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Transitioning from Hospital Back to Home

Transitioning From Hospital Back to Your Home

man getting out of wheelchair with nurse

The transition involves discharge planning from a multidisciplinary team of health professionals. The thought of going back to home after a hospital admission is daunting for many people. Many seniors haven’t accessed aged care support services, and a stay in hospital could be the first time that they’ve ever had to consider aged care options.

Discharge Planning

Planning your discharge from hospital to the home starts as soon as you’re admitted to hospital. Healthcare professionals work together to coordinate a smooth transition back to home, or somewhere else if required.

A discharge plan will be put into effect, which will include all support services and interventions that’ll be required once you leave hospital.

So what’s this mean for you? If you require continuing care post-discharge, a discharge planner or social worker will help to arrange this care. Some patients transfer to a rehabilitation, to help prepare them to manage at home.

Others might be eligible for hospital-in-the-home, or transition care. If you require ongoing assistance when you leave hospital, the discharge planners can arrange an assessment with the Aged Care Assessment Team (ACAT) too.

ACAT Assessments

The ACAT assessment is for ageing people, where the time has come that they’ll need additional support and services. This could be in home care, residential aged care, transition care after hospital, or respite care.

The ACAT assessor determines the level of care that’s required to best meet your present needs by conducting a comprehensive and holistic assessment that’s patient centred.

Options When You Can’t Return Home

In some cases, discharge options might not be back to the home. Some people do require greater levels of care and support after hospitalisation, such as palliative care or residential aged care.

Arranging Services At Home

However, for elderly people who’re returning to the home after hospital, there are several factors to consider. Consider if your care needs have changed, and what services are available to meet these needs. Also consider whether your home will still remain suitable and safe after hospitalisation.

For example, if your hospital admission was due to a fall down some stairs, do you need some home moderations such a  ramp, to make your home suitable?

Don’t be afraid to discuss such topics with health care professionals. Having good discharge planning reduces your risk of returning to hospital.

The Carer’s Role

For carers who are concerned about their loved one’s return to home after hospital, speak with the hospital discharge planners or social workers directly. You might bring light to a situation or circumstances that they aren’t aware of, that could impact on the discharge planning process.

holding hands from hospital bed


What If You’re The Primary Carer?

Under many circumstances, the person who’s hospitalised may in fact be the primary carer for their loved one. They might be concerned about stepping back into their role as carer post-discharge from hospital.

Life After Hospital

Rest assured that if you’re concerned about going back home, that there are discharge planners that you can speak with at hospital to help you with the transition back to home, or alternative aged care support services. Once you’re home if your care needs change, contact My Aged Care to arrange an assessment with the Aged Care Assessment Team.

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