nursing instructions, mobility and transfer information, equipment requirements, identified risks, follow-up appointments, treating-team details and the requested date for service commencement.
SA Health advises patients leaving hospital to understand their medicines, know who to contact if they become unwell, ask about community services that may assist them and arrange appropriate GP follow-up. SA Health
Refer before discharge where possible
Where post-discharge care can be anticipated, an earlier referral gives the receiving service more opportunity to review the person's needs, clarify documentation, assess capacity and coordinate the proposed commencement of care.
Please provide the expected discharge date and clearly identify referrals where support is required immediately following discharge.
Community nursing after hospital
Depending on the person's needs and arrangements, community nursing may assist with services such as wound management, medication support, health assessment and monitoring, continence or catheter care, diabetes support, skin integrity and other appropriate clinical care at home.
Support at Home
If an older person requires ongoing aged-care services and is not already approved, hospital-based health professionals can refer them to My Aged Care for assessment. My Aged Care accepts referrals from hospital health professionals as well as GPs, allied-health practitioners and other relevant community professionals. My Aged Care
Where the person already has Support at Home arrangements, provide relevant support-plan and provider information where available so that services can be appropriately coordinated.
Make discharge planning easier
Or discuss a proposed discharge with our team:
Office: 08 6388 0982 Dial # 2
Clinical Care Manager: 0494 722 663
connect@sacommunitysupport.com.au