Hospital to aged care: what to do when a parent cannot go home

What happens when the hospital says your parent cannot go home?

When hospital staff say an older person cannot safely go home, the next step is usually an aged care assessment done on the ward, followed by a discharge plan. That plan might be short-term recovery care, respite, more help at home or a move into an aged care home. The decision is not the hospital's alone to make.

The people you will deal with are the treating team, the ward social worker and a discharge planner or patient flow coordinator. Their job is to get the older person out of an acute bed safely. Your job is to make sure the plan suits the older person, not just the bed situation.

Moving from hospital to aged care is often fast. Families are sometimes told a permanent aged care home is the only option. The advocacy network OPAN says plainly that people feel pressured into this, and that it is okay to take time over the decision. There are usually several routes out of hospital, some temporary.

• Recovery first: the Transition Care Program or the Support at Home Restorative Care Pathway.
• A bridge: residential respite while you work out the long-term plan.
• Home with more help: an ongoing Support at Home classification, if one can be arranged in time.
• A permanent move: an aged care home, chosen by the older person or their decision maker.

How does an aged care assessment work in hospital?

An older person can be assessed for aged care while still an inpatient. Under the Single Assessment System, which replaced the old assessment teams (ACAT and RAS) from 9 December 2024, state and territory governments continue to deliver all hospital-based assessments. The hospital usually arranges the referral, so you do not have to start it yourself.

The assessor uses the Integrated Assessment Tool, the same tool used in the community. They look at health, mobility, memory, daily tasks, supports at home and what the older person wants. The outcome decides which types of care they are approved for, such as residential care, respite, transition care or Support at Home.

Ask to be present for the assessment, or at least to speak with the assessor. The older person should be part of the conversation if they are well enough. If they have a registered supporter or a legal decision maker, that person should be involved too. Our guide to how an aged care assessment works covers what the assessor asks and what the outcome letter means.

What is the Transition Care Program?

The Transition Care Program gives short-term care and rehabilitation to older people straight after a hospital stay. It lasts up to 12 weeks, with an extension of up to six more weeks possible if approved. It is run through state and territory governments, and it still operates under the new aged care system that began on 1 November 2025.

The official name is now spelled Transition Care Program (you may also see transition care programme). The aim is to help the older person recover enough to go home, or to give them time to make a considered decision about longer-term care instead of a rushed one from a hospital bed.

Care typically includes nursing, personal care, allied health such as physiotherapy, and social work. Near the end of the episode, the provider helps plan the move to the older person's preferred long-term option. Places are limited and vary by area, so ask the discharge planner early whether a place is available locally.

Restorative care and respite as a bridge after hospital

If transition care is not available or not the right fit, two other short-term options exist. The Support at Home Restorative Care Pathway funds intensive allied health and nursing at home. Residential respite gives a temporary stay in an aged care home. Both buy time to recover or decide, without committing to a permanent move.

Restorative Care Pathway. Each episode provides $6,167.33 of funding (from 1 July 2026) for up to 16 weeks of intensive services, according to the Department of Health, Disability and Ageing. Episodes starting from 1 October 2026 get $6,179.40. It is for people expected to keep living at home without ongoing Support at Home services, or with no change to the services they already have, once the episode ends. Clinical supports such as nursing and physiotherapy are fully funded. The older person contributes to independence and everyday living services based on a financial assessment. An aged care assessment decides whether they qualify. See Support at Home explained for how the wider programme works.

Residential respite. Eligible people are entitled to 63 days of residential respite in a financial year, which can be extended by up to another 21 days if an aged care assessor approves it. In an emergency, respite can start before formal approval is in place. Respite is often used as a bridge from hospital: the older person moves into a home for a few weeks, and the family uses that time to find a permanent place or set up care at home. Our respite care guide explains the types of respite and what they cost.

Can you accept a temporary aged care home while you wait?

