Coming home from hospital: how to get support in place before you leave

The discharge itself is rarely the problem. The fortnight afterwards is.

The weeks following a hospital stay carry the highest risk of readmission, and a good share of those readmissions are avoidable — a wound that was not reviewed, a medication change nobody explained, a person who could not manage stairs and did not want to make a fuss.

Most of it is fixable, but only if the arranging happens before you leave, not after.

Start the conversation earlier than feels necessary

The best time to raise going home is the day after you are admitted, while you are still unwell enough that nobody argues about whether you will need help.

Ask to speak to the discharge planner or social worker early. Wards are busy and discharge can move faster than expected — a bed is needed, you are declared medically fit, and suddenly you are going home on Friday afternoon with a plastic bag of medications and a follow-up appointment in three weeks.

If you have a support coordinator or recovery coach, tell them you are in hospital. They can start arranging things while you are still an inpatient. Many people do not think to call them until they are already home.

What to sort out before you leave

Work through this list, and write the answers down rather than trusting that you will remember them.

Clinical care. If you have a wound, catheter, drain, PEG or new injection regimen, who is doing that care at home, and when is the first visit? “A nurse will be in touch” is not an answer. Get a name, an organisation and a day.

Medications. What has changed? What has stopped? What is new, and what is it for? Medication changes made in hospital are one of the most common sources of harm in the first fortnight home, particularly when the discharge summary reaches your GP after you do.

Personal care. Showering, dressing, toileting. Be honest about what you will struggle with. A week or two of support while you recover is straightforward to arrange, and much easier than recovering from a fall.

The house itself. Can you get in the front door? Are there steps? Is the bathroom manageable? Is there anything you need — a shower chair, a rail, a raised toilet seat — and who is providing it?

Food. Who is shopping and cooking for the first fortnight?

Follow-up. Which appointments are booked, where, and how are you getting there?

Warning signs. What should make you call someone, and who do you call — during the day, and at 10pm on a Sunday?

The DVA referral rule that catches people out

If you hold a DVA Gold or White Card, this one matters and it is not well publicised.

A referral for community nursing from a hospital discharge planner is valid for seven days only.

It exists to get care started the moment you get home. But within that week, you need a referral from your GP, nurse practitioner or medical specialist for care to continue. A referral from any of those three lasts 12 months.

That seven-day window is where care most often falls over. People come home, care starts, and then stops abruptly a week later because nobody booked the GP appointment.

Book the GP appointment before you leave the ward. Our guide to DVA community nursing covers the referral rules in full.

If you are an NDIS participant

Two things are worth understanding.

The health system and the NDIS fund different things. Acute treatment and hospital care sit with the health system. Support that helps you live with your disability day to day generally sits with the NDIS. Care immediately after discharge often sits somewhere in between, and it is reasonable to ask a provider to be straight with you about which side of the line your situation falls on.

A hospital admission may be a change of situation. If what you can do has changed meaningfully — you are less mobile, you now need nursing you did not need before, your informal supports cannot manage what they used to — that is worth telling your my NDIS contact about. It may lead to a plan reassessment. Our guide to preparing for a plan reassessment explains what evidence helps, and a hospital discharge summary is good evidence.

Do not assume your existing plan stretches to cover a new situation just because there is funding sitting in it.

Questions worth asking the ward

Discharge conversations move quickly. These are the ones that get missed.

• Who is doing my wound care at home, and when is the first visit?
• Has the discharge summary gone to my GP, and when?
• What medications have changed, and why?
• Do I need any equipment, and who is supplying it?
• What follow-up is booked?
• What are the warning signs, and who do I call after hours?
• Has anyone told my support coordinator or my provider that I am coming home?

That last one is worth asking directly. Providers are frequently not told, and turn up to a scheduled visit to find nobody home, or worse, do not turn up at all because they did not know you were back.

The first fortnight

Some practical things that make a real difference.

Keep the discharge summary somewhere obvious. On the fridge. If something goes wrong and you need an ambulance, it is the single most useful piece of paper in the house.

Write down what changes. Pain, swelling, appetite, sleep, confusion, wound appearance. If you need to call someone, specifics get you taken seriously in a way that “not feeling right” does not.

Do not tough it out. People wait until Monday because they do not want to bother anyone on a weekend. Deterioration does not observe office hours.

Expect to be tired. Recovery at home is slower than most people expect, particularly after a long admission or a general anaesthetic.

How we help

We take hospital discharge referrals across Mandurah, the Peel Region, Rockingham and the South West, for both NDIS participants and DVA card holders.

Our community nursing is delivered in-house rather than subcontracted, so the person who takes the referral and the nurse who visits you work for the same organisation. We can also put daily living support in place for the first weeks home while you get back on your feet.

We acknowledge every referral within 24 hours, and contact you within 48 hours to arrange a visit. If it is urgent, say so and we will move faster.

If you or a family member are in hospital now, call 0410 560 769 or make a referral — you do not need to wait until discharge day.

Frequently asked questions

Who arranges support when I leave hospital?

The discharge planner or social worker coordinates it, but you or your family can contact providers directly too. Do not wait to be organised for.

How quickly can nursing start after discharge?

It depends on the provider’s capacity. Ask for a specific start date rather than a range, and ask before discharge rather than after.

I am a DVA card holder. How long does a hospital referral last?

Seven days only. You will need a referral from your GP, nurse practitioner or medical specialist within that week for care to continue.

Can I use NDIS funding for support after hospital?

Supports related to your disability can generally be funded, but acute health care sits with the health system. If your needs have changed significantly, speak to your my NDIS contact.

What should I ask before discharge?

Who is doing my clinical care and when, what medications changed, what are the warning signs, who do I call after hours, and what follow-up is booked.

What if my support does not turn up?

Call the provider immediately. If it is clinical care that cannot wait, contact your GP or the hospital team who discharged you. Do not wait days to see if it resolves.

This article is general information and not a substitute for advice from your treating team.