What services are included in the Support at Home program?

The Support at Home program funds in-home aged care services including personal care, domestic assistance, transport support, social support, allied health services, nursing care and home modifications tailored to individual needs.

Who is eligible for in-home aged care services in South East Queensland?

Eligibility is determined through a My Aged Care assessment. Generally, you must be aged 65 years or older, or 50 years or older for Aboriginal and Torres Strait Islander people, require assistance with daily tasks, and be living at home in Australia.

How much will I pay under the Support at Home program?

Your contribution depends on your approved funding level, approval date and service type. Clinical supports attract no contribution. Independence services may attract 5 percent. Everyday living services may attract 17.5 percent.

What if I cannot afford aged care services?

If you are experiencing financial hardship, you may apply for government assistance through Services Australia to reduce or waive aged care fees. Supported Care can assist you with the application process.

What is the Support at Home program?

The Support at Home program is an Australian Government initiative commencing from November 2025 that provides funding for personalised in-home aged care services.

What areas do you service?

Supported Care provides in-home aged care services throughout Brisbane, Logan, Caboolture and the Sunshine Coast in South East Queensland.

Can Supported Care assist with dementia or complex behaviours?

Yes. Supported Care provides specialist in-home support for dementia, cognitive decline and complex behavioural needs delivered by trained support workers and registered nurses.

Why Poor Discharge Planning Leads to Hospital Readmissions

An Evidence Based Perspective on Transitional Care

Hospital readmission within 30 days of discharge is widely recognised as an important indicator of healthcare quality and system performance (Jencks et al., 2009)

When patients return to hospital shortly after discharge, it often signals that something in the transition process did not work as intended. Readmissions place additional pressure on hospital resources, increase healthcare costs, and disrupt the recovery journey for patients and families.

Clinical complexity is one factor that can contribute to readmissions. However, research increasingly shows that many readmissions are linked to challenges that occur during the transition from hospital to community care.

The period immediately after discharge is one of the most vulnerable stages in the patient journey. If communication breaks down, support services are delayed, or the receiving environment is not ready, patients may struggle to manage their recovery outside the hospital setting (Coleman et al., 2004)

Understanding how discharge planning influences these outcomes is essential for improving healthcare systems.

The Role of Transitional Care

Transitional care refers to the coordinated actions taken to ensure continuity of care as patients move between healthcare settings.

This process often involves multiple stakeholders, including hospital clinicians, discharge planners, community providers, and support services. When these groups work together effectively, patients are more likely to experience stable recoveries after leaving hospital.

Research consistently shows that well-structured transitional care programs can significantly reduce hospital readmission rates (Naylor et al., 2011).

Studies examining discharge interventions have found that coordinated care transitions improve patient outcomes and reduce avoidable readmissions (Leppin et al., 2014).

Programs that combine several support elements such as multidisciplinary discharge planning, medication reconciliation, patient education, and follow up communication are particularly effective (Verhaegh et al., 2014).

These elements commonly include:

• Multidisciplinary discharge planning

• Medication reconciliation

• Education for patients and caregivers

• Follow up communication after discharge

• Coordination with community-based care providers

Evidence from systematic reviews suggests that interventions incorporating multiple components are more successful than single interventions in reducing the risk of readmission (Gonçalves-Bradley et al., 2016). In practice, this means discharge planning should begin early during hospitalisation rather than on the day of discharge.

Communication Failures During Discharge

Breakdowns in communication are one of the most frequently reported causes of hospital readmissions (Kripalani et al., 2007).

During discharge, important information must move quickly between hospital teams and community providers. If key details are missing or delayed, the receiving care team may not have the information required to support the patient effectively.

Discharge summaries sometimes lack sufficient clinical detail. Medication changes may not be clearly documented or follow up care instructions may not reach the appropriate providers (Kripalani et al., 2007).

These gaps can lead to medication errors, duplicated treatments, or delays in care.

Research shows that structured communication processes during discharge are associated with improved treatment adherence and lower readmission rates.

Effective discharge communication therefore requires coordination not only between clinicians, but also between patients, families, and community-based support services.

When everyone involved clearly understands the care plan, the transition into the community becomes safer and more stable.

Environmental Readiness After Discharge

The environment into which a patient is discharged plays a critical role in recovery outcomes.

Patients who return to environments without adequate support may struggle to manage medications, attend follow up appointments, or maintain daily routines required for recovery.

Studies have found that discharge settings and post hospital care environments are significant determinants of readmission risk (Calvillo-King et al., 2013).

For individuals with complex health conditions, psychosocial disabilities, or limited social support networks, these environmental factors become even more important.

A stable environment that provides supervision, support, and clear care pathways can significantly reduce the likelihood of hospital readmission.

In contrast, environments that are unprepared for the patient’s needs can quickly lead to deterioration and return to hospital care.

Clinical Example 1

Transitional Care Coordination

Evidence of the value of coordinated discharge planning can be seen in transitional care programs implemented in several healthcare systems.

One study in the United States introduced a transitional care coordination model involving specialised nurse transition care coordinators. These nurses supported patients during the transition from hospital to community care.

The program included discharge education, follow up telephone calls, and coordination with community providers after discharge.

Results showed significant reductions in both 30 day and 90-day hospital readmissions. The program also contributed to lower healthcare costs by preventing avoidable hospital returns (Kripalani et al., 2019).

This example illustrates how dedicated coordination roles can bridge the gap between hospital care and community support services.

Implications for Healthcare Systems

Reducing hospital readmissions requires a coordinated systems approach.

Hospitals cannot address this challenge alone. Effective discharge planning depends on strong collaboration between healthcare providers, community services, and accommodation or support providers.

Evidence suggests that discharge planning should begin early during hospitalisation. Multidisciplinary collaboration, clear communication, and preparation of the receiving environment are essential components of successful transitions.

Healthcare systems that invest in coordinated transitional care models often see improvements in patient outcomes, patient satisfaction, and overall system efficiency (Naylor et al., 2011)

Hospital readmissions are therefore not only a clinical issue. They are also a reflection of how well healthcare systems manage transitions between care settings.

As an organisation that focuses on providing care for those with complex needs, we at Supported Care believe that many hospital readmissions are preventable

Evidence consistently shows that early discharge planning, strong communication between providers, and stable post hospital environments significantly reduce the likelihood of patients returning to hospital.

Improving transitional care pathways is therefore a critical priority for healthcare systems seeking to deliver safer and more sustainable care.

By strengthening coordination between hospitals and community providers, healthcare systems can support safer recoveries while reducing avoidable pressure on hospital services.