Hospital discharge in Australia is managed by the hospital's Discharge Planning team — usually a social worker and a nurse. Request a meeting with the social worker on day one. Do not wait to be approached.
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Before they leave — what to demand
These are your rights. Ask specifically. Get answers in writing where you can.
Request a formal discharge assessment
You have the right to be involved in discharge planning. Ask: "Can we have a formal discharge meeting with the social worker before a date is set?" This triggers a structured process and is much harder to rush.
🔴 Do not accept a verbal discharge date as final
Request a Home Care Package referral before discharge
If your parent doesn't already have a Home Care Package, the hospital social worker can initiate a My Aged Care referral for an ACAT assessment while they're still admitted. This is far faster than applying after discharge. Waiting lists are long — start the clock now.
🔴 Don't leave without this referral started
Ask about Transition Care Programme (TCP)
TCP provides short-term support (up to 12 weeks) for people who need time to recover before returning home or moving to residential care. It is assessed during admission and must be arranged before discharge — it cannot be arranged after. Ask directly: "Is my parent eligible for the Transition Care Programme?"
🔴 Window closes at discharge
Get a complete, reconciled medication list
Ask the hospital pharmacist (not just the ward nurse) for a reconciled medication list — what they were on before, what changed during admission, and what they're going home on. Medication errors at discharge are one of the leading causes of readmission within two weeks.
Request a discharge summary for the GP
A written discharge summary should go directly to your parent's GP. Ask: "Will the discharge summary be sent to our GP today, and can we have a copy?" Book a GP appointment within 3–5 days of discharge — this is when problems surface.
Request an occupational therapy (OT) home assessment
Ask: "Can an OT assess the home before discharge?" They can arrange rails, grab bars, shower chairs, and ramp modifications — often funded through CHSP or the hospital. This takes a few days to arrange, which is another reason not to rush discharge.
Confirm the plan for wound care, physio, or nursing
If ongoing wound care, physiotherapy, or nursing is needed — get the referral made before discharge, not after. Ask: "Who is organising the community nursing referral, and when will the first visit be?"
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Your rights if discharge feels too soon
You can push back. Here's how.
The most important thing to know
Hospitals cannot discharge a patient if it is clinically unsafe to do so. If you believe your parent is not medically ready, say: "I have concerns about the safety of this discharge and I'd like to speak with the ward consultant." Document your concerns in writing to the social worker and ward nurse. Ask for the hospital's patient liaison officer or PALS equivalent if you're not being heard.
Put your concerns in writing
Email or give a written note to the ward nurse and social worker stating your specific concerns. "I am concerned that Mum cannot safely manage at home without [specific service] being in place. I am requesting that discharge be delayed until [specific thing] is arranged." Written concerns are taken more seriously than verbal ones.
Contact the hospital's Patient Liaison Officer
Every public hospital has a patient liaison or consumer advocate. They are independent of the ward team and can escalate concerns. Ask at the front desk or call the hospital's main number and ask for "patient liaison."
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The first two weeks home — what to watch for
Most readmissions happen in this window. Know the red flags.
🔴 Return to hospital if you see any of these
Fever (38°C / 100.4°F or above)
A new fever in the first two weeks post-discharge is a red flag. Common causes: wound infection, urinary tract infection, chest infection. Don't wait and see — contact the GP that day or present to ED.
New confusion or significant change in behaviour
Sudden confusion in an older person is a medical symptom — often a UTI, medication reaction, or dehydration. It is not just "getting older." Same-day medical review needed.
Wound that looks infected — red, warm, swollen, or discharging
Redness spreading beyond the wound edge, warmth, increased pain, or any discharge that isn't clear. Contact the GP or community nurse immediately.
Medication confusion or missed doses
Medication errors are the leading cause of hospital readmission in older people. If the medication list is confusing, call the GP or community pharmacist for a medication review — most will do a home visit.
Breathlessness, chest pain, or swollen legs
These may indicate fluid retention or cardiac issues, particularly common after surgery or prolonged bed rest. Call 000 if severe. GP same day if mild but new.
The 72-hour rule
The first 72 hours home are the highest risk. Visit or call daily. The biggest mistake families make is assuming "they're home now, so they're fine." Home is where the real recovery — and the real risks — begin.
