Aged care: Coming home safely — what needs to be in place before hospital discharge

For many older people, leaving hospital can feel like the moment things are finally getting back to normal. But being medically well enough to leave hospital does not always mean someone is ready to manage safely or independently at home. For families, the important question is often not simply, “When can a loved one come home?” but, “What needs to be in place before they do?” A hospital stay can change what an older person is able to manage. Someone who was previously coping at home may return weaker after an illness, less steady following a fall, unable to manage stairs or showering safely, or needing help with wounds, medication, meals or transport to follow-up appointments. In some cases, existing aged-care or community services may need to restart. In others, new support may need to be arranged before the person leaves hospital. Ruben Irving, Nurse Unit Manager of Community Nursing and Palliative Care at Mercy Care Centre Young, said one of the important things to consider was “what services they may need after leaving hospital and whether appropriate referrals have been made”. “This could include referrals for community nursing, allied health services, either through a hospital outpatient clinic or private providers, their GP, or medical specialists,” she said. Start planning before leaving hospital Older people and their families should raise concerns about managing at home while the person is still in hospital. That may include questions about mobility, personal care, medication, meals, wound care, equipment, transport, follow-up appointments and whether someone will be available to provide support. Existing home-care services may need to be restarted, while other people may require new services through My Aged Care or short-term rehabilitation and reablement support. One option available locally through Mercy Care Centre Young is the Transitional Aged Care Program. The program provides short-term rehabilitation and reablement support for eligible older people after a hospital stay, with the aim of helping them regain independence and confidence as they recover at home and in the community. Clare Findlay, Allied Health Team Leader at Mercy Care Centre Young, said care was provided by a multidisciplinary team. “Care is provided by a multidisciplinary team that may include nurses, physiotherapists, occupational therapists, social workers, diversional therapists, allied health assistants, and a care coordinator,” she said. Support can be provided for up to 12 weeks. Eligibility is assessed while the person is still in hospital and referrals are generally made by the treating team before discharge. Patients and carers can also ask whether the Transitional Aged Care Program may be appropriate if they are concerned about how someone will manage once they return home. For people preparing for planned surgery, it may also be worth discussing likely support needs before they are admitted. What can help make home safer? Sometimes relatively small changes can make a significant difference to whether an older person can manage safely at home. Physiotherapy may help rebuild strength, improve balance and mobility, manage pain and increase confidence moving around the home. Occupational therapy can look at how someone manages everyday activities and whether equipment, strategies or changes within the home could make those tasks easier or safer. That might include difficulties with showering, dressing, preparing food, getting in and out of a chair, or moving around the house. Community nursing may also be needed for clinical care such as wound management, catheter or stoma care, as well as education and support for patients and carers. Speech pathology can assist people experiencing swallowing or communication difficulties, while social work may help where there are more complex family, emotional or social issues surrounding a person’s return home. Mercy Care Centre Young also provides outpatient and community services including physiotherapy, occupational therapy, community nursing, cardiac and pulmonary rehabilitation, palliative care and the Hennessy Recreational Day Centre. Support may not all come from one place Coming home safely may involve several different services. Clinical support such as nursing or allied health may be provided alongside assistance with everyday tasks. Depending on a person’s needs and eligibility, that could include personal care, domestic assistance, transport, meals, social support or respite. These are the kinds of supports already available through aged-care and community organisations across the Hilltops. For families, this can mean there is not always one organisation responsible for everything. Knowing who is providing each part of the support — and making sure referrals have actually been made — can be an important part of discharge planning. It is also worth knowing who to contact if something does not go according to plan once the person is home. What if home does not feel safe? Families should speak up if they are worried an older person will not cope after leaving hospital. That concern may be as simple as wondering how someone will get into the shower safely, or as significant as believing they cannot currently be left alone. Ms Irving said every person’s situation was different, but families should make sure their concerns are discussed before discharge. “Important questions to discuss before discharge include what services may be available to support them at home, and whether the appropriate referrals have been made,” she said. “This could include referrals to a GP, allied health professionals, community nursing services, or My Aged Care.” Families should also check whether specialist appointments and other follow-up care have been arranged. If the older person already receives aged-care services, it may be necessary to contact the provider and confirm when those services will restart. If their needs have changed significantly, further assessment may also be required. Think beyond the first few days While the immediate focus may be getting someone safely through the front door, a hospital admission can also be a useful time to consider longer-term planning. Mercy Care Centre Young recommends older people consider whether important legal and healthcare arrangements are up to date, including an Advance Care Directive, Power of Attorney, appointed Guardian and will. A hospital stay can also reveal that someone was managing at home only because a partner, family member or neighbour was quietly filling the gaps. If that informal support is no longer enough, it may be time to look at additional services rather than waiting for another crisis. For older people and their families, discharge day can feel like the end of a difficult period. But in many cases it is also the beginning of the next stage of recovery. Asking the right questions before leaving hospital — and making sure the right support is in place — can make that return home safer and give an older person the best chance of rebuilding their independence.