Leaving the hospital can be a significant transition, and proper planning is key to a smooth and successful recovery at home.  

This guide is designed to help you navigate the discharge planning process, ensuring you have the information, support, and resources you need. There’s much to think about before you go home from the hospital. 

The hospital will develop a discharge plan to make sure your move home is as smooth as possible. The hospital should also prepare a discharge summary that tells your local doctor why you’ve been there.

What should I think about before I go home from the hospital?

After a stay in hospital, you must continue to get the proper care and support from the right people when you go home. 

Before you go home from hospital, make sure that you:

• have arranged your transport home

• have collected all your personal belongings

Make sure that you know:

• how to care for any surgical wounds, sutures, casts, or how to use any aids, such as crutches

• what medicines to take and when to take them

You should also check with your doctor whether: 

• Do you need any further tests

• when to see your doctor or attend an outpatient clinic

Questions to ask before you go home from hospital

• Do I understand what happened in the hospital?

• Do I have enough medicines until I can see my doctor?

• Do I need to change what I’m eating?

• Do I need care from family members?

• Am I allowed to drive once discharged?

• Do I know how long it will take me to recover or time for my wounds to heal?

If unsure, ask your hospital doctors and nurses for more information. They are responsible for ensuring you understand the next steps in your treatment and care.

If you still have questions, ask for the Nurse Unit Manager.

What is a hospital discharge plan?

The discharge plan, a crucial component of your care, is meticulously developed to ensure a smooth transition from the hospital to home. It serves as the vital link between your hospital treatment and the care you will need in the community, providing you with reassurance and confidence in your transition.

It links your hospital treatment and the care you will need in the community.

Good discharge planning can avoid complications after a hospital stay. It can help prevent medication errors and may help stop you from being readmitted to the hospital.

Who is involved in hospital discharge planning?

Usually, there will be a Discharge Planner or Continuing Care Coordinator who manages the process at the hospital. 

They will work with:

• you

• your family

• the staff involved in your care

A discharge plan helps ensure a smooth transition from the hospital to your home. 

If you’re not going home, it will be prepared for wherever you will be cared for next. 

This might be:

• a residential care facility

• respite care

• palliative care

• somewhere else

What is the purpose of hospital discharge planning?

Discharge planning aims to:

• make sure that you have care or support when you leave the hospital

• improve the coordination of services once you leave the hospital

• reduce how long you stay in the hospital

• help reduce unplanned readmissions to hospital

What is included in hospital discharge planning?

In creating your discharge plan, hospital staff will consider things like:

• whether you live alone

• how mobile you are

• whether you need assistance at home

• whether you will have physical restrictions, for example, not driving or lifting

They will also consider what ongoing treatment you will need, such as:

• medicines, especially if you need multiple medicines

• wound care

• follow-up tests and appointments, such as rehabilitation

• equipment to help you recover

Discharge planning should ensure that all the services you need to support you are in place before you go home.

What is a discharge summary?

A discharge summary is one part of your discharge plan. It’s a document that is usually prepared while you are in hospital.

Your discharge summary will be sent to other healthcare professionals involved in your care, such as your doctor, pharmacist or carer.

Your discharge summary will include:

• the name of the hospital you stayed in

• your main diagnosis

• which medical or surgical procedures have you had done

• whether you had any allergies or bad reactions in hospital

• a clinical summary of your situation and follow-up actions

Your discharge summary will also note what is needed after leaving hospital, such as:

• which medicines you are taking

• any dietary requirements

• any home modifications that have been arranged or that are needed

• which services have been arranged, such as community services

• any follow-up appointments that have been made

Who will see my discharge summary?

Your discharge summary may be an electronic document, known as an electronic discharge summary (eDS). This will be sent electronically to your doctor and can be shared with other professionals involved in your care.

A copy of the electronic discharge summary may also be added to your My Health Record. This won’t happen if you opt out of a My Health Record.

You may be given a paper copy of your discharge summary when you leave the hospital. Your doctor must get a copy of this document.

Post Hospital Support at Home from your local Just Better Care

Leaving the hospital can be a relief, but the transition home often comes with challenges. Just Better Care understands this, offering a range of personalised in-home care services to ensure a smooth and comfortable recovery. 

Our experienced healthcare professionals, such as Registered Nurses and Support Workers, will assist you with everything from medication management and personal hygiene to meal preparation and light housekeeping, allowing you to focus on healing in the familiar surroundings of your own home. 

We work closely with your medical and hospital teams to create a tailored care and support plan, ensuring continuity of care and addressing any specific needs you may have, in collaboration with the hospital.

Our focus is on you and your comfort at home

With Just Better Care, your well-being and independence are our priority. We provide various support services to help you regain strength and confidence. 

Our workplace culture is award-winning. All team members who enter your home are rigorously screened and trained to provide respectful and dignified support, fostering a sense of security and peace of mind for you and your family members. 

By choosing Just Better Care, you're selecting a return home that is safe, comfortable, and focused on your individual needs.

Other resources and support

If you are Aboriginal and/or Torres Strait Islander, the Aboriginal Hospital Liaison Officer can help you prepare to go home.

You can call the health direct helpline at 1800 022 222 (known as NURSE-ON-CALL in Victoria). A registered nurse will answer 24 hours a day, 7 days a week.

Sources:
Information from this article is accurate as at November 2024
Healthdirect (Going home from Hospital) https://www.healthdirect.gov.au/going-home-from-hospital#/ 
Healthy WA (Going home after a stay in hospital) https://www.healthywa.wa.gov.au/
NSW Health (Going homfromrm hospital) https://www.health.nsw.gov.au/
Discharge Planning Association (What is discharge planning?) https://www.dischargeplanning.org.au/
Department of Veterans Affairs (Discharge planning resource guide) https://www.dva.gov.au/
South Western Sydney PHN (Electronic discharge summary practice support) https://swsphn.com.au/