The period immediately after hospital discharge is one of the most clinically vulnerable times in an older person's life. Inadequate support in the first two to four weeks after discharge is the primary driver of readmission. Being adjacent to Westmead health precinct, we understand the discharge process and know what good transitional care looks like.
What is Post-Hospital Support?
Post-hospital support is care provided in the home during the recovery period after a hospital admission. It bridges the gap between hospital and independence, providing personal care, medication reminders, domestic support, mobility assistance and clinical nursing where required. Our team coordinates with your GP and community nurse to ensure care continues safely at home.
What's included
Who benefits from this service?
Post-hospital support is appropriate for any older adult returning home from hospital, following surgery, after a stroke, following a significant infection, after a fall with injury, or any admission that has left the person temporarily more vulnerable. Particularly important for people who live alone or have limited nearby family support.
How it works
Pre-discharge coordination
When possible, we liaise with the hospital team before discharge, reviewing the discharge summary and planning the first home visit.
Day-of-discharge home visit
Our RN visits on discharge day, conducts a home safety assessment, reviews medications and establishes the care plan.
Intensive initial support
Daily or near-daily visits in the first week, tapering as function and confidence return.
Transition to ongoing care
Once the acute phase passes, we transition to an ongoing support package, or step back if full independence is restored.
🩺 Clinical note: Our clinical team treats the transition from hospital to home as a clinical handover, not an administrative event. We liaise with discharge teams and coordinate care that begins from day one at home.