After a fall or a hospital stay: what happens next

A fall, an infection or an operation can turn an ordinary week upside down. Afterwards, it’s natural to feel less steady and less sure. That feeling often eases with time, the right help and some practice. It’s a setback, not a verdict.

Hospitals plan for the day you leave. Doctors, nurses, physiotherapists, occupational therapists (OTs, who help people manage everyday tasks) and social workers may all have a say. Their job is to make sure you can go home safely, or to work out what support would make that possible.

Ask early who is planning your discharge, and ask for a meeting that includes you and anyone you want there. Some hospitals arrange for an OT to visit the home before discharge to check steps, the bathroom and the bed. It’s worth asking whether that will happen. When you leave, the hospital usually sends a discharge summary to your GP. Ask for a copy too.

• When am I likely to go home, and what needs to be in place first?
• Will someone check my home, or talk me through what to change?
• What equipment will I need, and who arranges it?
• Can I be assessed for aged care before I leave?
• Who do I call if things go wrong in the first few days?
• Has my medicine changed, and has that been explained to me?

Most government-funded aged care starts with an assessment through My Aged Care. You don’t have to wait until you’re home. Ask the hospital staff to arrange one, or call My Aged Care on 1800 200 422. A family member can make the call with your permission.

One assessment can cover several kinds of help at once. After a hospital stay, that might include transition care, the Restorative Care Pathway, ongoing Support at Home services, funding for equipment and home changes, and respite. The assessor works out which ones fit, and gives you a priority, which affects how quickly ongoing help can start.

An assessment doesn’t commit you to anything. It opens doors, and you choose which services to take up. Describe the hard days honestly. After a fall, people often say “I’ll be fine”, and that can mean less help than they need.

Transition care is short-term care straight after a hospital stay. It aims to help you get your strength, skills and confidence back, and to avoid needing longer-term care if possible.

To be eligible, you need to be a patient in a public or private hospital, be ready to leave, and be likely to benefit from a short period of extra help. An assessor visits you in hospital. If you’re approved, a transition care provider helps you leave hospital and coordinates your care.

Care can happen at home, in the community, in an aged care home, or a mix of these as you recover. People with higher needs may spend part of the time in an aged care home, where help is on hand around the clock. That stay is part of a recovery program. It isn’t a permanent move.

Under the program rules, transition care lasts up to 12 weeks (84 days). In some cases it can be extended by up to 6 weeks (42 days), which needs another assessment. You can be approved for transition care again after a later hospital stay, even in the same year.

There’s no means assessment. Providers set fees with you, up to maximum daily amounts set by the government, which are lower at home than in an aged care home. Not being able to pay doesn’t affect your access. My Aged Care publishes the current maximums.

The Restorative Care Pathway is part of Support at Home. It offers a short burst of allied health and nursing care, such as physiotherapy, occupational therapy and exercises for strength and balance, to help you do the things you enjoy again. It can also include equipment and minor changes around the house, plus help like cleaning, transport or showering while you recover.

If you’re approved, you get a support plan and budget for up to 16 weeks. Under the current rules, you can have up to two episodes in 12 months. If your provider asks for extra funding during an episode and it’s approved, a second episode in that 12 months isn’t available.

Funding for this pathway is allocated straight away, with no waiting list. You need to start services before the take-up date on your letter, which is within 56 days of approval. You can ask My Aged Care for a 28-day extension.

Clinical services, such as nursing and physiotherapy, are fully funded, and since 1 October 2026 so is personal care, such as help with showering. You may pay a contribution towards other services, such as cleaning, based on your income and assets. If you already have ongoing Support at Home services, you can use the pathway at the same time. If restorative care is the only thing you’re approved for, ongoing services aren’t started until the episode ends.

Transition care and restorative care can’t run at the same time. The assessor works out which suits your situation.

Ongoing Support at Home funding can take months to arrive, depending on your priority. Several things can fill the gap.

