We can help patients make a smooth transition from the hospital to their home or residential aged care facility through comprehensive and clear discharge planning and communication.

Educate patients, family and carers

  • Remind patients and their family and carers about strategies to optimise function and wellbeing at home.
  • Emphasise the importance of maintaining a combination of interventions, which includes optimising opportunities for social connections.

Refer to health professionals and support services

  • Include documentation about frailty and contributing factors in the discharge summary to the GP and other services.
  • Inform the patient’s GP about ongoing treatment goals for the patient.
  • Refer the patient to community or hospital based specialists to support functional independence in the longer term.
  • Discuss services and opportunities for social participation based around the patient’s interests. This could include planned activity groups, or activities sourced through local councils, local newspapers, libraries, Neighbourhood Houses or Men’s Sheds that can keep the patient socially connected.

Practise person-centred care

  • Encourage patients to ask questions or raise concerns about their recovery.
  • Tailor plans to the individual patient, as discharge planning is not a one size fits all approach.