Yes. Some families accept a place in an aged care home that is available now, knowing it is not their first choice, and move later when a preferred home has a vacancy. This is sometimes called an interim placement. It can get the older person out of hospital sooner, but a second move has costs and disruption of its own.

Before agreeing to an interim place, weigh up the trade-offs rather than deciding at the bedside.

• Accommodation payment: for people entering a home on or after 1 November 2025, there is no 28-day deadline to choose between a lump sum, daily payments or a mix, and a lump sum can be paid at any time after entry. Our guide to RAD or DAP explains the choice.
• Another move: each move means a new room, new staff and a new routine. This can be hard on someone with dementia. Our guide to dementia care options covers what to look for.
• Waiting lists: ask the preferred home directly how waiting works and whether the older person can stay on its list after entering somewhere else.
• Quality: an interim home is still where the older person will live. Check it the way you would any home, using our questions to ask a provider.

Can a hospital force discharge to aged care?

A hospital can discharge someone who no longer needs hospital care, but it cannot choose an aged care home for them. A person who is able to make their own decisions can refuse a particular home, or refuse residential care. If they cannot decide, the decision falls to their legal decision maker, or in some cases a state guardianship tribunal.

NSW Health's guideline on guardianship for adult inpatients (June 2025) states that each person has the right to make their own decisions if they are able to, even when staff disagree. It says transfer to a residential aged care home can only happen if the person has been approved for that level of care and does not object. Where a patient who lacks capacity objects and there is no guardian in place, the hospital may apply to the tribunal. Guardianship laws differ between states and territories, so ask the social worker how it works where you live.

Saying no to a home is not free of consequences, though. Public hospitals can charge a daily contribution to a patient who has been in hospital continuously for more than 35 days and no longer needs acute treatment. This patient is called a nursing home type patient. Victoria's Department of Health says the contribution is set under the Health Insurance Act 1973 and is calculated at 87.5 per cent of the combined standard pension and maximum rent assistance. Canberra Health Services lists people waiting for a nursing home place as an example.

Start the financial means assessment now

If a permanent aged care home is likely, apply for the means assessment through Services Australia straight away. The Department's fee guide says to lodge it as early as possible, even before entering a home, and that results completed before entry are valid for 120 days unless circumstances change significantly. Without it, the provider can charge the maximum fees.

The form is the Residential aged care calculation of your cost of care (SA457). Services Australia says not to use it if the older person gets a relevant income support payment, such as the Age Pension, because their income details are already on file. They may need a shorter property form instead. You can lodge online through a Centrelink online account in myGov, or on paper.

If you are acting for a parent, you will need authority to deal with Services Australia on their behalf. Setting that up takes time, so start early. The assessment decides what the older person pays in daily fees, contributions and accommodation costs. Our guide to what aged care costs explains each fee and how it is worked out.

Questions to ask the hospital discharge planner

Ask the discharge planner or social worker about the options, the timeline and who pays, and write down the answers. Clear questions early in the admission give you more room to choose. These are the ones that matter most when a parent is moving from hospital to aged care or another form of care.

• Has an aged care assessment been requested, and can we be there for it?
• Is the Transition Care Program available here, and is there a place free?
• Would the Restorative Care Pathway or residential respite be an option instead?
• What is the expected discharge date, and what happens if we have not found a home by then?
• Is the hospital suggesting a particular home, and why that one?
• Will the older person be charged as a nursing home type patient, and from what date?
• Who makes the decision if our parent cannot decide, and do you need to see our documents?
• Can we have the discharge plan and any assessment outcome in writing?

When you visit aged care homes, take a separate list covering staffing, costs and care, and ask each home the same questions so you can compare.

Who to call when a parent is leaving hospital

Start with the hospital social worker. For help outside the hospital, call My Aged Care on 1800 200 422 about assessments and approvals, and the Older Persons Advocacy Network (OPAN) on 1800 700 600 for free, independent advocacy. OPAN can help the older person understand their options and speak up when they feel pressured.

For every other aged care number, from dementia support to complaints, see who to call about aged care.

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