Just Left Hospital?
A fall, a stroke, a broken hip — and suddenly everything has changed. If someone you love is in hospital or has just been discharged and can’t safely go home, this page tells you exactly what to do.
🚨 If you’re being pressured to discharge
Hospitals sometimes need beds urgently. But you have the right to a safe discharge plan. If you feel your family member is being sent home before it’s safe, speak to the hospital social worker, the ward nurse manager, or the Patient Liaison Officer. You can also call OPAN on 1800 700 600 for immediate advocacy support.
A person should not be discharged without a plan for how their care needs will be met at home.
Where are you right now?
Different situations need different actions. Find the one that fits.
🏥 Still in hospital — discharge is being discussed
This is actually the best time to act. The hospital can request an urgent My Aged Care assessment while your family member is still admitted. Ask the hospital social worker to arrange this — don’t wait until discharge day.
If home isn’t safe yet, ask about Transition Care (see below) — it buys you time.
🏠 Just arrived home — struggling without support
Call My Aged Care immediately on 1800 200 422 and explain the situation is urgent. Mention the recent hospital stay and that the person is at risk without support. They can prioritise the assessment.
In the meantime, ask the GP for an urgent home visit, and consider short-term private help (even a few hours of in-home care) to bridge the gap.
⏲ Waiting for services to start after assessment
You’ve been approved but services haven’t begun? Call your chosen provider and ask them to expedite. If you haven’t chosen a provider yet, use the Find a Provider tool and pick one that can start quickly in your area.
While waiting, ask the GP about Commonwealth Home Support Programme (CHSP) services — these are more basic but can often start faster.
Transition Care — the bridge most families don’t know about
The Transition Care Programme (TCP) is one of the most useful and least-known parts of the aged care system. It’s designed for exactly this situation — when someone is leaving hospital but isn’t ready to go home or into permanent care.
Transition Care provides up to 12 weeks of support (sometimes extended to 18 weeks), including physiotherapy, occupational therapy, nursing, personal care, and help at home. The goal is rehabilitation — getting the person strong enough to live at home again.
It can be delivered in two ways: at home with visiting support, or in a dedicated Transition Care bed (often in an aged care home, but it’s not permanent residential care).
Key facts about Transition Care
Who’s eligible: People who’ve had a hospital stay and need more time to recover before going home. Must be assessed as needing it.
Cost: Heavily subsidised. You pay a basic daily fee similar to residential care (roughly $12–$13/day). Clinical services are free.
How long: Usually up to 12 weeks, can be extended to 18 weeks in some cases.
How to get it: The hospital must refer you — it can’t be arranged after discharge. This is why it’s critical to ask before leaving hospital.
💡 This is the most important thing on this page: If your family member is about to leave hospital and you’re worried they’re not ready, ask the social worker about Transition Care today. Once they’re discharged, this option disappears.
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What to ask the hospital social worker
Every public hospital has a social worker or discharge planner. They’re your most important ally right now. Here’s what to ask.
Short-term options to bridge the gap
The aged care system doesn’t always move as fast as you need it to. Here are ways to get help while you’re waiting.
Transition Care Programme
Up to 12–18 weeks of rehab and support. Must be referred from hospital before discharge. The best option if available.
CHSP (Commonwealth Home Support Programme)
Basic entry-level home support — cleaning, meals, transport, social support. Often starts faster than Support at Home. Contact My Aged Care to arrange.
Respite care
A short-term stay in a residential aged care home (up to 63 subsidised days per year). Good if home isn’t safe yet and Transition Care isn’t available. Arrange through My Aged Care.
Private home care (self-funded)
If you can afford a few days or weeks of private care while waiting for government services, many home care agencies offer this. Expect to pay $40–$70/hour for a care worker. Ask the hospital social worker for local recommendations.
Local council services
Many local councils offer short-term support like Meals on Wheels, transport, or home help. These often have short wait times and low or no cost. Call your local council directly.
When going home isn’t an option
Sometimes a hospital stay reveals that someone can no longer live at home safely — even with support. This is an incredibly difficult realisation.
If the hospital team is recommending residential care, they can arrange an assessment while the person is still admitted. This means a My Aged Care assessor comes to the hospital, and if approved, the family can start looking for an aged care home immediately.
While searching, the person can stay in hospital (though hospitals prefer this to be as short as possible), or move into respite care at an aged care home as a temporary measure while a permanent place is found.
Our Residential Care page explains what to look for, and the Costs page breaks down what you’ll pay.
This is hard — and that’s normal
A hospital admission often marks the moment when a family realises things have changed. The person you love may not return to the way they were before. That’s a grief, even when the person is still alive, and it deserves to be acknowledged.
You don’t have to figure everything out right now. The system exists to help — even though it doesn’t always feel that way. Take it one step at a time, ask for help, and know that you’re not failing by finding this difficult.
If you’re a carer feeling overwhelmed, the Carer Gateway provides free counselling and support — call 1800 422 737.
Your action plan
If they’re still in hospital:
1. Find the social worker or discharge planner — today.
2. Ask about Transition Care and urgent My Aged Care assessment.
3. Don’t agree to a discharge date until you have a plan.
4. Print the checklist above and use it.
If they’re already home and struggling:
1. Call My Aged Care now: 1800 200 422. Tell them it’s urgent.
2. Book a GP visit (home visit if possible).
3. Call your local council for immediate support (Meals on Wheels, etc.).
4. Consider a few days of private home care while waiting.
📋 Hospital Discharge Checklist
Print this and bring it to your next conversation with the hospital team.