For hospital discharge teams
A clinical transition pathway after discharge
Hospital-to-Home supports nursing-led clinical care after discharge, with physiotherapy for essential mobility or safety needs when appropriate. People who are medically stable but have lost physical capacity may be able to enter Post-Hospital Rehabilitation directly.
What happens after you refer
Intake confirms clinical suitability, the receiving team and agreed next steps before care starts.
1. Before discharge
Send the referral, expected discharge date and summary, destination, current function, equipment and immediate clinical concerns.
2. At home
The proposed pathway reviews clinical, mobility and functional priorities alongside the actual home environment and support available.
3. Clinical review
Nursing-led transition care continues as required. Physiotherapy can address essential mobility or safety needs when assessment indicates it.
4. Recovery
A focused Post-Hospital Rehabilitation episode or broader Rehabilitation may follow if further functional goals remain.
5. Hand-back
The proposed transition plan identifies ongoing needs, clinically relevant progress, the receiving provider and the next review, with consent-based communication.
What to send
- Patient details, discharge address and contact person.
- Hospital, expected or actual discharge date and reason for admission.
- Mobility, transfers, falls, wounds or devices, nursing concerns and current supports.
- Discharge summary, funding or provider details, and consent to share information.
If the discipline is unclear, select “Uncertain — please triage”. Do not delay a referral just to select a clinician.
How quickly can care start?
Contact intake with the discharge date and urgency. Intake must confirm suitability, coverage, clinician availability and the first appointment. No fixed acknowledgement or appointment interval is currently promised for this pathway.
A submitted referral does not confirm acceptance of a discharge plan. Retain the existing discharge and escalation arrangements until the receiving service confirms care. Call 000 for emergencies.
Match the referral to the current need
The Post-Hospital Recovery guide compares nursing-led transition care, focused physical recovery and broader Rehabilitation. A person can enter at the service that fits now.