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Services to arrange immediately
Before the hospital support disappears
Register with My Aged Care — if not already done
Call 1800 200 422 or visit myagedcare.gov.au. If a referral was made during admission (you requested this in Phase 1), follow up within 48 hours to confirm it's been received. Waitlists are long — every day counts.
GP appointment within 3–5 days
Book before you leave the hospital. Bring the discharge summary. Ask the GP to review all medications, check wound healing, and — if it hasn't been initiated — refer for an ACAT assessment.
Visit myagedcare.info for step-by-step AU system guidance
Our sister site walks through registration, waitlists, costs, and has a GP letter generator to fast-track your assessment. myagedcare.info →
In England, Wales, Scotland and Northern Ireland — discharge planning is governed by the NHS Discharge to Assess framework. You have legal rights here. The key word to use is "safe and timely discharge" — both words matter.
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Before they leave — what to demand
The NHS Discharge to Assess model means services can follow — but only if you ask.
Request a Section 9 / discharge assessment before leaving
Under the Care Act 2014, your parent has the right to a needs assessment before discharge if they are likely to need ongoing care. Ask the ward social worker: "Has a Section 9 assessment been requested?" If not, request one immediately. This must happen before discharge if care needs are anticipated.
🔴 Your legal right — not a request they can decline
Ask about NHS Continuing Healthcare (CHC) eligibility
If your parent has complex health needs, they may qualify for CHC — which means the NHS funds all care costs, including residential care if needed. The hospital must screen for CHC eligibility before discharge. Ask: "Has a CHC Checklist been completed?" If not, request one. This is the most commonly missed entitlement in the UK.
🔴 Most families are never told to ask this
Request Discharge to Assess (D2A) / reablement support
D2A means your parent goes home with a package of support to allow proper assessment in their own environment. Ask: "Is my parent eligible for a Discharge to Assess or reablement package?" This typically provides 6 weeks of free care at home — and many families never know to ask for it.
🔴 Free for up to 6 weeks — but only if requested
Reconciled medication list from the pharmacist
Request a written list of all medications — pre-admission, changes made during admission, and discharge medications. Ask the ward pharmacist, not just the nurse. Ensure a copy goes to the GP. Medication errors at discharge are a leading cause of readmission.
Discharge summary to GP — confirmed sent
Ask: "Will the discharge summary be sent to our GP electronically today?" Book a GP appointment within 48–72 hours of discharge — this is the highest-risk window.
Request a Carer's Assessment for yourself
If you are going to be providing care at home, you are entitled to a Carer's Assessment from the local council — completely free. This can result in funded respite, a personal budget, or direct payments. Ask the ward social worker to initiate the referral before discharge.
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If discharge feels too soon
Your rights
The NHS cannot discharge your parent until it is both clinically safe to do so and appropriate community support is in place. Say: "I do not believe it is safe to discharge without [specific service] being confirmed." Ask for the PALS (Patient Advice and Liaison Service) — every NHS trust has one and they are independent of the clinical team. Call NHS 111 or contact your local Healthwatch if PALS is not responsive.
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First two weeks home — watch for
🔴 Contact NHS 111 or GP same day for any of these
Sudden new confusion
Often a UTI, medication reaction, or dehydration — not "just getting older." Needs same-day review.
Temperature above 38°C
New fever in the first two weeks post-discharge needs same-day GP review or NHS 111 assessment.
Signs of wound infection
Increasing redness, warmth, swelling, or discharge beyond what was expected. Contact district nurse or GP the same day.
Breathlessness, chest pain, or new leg swelling
Call 999 if severe. GP or NHS 111 same day if mild but new or worsening.
Medication confusion
Contact the GP or community pharmacist for a medication use review — free on the NHS and available as a home visit.
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Services to arrange immediately
GP within 48–72 hours
Book before leaving the hospital. Bring the discharge summary. Ask for a CHC Checklist if it was not done in hospital. Ask about district nursing, physiotherapy, and any specialist follow-up.
Contact your local council Adult Social Care team
Even if the hospital initiated a referral, follow up directly. Call your local council and ask for the Adult Social Care duty team. Reference the hospital discharge. Carers UK helpline: 0808 808 7777.
The most important thing to know about US hospital discharge: The hospital is under significant financial pressure to discharge quickly. Medicare pays by diagnosis — the sooner you're out, the better for their budget. Your interests and the hospital's financial interests are not aligned. You must advocate actively.
