They're being discharged. Here's what to do before they leave.
Hospital discharge triggers the aged care clock. Some options — especially Transition Care — close permanently the moment the person leaves. This guide works backwards from the discharge date so nothing gets missed.
Three things are critical regardless of timing: Ask to speak with the hospital social worker today. Ask about Transition Care before discharge — this window closes permanently at discharge. Confirm a My Aged Care referral has been submitted.
Transition Care closes at discharge. This short-term recovery support (up to 12 weeks) must be arranged before discharge. Once the person is home, this option is gone. It is the single most missed step in a hospital discharge situation.
Enter a date and your action list will be sorted by urgency. If you don't know the date yet, all actions are shown — start with the ones marked critical.
0 of 11 actions completed
CriticalAsk to speak with the hospital social worker
Hospital social work department · immediately
▼
CriticalAsk about Transition Care — this window closes at discharge
Hospital social worker or ACAT · today
▼
CriticalKnow your rights — you cannot be forced into an unsafe discharge
Hospital care team · today
▼
Confirm a My Aged Care referral has been submitted
Hospital social worker · today
▼
Request an aged care assessment in hospital (still often called ACAT)
Hospital social worker or ACAT · within 48 hours
▼
Request a home safety assessment before discharge
Hospital OT or social worker · 5+ days before discharge
▼
Ask about interim support services for when they get home
Hospital social worker or My Aged Care (1800 200 422) · 3–5 days before discharge
▼
Get a full medication list and administration plan
Hospital pharmacist and care team · 2 days before discharge
▼
Plan transport home and first-day support
Hospital discharge team · 2 days before discharge
▼
Book a GP follow-up appointment
GP · before discharge
▼
Get the discharge summary and care instructions in writing
Hospital nursing staff or discharge coordinator · discharge day
▼
What do families most often get wrong about hospital discharge?
What is Transition Care and do I need to ask for it?
Transition Care provides short-term support for up to 12 weeks after a hospital stay — at home or in a facility — to give the person time to recover. Yes, you need to ask for it. The hospital will not automatically offer it. Ask the social worker whether the person is eligible and how to apply. It must be arranged before discharge.
Can the hospital force them to leave before care is in place?
No. Discharge should not happen without a safe plan. If you feel discharge is being rushed, ask the social worker to advocate for more time and request a family meeting with the care team. Contact OPAN on 1800 700 600 for free advocacy if pressure is being applied.
How long does a My Aged Care assessment take after a hospital referral?
The hospital can request an urgent assessment if their situation warrants it. An ACAT assessment done in hospital is typically faster than waiting for a home visit after discharge. Ask the social worker to request an in-hospital assessment.
What interim support is available while waiting for a Home Care Package?
The Commonwealth Home Support Programme (CHSP) can provide basic services — cleaning, meals, personal care — within days. Ask My Aged Care (1800 200 422) about CHSP services available in the local suburb. This fills the gap while waiting for longer-term support to be arranged.
Last updated: 15 May 2026 · Phone numbers verified May 2026
Ask the nurses' station or hospital switchboard to connect you
Ask on arrival
Hospital switchboard
After discharge
Discharge is handled. Now the funding fight begins.
The assessment that determines years of care funding typically happens within weeks of discharge. Most families walk in unprepared — and the algorithm scores vague answers as if the need isn't there. The 28-day review window starts from the assessment result date, not when you receive it. The Action Plan covers every step: assessment prep, provider selection, and what to do if the classification comes back too low.