From hospital to community rehabilitation: making the handover work

Start before discharge day

Good discharge planning begins while the person is still receiving inpatient therapy. That is when goals, likely support needs and the home environment can be assessed, and when referrals to community services can be lodged early enough to matter.

What the handover should contain

• Diagnosis, procedures, precautions and any weight-bearing or activity restrictions.
• Current functional status and the goals worked on in hospital.
• Medication list and who is following up changes.
• Therapy program to continue, with frequency and progression.
• Equipment supplied, ordered or still required, and expected delivery.
• Home modification needs and who is arranging assessment.
• Named contacts for the hospital team and for each community service.

Funding the next stage

Which pathway continues the care depends on the person's circumstances. Options may include public community rehabilitation services, Medicare-subsidised allied health under a GP Chronic Condition Management Plan, private health cover, NDIS therapy supports for eligible participants, DVA arrangements for eligible veterans, a compensation scheme, or aged care.

For older people receiving in-home aged care, the Support at Home program replaced the Home Care Packages Program and the Short-Term Restorative Care Programme on 1 November 2025, and the Commonwealth Home Support Programme is scheduled to transition no earlier than 1 July 2027. Assessment and eligibility are decided through My Aged Care.

Equipment, transport and the home environment

• Has a home assessment been done, or is one needed before discharge?
• Is essential equipment in the home before the person arrives?
• Is there a plan for stairs, bathroom access and night-time safety?
• How will the person get to appointments, and can they afford it?
• Is telehealth appropriate for any part of the program?

Carers and family

Family members are frequently expected to assist with transfers, exercises or personal care without training. Ask the ward or rehabilitation team to demonstrate anything unfamiliar before discharge, and to write it down. Carer support services exist nationally and should be discussed as part of planning rather than after a crisis.

The first fortnight

Set a review point in the first two weeks. That is when problems surface: fatigue greater than expected, an appointment that never got booked, equipment that does not fit the home. A short scheduled check-in prevents a slow drift out of therapy.

Getting help arranging the next service

If community rehabilitation has not been organised before discharge, a referral can be sent through this platform. Get Rehab collects referral information and helps connect people with suitable participating providers; it does not determine funding approval or clinical suitability, and it is not an emergency service. In an emergency, call 000.