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Before they leave — what to demand
Request the hospital's discharge planner / social worker — day one
Don't wait to be offered this. Go to the nurses' station and say: "I'd like to speak with the discharge planner today." They are responsible for arranging post-acute care and home services. The sooner they're involved, the more options you have.
🔴 Don't wait — they'll come to you when it's too late
Understand Medicare's SNF (Skilled Nursing Facility) benefit
Medicare covers up to 100 days in a skilled nursing facility after a qualifying inpatient hospital stay of at least 3 days. Days 1–20 are fully covered. Days 21–100 require a daily co-payment (~$200). This benefit disappears if your parent goes directly home. If skilled nursing is needed, ask now — not after discharge.
🔴 The 3-day rule is strict — confirm inpatient status vs observation
Confirm "inpatient" vs "observation" status
This is a Medicare trap. If your parent is admitted as "observation status" rather than full inpatient, the 3-day qualifying stay for SNF coverage does NOT apply — even if they spent days in a hospital bed. Ask the billing department directly: "Is my parent admitted as inpatient or on observation status?"
🔴 Observation status is financially devastating if missed
Request home health agency referral before discharge
Medicare covers home health care (skilled nursing, physical therapy, occupational therapy) after discharge if your parent is "homebound" and a doctor certifies the need. This must be arranged before discharge. Ask: "Can a home health agency referral be made today?"
Medication reconciliation list
Request a complete written medication list from the hospital pharmacist. Ensure it goes to the primary care physician. Medication discrepancies at discharge cause 20% of readmissions in the US.
Get the "Important Message from Medicare" in writing
Medicare requires hospitals to give you a written notice of your rights. If your parent is a Medicare patient, you have the right to appeal a discharge decision. The notice explains how. If you haven't received it, ask for it.
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First two weeks home
🔴 Go to the ER or call 911 for any of these
Sudden new confusion
UTI, medication interaction, or dehydration — all common causes of acute confusion in older adults. Needs same-day evaluation.
Fever above 100.4°F (38°C)
New fever within two weeks of discharge needs same-day medical review.
Shortness of breath, chest pain, or sudden leg swelling
Call 911 immediately if severe. Primary care or urgent care same day if mild and new.
Signs of surgical site infection
Redness extending beyond wound edges, warmth, swelling, or purulent discharge. Contact surgeon's office same day.
Hospital discharge in Canada is provincially managed. The process varies between Ontario, BC, Alberta, and other provinces — but the core rights and steps below apply across the country.
1
Before they leave — what to demand
Request a Social Worker assessment — day one
Ask to speak with the hospital social worker on the first day of admission. They coordinate the discharge plan, arrange community services, and can initiate referrals to CCAC (Ontario), Home & Community Care Support Services, or the provincial equivalent.
🔴 Don't wait to be offered — request it
Request a Transitional Care / short-term rehab assessment
Most provinces offer short-term transitional or restorative care after a hospital stay. In Ontario this is called CCC (Complex Continuing Care) or rehabilitation. Ask: "Is my parent eligible for transitional care before going home?" This is assessed during admission.
Medication reconciliation from the pharmacist
Ask the hospital pharmacist — not just the ward nurse — for a complete written medication list. This should be sent to the family physician. Medication errors are the leading cause of hospital readmission across Canada.
Arrange home care before discharge
The social worker should make a referral to the provincial home care program before discharge. In Ontario: Home & Community Care Support Services (HCCSS). In BC: Home Health. Don't leave without confirmation the referral has been made and a first visit is scheduled.
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First two weeks home
🔴 Contact 811 or go to the ER for any of these
Sudden new confusion
UTI, dehydration, or medication reaction. Call 811 (Health Link) or present to the ER same day.
Fever above 38°C (100.4°F)
New fever within two weeks of discharge needs same-day review. Call 811 or the family physician.
Shortness of breath or chest pain
Call 911 if severe. Go to urgent care or ER same day if mild and new.
Hospital discharge in New Zealand is coordinated by the hospital's discharge planning team, which includes social workers and community health nurses. The key contact is the ward social worker — ask for them on day one.
1
Before they leave — what to demand
Request a NASC referral before discharge
Needs Assessment and Service Coordination (NASC) is the gateway to all funded home support in New Zealand. The hospital social worker can make a referral to your local NASC agency while your parent is still admitted. This is faster than applying after discharge. Ask: "Has a NASC referral been made?"
