Hospital Discharge Planning
The Team believe our patient centred approach to hospital discharge will reduce length of stay and prevention of readmissions to hospital. We practice integrated discharge planning which involves collaboration with hospital services, GPs, public health nurses and other community services.

We believe coming home from hospital should be a seamless progression from one stage of care to the next.
Leave it up to us. Our nurses will co-ordinate your transition from hospital to home when you are ready to be discharged.
The process of discharge planning prepares you for when you are ready to leave hospital. It is now common practice in hospitals to start this process soon after you are admitted. If you are going into hospital for a planned admission from home you can prepare most of this yourself.
The Team believe our patient centred approach to hospital discharge will reduce length of stay and prevention of readmissions to hospital. We practice integrated discharge planning which involves collaboration with hospital services, GPs, public health nurses and other community services.
You should be aware of requirements you will need at home after you are discharged. Our nurse will visit you in hospital before you go home and assess your needs. If you require an occupational therapy assessment prior to leaving we can arrange our occupational therapist to visit you in hospital and also assess your home before discharge.
Depending on your assessment, you may be advised to arrange someone to stay with you once at home. Our nurse may suggest a suitable home care package tailored to your needs. Your medications may have been changed since your admission into to hospital – our nurse will ensure you understand the reason you are receiving them and know how often you should be taking them. You may need a prescription collected from the pharmacy on the day of discharge which we are happy to arrange for you. Your ability to carry out certain activities may change and our occupational therapist and nurse may recommend aids to increase your independence at home.
Most hospitals will have discharge planners, social workers and bed managers, our nurse will liaise with these departments to ensure you have a seamless transition. If you have private health insurance you will be able to access some of The Care Teams services. Once we know the type of policy you hold we will guide you on your cover. The Care Team uses a multi-disciplinary approach by involving multiple healthcare professionals in the delivery of services to support your needs.
The Care Team act as a communication portal between hospitals, GPs, PHN, voluntary and private service providers when caring for you at home.
