Care Transitions: From Hospital to Home


During your caregiving journey, there may be times when your care recipient needs to change from one type of care to the next, or from one care setting to another. They may, for instance, be discharged from a hospital to a rehab centre or need to move from their family home to a long-term care facility.

In order to make this transition as easy as possible for all concerned, it’s important to do your homework and be ready with a viable plan.

What is Discharge Planning?

Discharge planning is the quality of links between hospitals, community-based services, non-government organisations, and carers. Effective discharge planning supports the continuity of healthcare, between the healthcare setting and the community, based on the individual needs of the patient. It is described as “the critical link between treatment received in hospital by the patient, and post-discharge care provided in the community.

Discharge planning is the development of a personalised plan to ensure the smooth transition of a patient from a health organisation such as a hospital to wherever the patient is going next — it might be home, residential care, respite care, palliative care, or somewhere else.

Good discharge planning can avoid complications after discharge from the hospital, avoid errors with medications, and may help prevent a person from being readmitted to the hospital later on.

Who is involved in hospital discharge planning?

Discharge planning should involve the patient, carer, family, and any staff involved in the patient’s care. Usually, there will be one person, such as a discharge planner, who coordinates the process.

What is included in hospital discharge planning?

Discharge planning involves taking into account things like:

  • follow-up tests and appointments
  • whether you live alone
  • whether someone can help you when you go home
  • your mobility
  • equipment needed for your recovery
  • wound care, if needed
  • medicines, especially if you need multiple medications
  • dietary needs
  • rehabilitation
  • whether there will be any restrictions on you once discharged, for example driving or lifting

Discharge planning should ensure that all the services you need to support you once you leave the hospital are in place. This might include things like community support with medications, dressings, food, or cleaning. It might include aids and appliances to help you stay in your own home, independently. In some cases, it is simple. For example, you might be expected to leave the hospital in 2 days with certain medications, and you might be told to see your GP 2 days after you get home. But if you have a chronic disease or need plenty of ongoing care, it could be more complex. It might involve you, your GP, other healthcare professionals, family members, and carers. All of these people should have a copy of the discharge plan so that everyone knows what they need to do to ensure that they have continuing care.
Where appropriate, other people or organisations should have a copy too. These could include a residential care facility, rehabilitation services, or community services.

When is hospital discharge planning done?

Ideally, discharge planning starts as soon as you are admitted to the hospital. And ideally, it also involves you and your family, as well as the hospital staff. If you are going in for elective surgery, discharge planning may occur before you go into the hospital — so appropriate care can be organised in advance for when you get out.

What is a hospital discharge summary?

A discharge summary is one part of a discharge plan. It is a document prepared while you are in the hospital, usually by your hospital doctor. It is generally an electronic document, known as an electronic discharge summary (eDS). The hospital should send it to other healthcare professionals involved in your care, such as your GP or sometimes a pharmacist or carer.

It is important your GP gets a copy of this document so that they know why you were admitted to the hospital, what care you received, and how to continue to care for you. A copy of the electronic discharge summary will also be added to your My Health Record unless you have opted out of having one. You may also be given a paper copy of the summary when you leave the hospital.

The discharge summary will explain:

  • why you were admitted to the hospital
  • the main diagnosis
  • which tests were performed
  • what care you received
  • which medications you are taking on discharge from the hospital, and possibly which medications you have taken in the past
  • which medical or surgical procedures were performed
  • whether you had any allergies or bad reactions
  • a clinical summary of your situation now and follow-up actions
  • which future services have been arranged, such as community services
  • any follow-up appointments that have been made

Advice for Carers

Above all else, carers need to look after themselves to avoid adding to Carer’s Stress and their already large load. Advice to take on board to avoid getting too overwhelmed includes:

  • Talk about it with your loved one and their healthcare team. Make sure you are clear on what is required of you. The more you understand what is required, the less overwhelming it will be for you.
  • Write it down. Don’t rely on your memory to remember what needs to happen. Keep a journal and write down what needs to happen. Take it out of your head, and onto paper, so you can refer to it if needed.
  • Funding. If your parent cannot afford any new medications, do not be embarrassed to tell the primary physician, primary nurses, discharge planner, or social worker. There could be options. But, you may not know about them, unless you ask.
  • Relax. Above all else, try to relax. The hospital will have a discharge planner, hospital social worker, charge nurse, or your parent’s primary nurse to go over all the discharge planning with you. So, try to not be so hard on yourself, and cut yourself some slack. By taking care of yourself and your needs, you are then better able to help your loved one with their needs.

Tips for a safe hospital discharge

Here are some questions you could ask yourself before you are discharged from the hospital:

  • Do I understand what happened in the hospital?
  • Do I understand which treatment I need now — and in the future?
  • Do I know which medications to take and when? Do I have enough of those medications until I can see my GP?
  • Do I need to make any dietary changes? Will I be able to shop for food and manage to feed myself?
  • Do I know when my follow-up appointments are?
  • Has my GP been informed of my admission and of my discharge plan?
  • Do I need care from family members? If so, has there been a family meeting?
  • Does everyone understand their roles and responsibilities?
  • Do I have transport arranged?
  • Am I allowed to drive once discharged?
  • Do I have an estimate of recovery time or time for any wounds to heal?
  • Are there any concerns or questions I should raise before I am discharged from the hospital?

If you can’t answer those questions, please ask your hospital doctors and nurses for more information. It is their responsibility to make sure you have it all. If you still don’t have everything you need, ask for a nursing supervisor.

More information

Find a healthcare service with healthdirect’s Service Finder tool or call 1800 022 222 (known as NURSE-ON-CALL in Victoria) for 24-hour health advice and information.

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