The readmission problem
Unplanned hospital readmissions within 28 days of discharge are a significant clinical and system challenge across Australia. For older patients, inadequate post-discharge support at home is one of the most modifiable contributing factors. Research consistently demonstrates that well-coordinated home care reduces readmission rates — particularly for patients with chronic conditions, post-surgical recovery needs, and those at risk of falls.
High-risk groups to prioritise for home care referral
- Patients over 75 who live alone
- Patients with dementia or significant cognitive impairment
- Patients with poor medication adherence histories
- Patients with recent falls or fall risk factors
- Patients following major surgery, joint replacement or cardiac events
- Patients with complex multi-morbidity and multiple medications
- Carers who are themselves elderly or unwell
What effective post-discharge home care looks like
The most effective post-discharge home care packages include:
- Wound care and nursing monitoring in the first days following discharge
- Medication management and adherence support
- Personal care assistance during recovery
- Meal preparation support while mobility is reduced
- Early OT and physiotherapy involvement to support recovery and prevent re-injury
- Regular check-in visits to monitor for deterioration
The referral pathway
For planned discharges, initiate the My Aged Care referral at least 5–7 days before discharge. For urgent discharges, contact home care providers directly as well as My Aged Care, as provider intake can sometimes begin before formal assessment is completed in urgent circumstances.
Working with Lyft Community
Lyft Community works with hospital discharge teams across Melbourne and the Mornington Peninsula to facilitate timely, safe transitions home. We can often commence services within 24–48 hours of referral for urgent discharge situations. Contact our intake team to discuss a patient or establish a referral relationship.