The relationship between hospital care and ongoing community care within a complex health system can be difficult to understand and navigate for an older person, family and their carers. Discharge summaries should be clear and complete and promote continuity and quality of care in the community.1 The older person and their family and carers, as appropriate, should understand the discharge summary and be provided with copies to keep, so they can refer to the summary and provide it to community services as required.

The older person should leave hospital knowing:

  • their next contact with the health system (next appointment)
  • their key contact within the health system (for example their GP) and how to contact them
  • the medications and ongoing management or care they should be undertaking until the next appointment
  • the medical, functional and psychosocial issues that were identified during the admission
  • what to be aware of on discharge
  • who to call if they need help or advice.

Psychosocial interventions can play a significant role in an older person’s recovery after discharge. If loneliness or social isolation has been identified as a risk factor, ensure you have identified meaningful activities for the person and refer them to appropriate and accessible resources and community programs.1 

Shared decision-making between us as clinicians, the older person, family and carers (as appropriate), is imperative to effective discharge planning. One method that has been trialled in a Victorian health service to assist discharge communication is Care Transfer Video.2 Care Transfer Video involves videoing ward rounds before discharge so patients can take home the discussions on a USB stick to watch with their families, GPs and other services as appropriate for follow-up. CareTV helps patients to remember details from their admissions and the plans for their ongoing care.


1. Jopling, K. Promising Approaches to reducing loneliness and isolation in later life, 2015 Age UK, Campaign to End Loneliness.

2. Newman, H. H., Gibbs, H. H., Ritchie, E. S., Hitchcock, K. I., Nagalingam, V., Hoiles, A., Wallace, E., Georgeson, E., Holton, S. A Feasibility Study of the Provision of a Personalized Interdisciplinary Audiovisual Summary to Facilitate Care Transfer Care at Hospital Discharge: Care Transfer Video (Care Tv), International Journal for Quality in Health Care Advance Access, 2015: 1-5.