Hospital Discharge Support & Nursing Care
COORDINATED NURSING SUPPORT FROM HOSPITAL TO HOME
Helping You Return Home Safely and With Confidence
Heal at Home provides hospital discharge nursing support for children, adults and older Australians returning to private homes, supported accommodation and community based care. Our registered nurses work with hospital discharge liaison nurses, discharge coordinators, treating teams and community providers to understand each client’s clinical needs and prepare the nursing support required at home.
We can complete nursing assessments, develop personalised care plans, coordinate nursing visits and educate clients, families and support staff. Our goal is to promote a safer transition, reduce gaps in care and help clients recover or manage their health confidently at home.Heal at Home accepts referrals from public and private hospitals across our Australian service regions. Service availability and commencement timeframes are confirmed for every referral.
Our Hospital Discharge Support Services
Personalised Nursing Care After Hospital
Hospital Liaison and Care Coordination
New Nursing Care Plans
Personalised Nursing Care Plans
Post-Discharge Nursing Visits
Medication Management
Wound and Device Care
Complex Clinical Care
Client and Family Education
Staff Training and Competency Assessment
Clinical Reviews and Progress Reporting
Working With Hospital Discharge Teams
Connecting Hospital Care With Community Nursing
- Heal at Home works collaboratively with hospital discharge liaison nurses, discharge coordinators, nurse navigators, ward nurses, medical teams and allied health professionals. Before discharge, we may assist by:
- Review referral, discharge summary and nursing requirements
- Confirm medical orders, instructions and discharge risks
- Develop care plans and escalation procedures
- Confirm nurses, services, equipment and consumables
- Educate clients, families and care teams
- Plan initial visit, ongoing reviews and discharge concerns
- Early referral allows more time to assess the client’s needs, prepare the care team and establish appropriate nursing support before the client returns home.
What We Assess
What We Assess
- A hospital discharge nursing assessment may include:
- Medical conditions and reason for hospital admission
- Discharge summary and current treatment requirements
- Medications and authorised medication orders
- Wounds, pressure injuries and skin integrity
- Continence, catheter, bowel and stoma care
- PEG tubes, enteral feeding and hydration needs
- Diabetes and blood glucose management
- Respiratory, oxygen, ventilator or tracheostomy support
- Intravenous therapy and vascular access devices
- Palliative and symptom management needs
- Pain, nutrition, mobility and falls risks
- The assessment is tailored to the client’s clinical condition, discharge instructions and individual circumstances.
What You Receive
What You Receive
Hospital Discharge Nursing Assessment
Personalised Nursing Care Plan
Nursing Service Schedule
Risk and Escalation Guidance
Education and Training Plan
Care Coordination Recommendations
Discharge Support Works
How Hospital Discharge Support Works
Hospital Referral
Clinical Information Review
Nursing Assessment
Discharge Planning
Education and Staff Training
Return Home
Staff Training Before and After Discharge
Preparing Care Teams For Safe Clinical Support
- Heal at Home nurses can provide training and competency assessment relating to:
- Medication support, Diabetes and insulin care, Epilepsy and emergency medication procedures
- Complex bowel care, Catheter and continence care, Stoma management
- PEG and enteral feeding, Ventilator, BiPAP, CPAP and oxygen support
- Tracheostomy care, Wound care and pressure injury prevention
- Recognition of clinical deterioration, Documentation and escalation procedures
- Training is based on the client’s current care plan, medical orders, equipment and support requirements. Training does not authorise staff to work outside their role, competence or organisational policies.
Service Does Not Include
What Our Hospital Discharge Service Does Not Include
- Heal at Home focuses exclusively on nursing. Our hospital discharge support service does not:
- Make the hospital’s decision about whether a client is medically ready for discharge
- Replace the hospital discharge liaison or treating team
- Provide a medical diagnosis or prescribe treatment
- Independently change medicines, dosages or medical orders
- Replace the client’s GP, specialist, pharmacist or allied health providers
- Arrange housing, transport or general domestic services
- Provide general support work or non-clinical personal care
- Guarantee immediate service commencement or nurse availability
- Guarantee funding from the NDIS, Support at Home, an insurer or another funding body
- Provide emergency or urgent medical treatment
- Discharge arrangements depend on receiving sufficient clinical information, valid medical orders, appropriate equipment and confirmation that the required nursing resources are available.
Benefits of Hospital Discharge Support
Benefits of Hospital Discharge Support
Safer Transition Home
Continuity of Care
Reduced Clinical Risks
Prepared Clients and Families
Confident Care Teams
Coordinated Communication
Why Choose Heal at Home?
Clinical Nursing Support Across Australia
- Heal at Home is a proudly Australian and family owned nursing organisation. Nursing is our sole focus and what we do best.
- Experienced registered nurses and specialist nurses with comprehensive nursing assessments
- Direct communication with hospital discharge teams and personalised clinical care plans
- Support for routine and complex nursing needs, client and family education
- Participant specific staff training, competency assessment and clinical delegation where appropriate
- Post-discharge nursing visits, clinical reviews and collaboration with GPs, specialists and community providers for children, adults and older Australians across metropolitan, regional and country communities
- We currently provide services across South Australia, Western Australia, Queensland, New South Wales and Victoria. Contact our team as early as possible to confirm local availability and discharge timeframes.
What Our Clients Say About Heal at Home
See what our clients and families have to say about their experience with Heal at Home and our personalised in-home nursing and care services.
Frequently Asked Questions
Referrals may be made by a hospital discharge liaison, discharge coordinator, nurse navigator, treating team, NDIS provider, Support at Home provider, insurer, client, family member or authorised representative.
Contact us as early as possible during discharge planning. Early referral provides more time to review clinical information, assess nursing needs, prepare care plans and arrange suitable nurses.
Yes. With the client’s consent or appropriate authority, we can work directly with the hospital discharge liaison and treating team to coordinate the required community nursing care.
Depending on assessed needs, we may provide medication management, wound care, catheter care, stoma care, PEG and enteral feeding support, diabetes care, respiratory care, tracheostomy care, intravenous therapy, palliative nursing and other prescribed clinical services.
Yes. Where arrangements permit, our nurse educators can provide participant specific training and competency assessment before discharge. Training may also be completed or reinforced in the client’s home.
Yes. We support eligible NDIS participants and Support at Home clients who require nursing assessment, care planning, clinical nursing visits or staff training. Funding approval remains the responsibility of the relevant funding body.
Service commencement depends on the client’s location, clinical complexity, referral information, medical orders and nurse availability. We assess every referral promptly and clearly communicate what can be arranged.
Arrange Hospital Discharge Support
Our Clinical Partners
We work with and maintain professional affiliations with respected Australian nursing and clinical organisations.
Wounds Australia
Clinical Partner
Continence Health
Australia Member
Australian College of Nursing
Affiliate Member
