Hospital-to-Home · Post-Hospital Recovery
Nursing-led clinical care continues after discharge while the team helps establish the person safely at home. Physiotherapy can address essential mobility or safety needs when assessment shows it is appropriate.
Intake confirms clinical suitability, coverage, funding and appointment timing before care starts.
Post-Hospital Recovery
Care can begin at the point that fits your needs now and change as your situation changes.
Compare the starting pointsWhat each service works toward
Nursing-led clinical transition
Clinical goalSufficient clinical stability for nursing-led transition care to step down or hand over.
Physiotherapy-led recovery
Clinical goalRecover as much useful physical capacity as reasonably possible.
Broader or continuing rehabilitation
Clinical goalProgress towards broader functional goals, with the plan reviewed as needs change.
You may not need all three services. You can start where care fits, continue with one service, or move between services after clinical review.
Our response standard
Referral acknowledged
Clinical triage
Urgent care where clinically appropriate and available
Routine care where clinically appropriate and available
Business hours are 8:00 am–5:00 pm, Monday–Friday, excluding public holidays, in Brisbane time. Referrals received outside these hours are treated as received on the next business day. Response timeframes run from receipt during business hours.
Urgent care is subject to clinical suitability and service availability. Clinics GRP is not an emergency service; acute or unstable presentations require urgent medical assessment.
This referral service is not monitored for emergencies. Call 000 in an emergency or seek prompt medical review for deterioration.
A coordinated transition
The nursing-led service connects discharge information, required clinical care and a review in the person’s actual home. The team checks when this transition care can safely step down or hand over.
Referral, clinical triage, discharge information and the first contact are brought together.
The team considers clinical needs, mobility, the home environment and support around the person.
Clinical stability, essential mobility and the next care arrangement are reviewed. A separate rehabilitation episode may follow when appropriate.
These stages describe nursing-led transition care from discharge planning to an agreed handover. The clinical lead, timing and care team are confirmed for each person. Further rehabilitation is assessed separately when needed.
The hospital, provider, GP, family or older person shares the discharge information and the clinical care still needed at home. Intake checks whether nursing-led transition care is the right starting point.
Why this stage matters
Gives intake the information needed to assess the immediate transition and route other recovery needs separately.
A senior clinician reviews discharge risks, the need for nursing-led care and any essential mobility or safety concerns. Intake can direct a person with different recovery needs to another service.
Why this stage matters
Clinical review establishes whether Hospital-to-Home fits and what the first response should address.
Clinics GRP connects the hospital handover to the person's actual circumstances at home.
Why this stage matters
Bridges the gap between what was planned in hospital and what is actually possible at home.
The early home review looks across clinical status, function, mobility, transfers, falls risk, environment, equipment and carer capability rather than one professional silo.
The first 72 hours are an early-care planning focus where clinically indicated. Timing depends on risk and availability; this is not an appointment guarantee.
Why this stage matters
Connects unresolved clinical concerns with functional priorities and the appropriate escalation or follow-up.
Nursing-led care addresses the clinical needs identified after discharge. Physiotherapy may help with essential mobility or safety when assessment indicates it is needed during the transition.
Why this stage matters
Keeps the agreed post-discharge clinical care connected to what is manageable at home.
The treating clinician reviews clinical stability, essential mobility and the support available at home. The team agrees whether nursing-led transition care should continue, end or hand over.
Why this stage matters
Makes the end of transition care a clinical decision rather than an automatic step in a longer rehabilitation programme.
The transition-care episode ends with clear communication about remaining clinical needs and the next care arrangement. Rehabilitation, when needed, is assessed as a separate service.
Why this stage matters
Makes responsibility for the next care step clear to the person, family and referring team.
The real transition
Clinics GRP connects the hospital handover to the person’s actual circumstances at home. The first few days may reveal problems that were not obvious at discharge; priority and timing are based on clinical need and availability.
Diagnosis, discharge instructions, mobility precautions, wounds or devices, follow-up, medicines information and equipment arrangements.
Can the person get out of a chair, reach the bathroom, manage stairs and use the equipment? Is the family coping? Has something changed?
Hospital-to-Home connects those two realities.
For individuals and families
Tell intake what has changed since hospital and what is difficult at home. You can ask for help without knowing which clinician is needed. Keep following your treating team’s discharge instructions.
Walking, transfers, stairs, toileting and getting in or out of bed.
Wounds, devices, monitoring and medicine-support concerns within clinical scope.
Equipment, access, hazards and what is actually manageable at home.
Family or carer capacity, existing services and who to contact if circumstances change.
Early review at home
Clinical status, daily function, the environment, support and recovery goals inform a transition plan. This review is tailored to the person; it is not a standard exercise package.
