Hospital to Home: Reducing Readmissions Through Better Community Handovers 

The transition from hospital to home represents one of the most vulnerable periods in an older person’s care journey. Without proper coordination between healthcare providers and community services, patients face increased risks of complications, falls, medication errors, and hospital readmission. For referral partners, understanding how to facilitate smooth handovers can significantly improve outcomes for the people you support. 

The readmission challenge 

Hospital readmissions within 30 days of discharge remain a persistent challenge across the Australian healthcare system. Many of these readmissions are preventable, often resulting from inadequate discharge planning, lack of community support, or poor communication between hospital and home care providers. When older Australians return home without proper arrangements in place, they may struggle with medication management, mobility challenges, or simply managing daily tasks whilst recovering. 

Critical elements of successful transitions 

Effective hospital-to-home transitions require coordination across multiple touchpoints. Discharge planners need timely responses from community care providers, whilst patients and families need clear information about available support options. The key is early engagement – ideally, discussions about post-discharge care should begin as soon as admission occurs, particularly for older patients with complex needs. 

Discharge summaries play a vital role in continuity of care. These documents outline why the person was admitted, what treatment they received, current medications, and necessary follow-up care. Ensuring that GPs, pharmacists, and home care providers all receive copies helps prevent gaps in information that could compromise recovery. However, the discharge summary alone isn’t enough – it needs to be accompanied by practical arrangements for medication management, follow-up appointments, and in-home support. 

Preparing the home environment 

Successful transitions also depend on practical preparation. Has the home been made safe for someone with reduced mobility? Are groceries available? Is bed linen clean? Can the person manage showering and meal preparation independently? These seemingly small details can make the difference between a smooth recovery at home and an emergency readmission. 

Home care providers can support this transition by offering settling-home services – helping prepare the home before discharge, providing transport from hospital, and ensuring immediate support is available for personal care, meals, and medication reminders. This wraparound approach addresses both clinical and practical needs during the vulnerable early days at home. 

The role of care coordination 

Strong partnerships between hospitals and community care providers are essential. When discharge planners have established relationships with responsive home care services, they can confidently arrange appropriate support quickly. Regular communication about shared clients – including updates after hospital admissions and sharing of care plans – helps both sectors provide more informed, coordinated care. 

For older Australians, continuity of caregivers who know them well can help identify early warning signs of deterioration and prevent hospitalisation in the first place. When the same care team supports someone both before and after a hospital stay, they’re better positioned to notice changes and escalate concerns appropriately. 

Supporting informed choices 

Patient choice remains paramount throughout the discharge process. Providing clear information about available services, funding options, and what different providers offer helps people make informed decisions about their care. Discharge planners can support this by offering educational resources and allowing time for families to explore options, rather than rushing decisions during the stress of discharge. 

Ultimately, reducing readmissions requires a shared commitment across the care continuum – from hospital teams who plan thoroughly, to community providers who respond quickly, to families who feel supported and informed throughout the transition.