For hospital discharge teams
A community clinical pathway for older adults leaving hospital
Refer once. We coordinate the next clinical step. The Hospital-to-Home pathway connects nursing, physiotherapy, functional assessment and reablement around supported discharge into the home.
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. First weeks
Nursing and rehabilitation are coordinated according to assessment, scope, capacity and agreed funding.
4. Recovery
Care may progress to clinic or community rehabilitation, clinically delegated assistant support, or ongoing provider services.
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.
Related care: post-hospital rehabilitation · nursing after hospital · home care providers.