Walking · transfers · stairs · fatigue · balance
Wounds · devices · observations · medicines concerns
Access · equipment · hazards
Family · carers · provider arrangements
Previous function · current function · personal goals
The proposed Hospital-to-Home Transition Plan records priorities, people involved, agreed follow-up and the next review. Medicine discrepancies or uncertainty are escalated to the GP, pharmacist, prescriber or hospital team as appropriate.
Choose your next step
Understand the first days at home, what information helps and how to ask for clinical review.
Get help after hospitalSend one referral with the discharge information, transition timing, risks and support already arranged.
Refer a patientHospital and provider teams
One referral supports nursing-led transition care after discharge. Physiotherapy may be involved for essential mobility and safety needs; further capacity rebuilding can be considered as a separate rehabilitation episode. Acceptance, the first visit and reporting are confirmed with intake.
The referring team does not need to determine the individual disciplines first.
A senior clinician determines the initial discipline mix and priority.
Nursing leads the episode; physiotherapy can address essential mobility or safety needs where indicated.
Progress, escalation and next-step reporting are agreed with the referring or provider team.
For time-sensitive discharge, share the proposed date, immediate risks and available support. Retain hospital discharge and escalation arrangements until the receiving team agrees the plan. Reserved capacity and commercial terms require separate agreement.
After the transition
Hospital-to-Home ends or hands over when nursing-led transition care is no longer required. If physical capacity remains below the person’s usual level, Post-Hospital Rehabilitation may be considered as a separate service. Post-Hospital Recovery explains all three starting points.
Service evaluation
Clinical, functional and service measures help the team evaluate care and adjust its approach. Measurement does not establish that Clinics GRP prevents hospital readmission.
Referral acknowledgement and initial-contact timing
Mobility, transfers and progress towards agreed goals
Escalations, falls and known presentations
Episode duration and movement towards lower-intensity care
Funding and access
Tell intake what arrangements may apply, or select unknown. Eligibility, covered services, fees and provider authorisation are confirmed for each person before care begins.
Care can be coordinated with an approved provider and plan where the services and authorisation are confirmed.
Appropriate self-funded care can be discussed directly with intake.
Medicare or other accepted funding routes depend on individual eligibility and service requirements.
Hospital-to-Home is a Clinics GRP nursing-led service within Post-Hospital Recovery. It is separate from the Australian Government Transition Care Program and Support at Home Restorative Care Pathway, and it is not Hospital in the Home. Those programmes have their own eligibility and care arrangements.
Funding informationWhere we provide care
Home visits depend on suburb, clinical need and clinician availability. Check the published guide, then let intake confirm your address and the appropriate setting.
Coorparoo, Yeronga and Taigum clinics also offer options as recovery progresses.
Home Physiotherapy: Movement and Recovery at Home
Understand how chairs, stairs, space and assistance can affect everyday transfers, and how home physiotherapy can support an individual assessment and plan.
7 min read
Home Physiotherapy: Movement and Recovery at Home
Learn what a home physiotherapist may assess after hospital, from discharge instructions and everyday movement to symptoms, support and meaningful recovery goals.
7 min read
Nursing for Older Adults: Clinical Care Explained
When nursing and physiotherapy may need to coordinate around an older person’s priorities, and what makes a shared care plan useful.
7 min read
Evidence and clinical governance
Published research informed this service design. It does not prove that Clinics GRP achieves the outcomes reported in those studies or that this pathway prevents readmissions.
Research informs multidisciplinary approaches across a transfer of care.
Function and clinical needs are considered in the environment where the person will live.
Further rehabilitation is assessed according to the person’s function and goals, outside the nursing-led transition episode.
Research and clinical governance
The pathway’s design is informed by research into discharge planning, multidisciplinary transitional care, home assessment, carer involvement and rehabilitation after hospitalisation. The studies below inform how care is connected and tailored.
Results vary by population, clinical condition and programme. This research does not establish that the Clinics GRP Hospital-to-Home service prevents readmissions or achieves the outcomes reported in these studies. Direct evidence for this pathway’s specific assistant-supported step-down model remains limited.
Across 49 trials involving 25,566 adults with complex care needs, pooled readmission risk was lower with multidisciplinary transitional care (RR 0.88; 95% CI 0.80–0.96). Certainty was low because results differed between studies and publication bias was possible.
Relevance and limits: Supports coordinated transition as a design principle; it does not predict an individual’s outcome or prove this service reduces readmissions.
Collet et al. · The Gerontologist · 2025For medical admissions, personalised discharge planning slightly reduced hospital stay and readmission over about three months (RR 0.89; 95% CI 0.81–0.97; moderate-certainty evidence).
Relevance and limits: Informs preparation and transfer of care. A single referral is an operational choice, not an independently proven intervention.
