Your guide to care after a hospital stay

Coming home from hospital is a relief, but the first few weeks can bring new challenges. Planning your hospital-to-home care before discharge helps you or your loved one settle back in with the right support.

This guide explains who to talk to, the short-term programs that can help, and how care at home is funded.

Start planning before you leave hospital

The best time to plan is while you're still in hospital. Talk to the hospital team early. This might be the discharge planner, social worker, nurse or doctor.

Ask them these questions before your discharge date.

• What help will I need at home, and for how long?

• Will I need equipment or changes at home to stay safe?

• Have my medicines changed, and who will help me manage them?

• Who'll arrange follow-up appointments and transport?

• Should I have an aged care assessment before I leave?

If a family member is helping, invite them to these conversations. You decide who's involved and how much they help.

Transition care: short-term support after hospital

Transition care helps older people recover after a hospital stay. It's funded through the government's Transition Care Program, and you can read about it on My Aged Care.

You may be eligible if you're in hospital, have been told you're ready to leave, and would benefit from short-term support. An assessor visits you in hospital. You can ask hospital staff to arrange this, or call My Aged Care on 1800 200 422.

• What it includes: nursing, physiotherapy, personal care and other support based on your needs

• Where it happens: at home, in an aged care home for higher needs, or a mix

• How long it lasts: up to 12 weeks, with a possible extension of up to six weeks after another assessment

• What it costs: providers can ask you to contribute, up to a maximum set by the government

At home, the maximum you can be asked to pay is currently $14.19 a day. You won't need a means assessment, and your ability to pay won't affect your access.

The Restorative Care Pathway

The Restorative Care Pathway is part of Support at Home, the government's in-home aged care program. It offers intensive allied health and nursing support to help you regain what you could do before.

It runs for up to 16 weeks, with a budget of around $6,000. A recent fall or hospital admission is one reason you might be eligible for an assessment.

You don't contribute to clinical supports such as nursing. You may contribute towards other services, like transport or cleaning, depending on your income and assets.

If you already receive Support at Home

Let your provider know you're in hospital and when you expect to come home. They can help plan your return and adjust your services.

If your needs have changed, ask about a support plan review or reassessment. You can also keep receiving Support at Home services while getting transition care at home.

Since 1 October 2026, the government has fully funded approved personal care under Support at Home. That includes help with showering, dressing and continence support.

What hospital to home care can include

Support after a hospital stay depends on what you need and what you're approved for. It might include:

• Personal care: help with showering, dressing and getting around the house

• Nursing: wound care and help managing your medicines

• Allied health: physiotherapy or occupational therapy to rebuild strength and confidence

• Everyday help: meals, cleaning, laundry and shopping

• Transport: getting to follow-up appointments and the pharmacy

Private support while funding starts

Government-funded support can take time to arrange. Some people pay privately for help in the first days or weeks at home, then move to funded support when it starts.

If you're thinking about this, ask the provider for a written quote first. Check whether they can continue your support once funding comes through.

Talk to us about coming home from hospital

At HomeCaring, we'll work with you, your family and the hospital team to plan support for your return home.

Our registered nurses and allied health team can support you as you recover. We'll explain what's available, what it may cost and what happens next. Availability depends on the support involved, your location and the times you need. Reach out to our Care Specialists on 1300 875 377.