Residential respite is a short stay in an aged care home. It needs approval through an assessment, although in an emergency a home may be able to arrange an urgent assessment. It’s funded for up to 63 days in a financial year, including planned and emergency stays, and the assessor can approve extensions of 21 days at a time. You pay the basic daily fee and possibly a booking fee, but no means-tested fees or accommodation costs. Approval doesn’t guarantee a bed, so ask homes about availability early.

If a family carer suddenly can’t keep caring, Carer Gateway can help arrange emergency respite at home or in an aged care home. Call 1800 422 737.

In NSW, some public hospitals can refer patients to ComPacks, a NSW Health program of short-term home care for up to six weeks after discharge. It can include personal care, cleaning, meals and transport, with a case manager. Ask the ward staff whether you’re eligible. In Queensland, ask the hospital what short-term services your local Hospital and Health Service offers after discharge. What’s available varies by area.

Many people also pay privately for a few weeks of cleaning, meals or personal care while funded help is arranged. Get prices in writing and check that workers are insured and screened.

Hospital physiotherapists and OTs often recommend equipment before you leave: a walking frame, a shower chair, a raised toilet seat, rails. Ask who will supply it and whether it’s a loan, a hire or a purchase. Arrangements vary between hospitals and states.

Through Support at Home, the Assistive Technology and Home Modifications scheme gives upfront funding for equipment and home changes, separate from any ongoing budget. The Restorative Care Pathway can include a separate budget for equipment and minor home changes too.

A personal alarm is worth thinking about after a fall, especially for anyone living alone. Some can detect a fall and call for help automatically. Some state schemes also help with equipment for people who meet their rules, such as Queensland’s Medical Aids Subsidy Scheme and EnableNSW. Both have their own eligibility rules, and people who get Commonwealth aged care funding, or are approved or waiting for it, often aren’t eligible, so check first.

• Clear walkways, and move rugs and cords that could trip someone
• Put frequently used things at waist height
• Add night lights between the bedroom and bathroom
• Have a phone or alarm within reach, including in the bathroom
• Keep a list of medicines and the discharge summary somewhere easy to find

Sometimes, in the rush of a hospital stay, a move into an aged care home is raised quickly. Hospitals need beds, and staff may be worried about safety at home. Those worries deserve a fair hearing. But a permanent move is a big decision, and it’s usually possible to take time.

Moving into an aged care home is the person’s own decision, or their legally appointed decision-maker’s if they can’t decide for themselves. It runs under the Aged Care Act 2024, with its own assessment, agreement and fees. Transition care, restorative care or a respite stay can give everyone breathing space. A respite stay can also show what life in a particular home is like.

The same goes for other big decisions: selling the house, signing a retirement village contract or moving in with family. These are better made once the dust has settled, with the right information. A retirement village isn’t aged care, and on-site aged care in a village is a separate move under separate law, with no guaranteed place.

Staying at home with more help is a full, respectable answer. If home turns out not to be safe even with help, that’s worth knowing too, and a reassessment can lead to more help or other options.

If you’re the son, daughter, partner or friend, you can make a real difference in the days around discharge. Be at the planning meeting if you can, with the person’s agreement. Take notes, ask for names, and ask what happens next.

Try to keep the person at the centre. They may be tired, sore or a little confused after a hospital stay, and decisions made around them can feel like decisions made about them. Ask what they want, and give them time to answer.

If you’re worried the plan isn’t safe, say so clearly to the treating team, and ask what support would make it safe. The Older Persons Advocacy Network gives free, confidential help to older people and their families on aged care questions. Call 1800 700 600. If you’re doing a lot of the caring, Carer Gateway on 1800 422 737 has free support for you too.

• Bring a list of medicines and the GP’s details to the hospital
• Ask for the aged care assessment before discharge
• Make sure the home is ready: heating or cooling on, food in the fridge, the bed easy to reach
• Plan who will visit or call in the first week
• Keep a folder with the discharge summary, letters from My Aged Care and provider details