🔴 Start the clock before discharge
Ask about Transitional Support Services
Hospital-level support can continue in the community for a short period after discharge for people who need it. Ask the social worker: "What transitional support is available for my parent?" This varies by DHB region but is commonly available.
Medication list from pharmacist
Request a written medication reconciliation from the ward pharmacist. Ensure it goes to the GP. Book a GP appointment within 3 days — this is the highest-risk window for medication errors.
Know your rights under the Code
The Code of Health and Disability Services Consumers' Rights gives your parent the right to services of an appropriate standard, to be fully informed, and to make decisions. If you feel discharge is being rushed, say: "I am invoking our rights under the Code to have adequate time to arrange appropriate support." Contact the Health and Disability Commissioner at hdcommissioner.health.nz if rights are not respected.
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First two weeks home
🔴 Call Healthline (0800 611 116) or 111 for any of these
Sudden confusion
UTI, dehydration, or medication issues. Call Healthline or GP same day.
Fever above 38°C
Same-day GP or Healthline 0800 611 116.
Chest pain or difficulty breathing
Call 111 immediately.
Hospital discharge in Ireland is coordinated by the hospital's Integrated Care team and social workers. The key pressure point is that Irish hospitals are under severe bed pressure — discharge can be rushed. Know your rights.
1
Before they leave — what to demand
Request a Home Care Package assessment before discharge
The HSE Home Support Service provides funded home care. A referral can be initiated by the hospital social worker before discharge. Ask: "Has a referral been made to the HSE Home Support Service?" Without this, your parent may go home with no support in place.
🔴 Waiting lists exist — start the process now
Ask about Transitional Care beds
Transitional care beds in step-down facilities give time to recover before returning home or to residential care. Ask the social worker: "Is my parent eligible for a transitional care bed?" These are funded by the HSE but allocation is competitive — ask early.
Reconciled medication list
Request a written medication list from the ward pharmacist. Ensure it goes to the GP. Book a GP appointment within 48–72 hours of discharge.
Your rights under the Patient Charter
You have the right to be involved in discharge planning and to be given adequate notice. If you believe discharge is unsafe, say: "I have concerns about the safety of this discharge and I am requesting a formal review." Contact the hospital's Patient Advocacy Service or HIQA (021 240 9300) if you are not being heard.
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First two weeks home
🔴 Call GP, ShannonDoc, or 999 for any of these
Sudden confusion
UTI, medication reaction, or dehydration — same-day GP review. If out of hours, contact ShannonDoc or your regional GP out-of-hours service.
Fever above 38°C
Same-day GP. If weekend, GP out-of-hours.
Chest pain or difficulty breathing
Call 999 or 112 immediately.
Wound infection signs
Contact the GP or public health nurse same day. Community nursing can arrange a home visit.
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Services to arrange immediately
HSE Home Support — follow up within 48 hours
If a referral was made during admission, call your local HSE office to confirm it has been received and ask for a timeline. Family Carers Ireland helpline: 1800 24 07 24.
Frequently asked questions
Sources and further reading
- 🇦🇺 My Aged Care — Hospital discharge and transition care
- 🇬🇧 NHS England — Discharge from hospital: your rights
- 🇬🇧 Care Act 2014 — Section 9 assessment rights (UK legislation)
- 🇺🇸 Medicare.gov — Your rights when leaving hospital
- 🇳🇿 NZ Health and Disability Commissioner — Code of Consumer Rights
- 📄 Rennke S, et al. "Hospital-initiated transitional care interventions as a patient safety strategy." Annals of Internal Medicine, 2013. — on medication reconciliation at discharge
Tools to use alongside this guide
🆘 Emergency Information Sheet — medications, allergies, contacts in one printable page→
💊 Medication Tracker — log what they came home on and track changes→
📋 GP Questions Builder — prepare for the post-discharge GP appointment→
💰 Entitlements Checker — find every payment and service you may be missing→
🏠 Care Home Guide — if this discharge leads to that conversation→
Important: This guide explains systems and processes — it is not medical advice. If you have concerns about your parent's condition or the safety of a discharge, speak with the treating medical team. For urgent concerns out of hours, call your country's health helpline or emergency services.
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