Gonçalves-Bradley et al. · Cochrane · 2022This review identified person-centred, tailored and continuous care, a small team, follow-up and carer involvement among components of transitional care models.
Relevance and limits: Informs the proposed clinical lead and shared plan; the effect of each individual component cannot be isolated.
Leithaus et al. · International Journal of Integrated Care · 2022A review of 22 trials in at-risk older adults found a small improvement in function with home-based comprehensive geriatric assessment at 6–24 months (SMD 0.17; 95% CI 0.09–0.25).
Relevance and limits: Supports looking beyond one discipline. Clinics GRP’s early home review is not a formal Comprehensive Geriatric Assessment and does not reproduce the full intervention studied.
Hayes et al. · Journal of the American Geriatrics Society · 2025Trials integrating informal carers into discharge planning reported fewer readmissions at 90 and 180 days than usual care.
Relevance and limits: Informs checking understanding of the plan and involving the person’s chosen support people, with consent. These findings are not service-level outcome claims.
Rodakowski et al. · Journal of the American Geriatrics Society · 2017Ten trials of home exercise after hospitalisation found improvements in some measures of daily activity, mobility and quality of life, depending on the comparison.
Relevance and limits: Supports considering individually prescribed rehabilitation; it does not establish that every person benefits from the same exercise package.
Lin et al. · Clinical Rehabilitation · 2022In 740 older people with frailty, the extended home exercise programme did not improve the primary physical quality-of-life outcome at 12 months and was not cost-effective.
Relevance and limits: This cautions against routine extended exercise for everyone after discharge. It does not validate Clinics GRP’s alternative model; assessment, reassessment and service evaluation remain necessary.
HERO randomised trial · Age and Ageing · 2026The Australian Commission on Safety and Quality in Health Care emphasises communication at transfers, agreed goals, patient and carer involvement, structured handover and continuity of medicines information. These are design references, not a claim of accreditation or endorsement.
The government Transition Care Program and Restorative Care Pathway have separate eligibility and funding rules. These references explain program context, not this service’s effectiveness.
Clinics GRP Hospital-to-Home does not provide Hospital in the Home or replace hospital-level acute care. HITH research is not used here as evidence of this pathway’s efficacy.
Review status: Reviewed and approved by the Clinics GRP Clinical Review Team on 7 September 2026. This is an evidence-informed service description, not a validated clinical protocol.
Service evaluation is active. Clinical, functional and service measures are used to review the pathway. Active evaluation does not establish that the service reduces readmissions or achieves the outcomes reported in published studies.
You, a family member, your hospital team, GP or care provider can send a Hospital-to-Home referral. Include the discharge date, address, contact details and main concerns, with the discharge summary if available. Intake confirms clinical suitability, funding, coverage and appointment timing before care starts.
Yes. Hospital-to-Home is nursing-led, and physiotherapy may address essential mobility or safety needs during the transition. Describe the person’s needs in the referral; intake and clinical review confirm the disciplines and scope of care.
No. Someone who does not need nursing-led transition care but has lost meaningful physical capacity around a hospital stay may be able to start Post-Hospital Rehabilitation directly. Intake confirms clinical fit and availability.
The treating clinician reviews clinical stability and remaining needs, then agrees a handover or closure plan. If rebuilding physical capacity is the main need, Post-Hospital Rehabilitation may be suitable as a separate service. Intake can help identify the right starting point; Hospital-to-Home is not a required first step.
Share the discharge date and urgency with intake. The first appointment must be confirmed according to clinical need and clinician availability. The first 72 hours is a planning focus, not a guaranteed visit window. A submitted referral does not confirm a booking or acceptance of a discharge plan.
Restorative care focuses on rebuilding function and independence. Clinics GRP Hospital-to-Home continues required clinical care after discharge, with physiotherapy for essential mobility or safety where indicated. A separate Post-Hospital Rehabilitation episode may address further loss of physical capacity. Both services are separate from the government Transition Care Program and Support at Home Restorative Care Pathway. Intake confirms clinical suitability, funding and provider arrangements; a referral does not establish government program eligibility.
No. Hospital in the Home provides hospital-level treatment under a hospital service. Clinics GRP Hospital-to-Home provides community-based clinical transition care after discharge. It does not replace hospital-level acute care, emergency care or the treating team’s discharge instructions.
Send one referral. Our clinical team will determine the appropriate disciplines and initial response.
Hospital-to-Home and home care are preselected. Add the discharge summary in the clinical step if available. A referral requests review; intake confirms timing, coverage and funding before care begins.
Another way to access care
Hospital-to-Home can also be discussed through appropriate self-funded arrangements. Clinical suitability, availability and applicable rebate requirements are confirmed before care begins.
