Before she comes home from hospital: what to sort out on the ward
Ask for an aged care assessment while she is still on the ward. That one thing decides how fast help arrives, and once she is discharged it becomes slower and harder to arrange. Everything else on this page matters less.
Most discharge advice online is American, which means it refers to a system your elderly mother or father is not in. This is the Australian version.
What to ask the ward, before she leaves
- Has an aged care assessment been requested? Hospitals can refer directly. Ask the discharge planner or social worker, by name, and ask what date it was lodged.
- Is she eligible for transition care? See below. It is the fastest post-hospital support in the system and it is not automatic.
- Can I have the physiotherapist’s discharge notes in writing? What she can do, what she cannot, and what the exercise program is. Whoever picks up her care next starts from that document.
- What was she actually tested on? Walking a flat, wide, well-lit corridor with a rail and a nurse beside her is not the same as her hallway at three in the morning.
- Which medications changed? New sedating medication is a falls risk, and hospital discharges frequently change the list.
What is transition care, and does she qualify?
Transition care is short-term aged care aimed specifically at recovery after a hospital stay. My Aged Care describes it as helping you “regain your functional independence and confidence sooner and potentially avoid the need for longer-term care”.
It runs for up to 12 weeks, can be extended by up to six weeks with another assessment, and there is no limit on how many times a person can apply. It can be delivered in her own home, in an aged care home, in the community, or a mix as she improves (My Aged Care).
It has to be assessed, and the assessment is far easier to arrange while she is in hospital than after she is home. That is the whole reason this page leads with it.
The three things to fix in the house first
Not a renovation. These are the ones that matter in the first fortnight, when she is weakest.
- Light between the bed and the bathroom. A plug-in sensor night-light. The overnight trip is the one that catches people.
- A clear path. Rugs, cords, the chair that has crept into the hallway. Walk the route she will actually walk, at night, and move what is in it.
- A chair she can get out of. Firm, with arms. The low soft one she loves is the hardest thing in the house to stand up from.
Why the first fortnight decides the next six months
She comes home weaker than she went in, and that weakness is a separate problem from whatever put her there. It does not reliably fix itself, and resting makes it worse, which is covered properly in why your parent is weaker after hospital.
The practical consequence is that the fortnight after discharge is when rehabilitation is both most needed and most effective, and it is also the fortnight when families are busiest and least likely to organise anything. If you only do one thing from this page, get the assessment lodged before she leaves the ward.
Who picks up her care at home?
Whoever it is should be reading the ward physiotherapist’s notes, not starting from scratch, and should be the same person each visit from then on. Recovery after hospital is judged week to week — whether Tuesday was progress or a bad day — and nobody can judge that who has not seen the previous Tuesday.
If she is coming home this week and nothing has been arranged, the pathway with no waiting list is usually the fastest route to physiotherapy, and our aged care page covers what a home visit involves.