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

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

An aged care assessment can be done on the ward, and the assessor works with the hospital's discharge planners to find the best care options for when the older person leaves hospital. 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.

In hospital, the people involved usually include the treating team, which can include a social worker, and the hospital discharge team. The hospital is responsible for making sure the discharge is safe. Your job is to make sure the plan suits the older person, not just the bed situation.

People often enter aged care after an unexpected hospital visit. 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 can be several routes out of hospital, some of them 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. You can ask the hospital staff to arrange the assessment, or call My Aged Care on 1800 200 422.

The assessor uses the Integrated Assessment Tool, the same tool used in the community. They ask about health, daily tasks, memory, the support already in place 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 the 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 the right fit, residential respite is another short-term option. The Restorative Care Pathway is too, but only for people who are not receiving, or eligible to receive, transition care. 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.

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. Residential respite is one of the options OPAN lists for people leaving hospital, as an alternative to moving straight into a permanent aged care 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. You can accept a place in an aged care home that has a vacancy now, even if it is not your first choice, and move later when a home you prefer has a vacancy. It can mean leaving hospital sooner, but a second move brings its own disruption.

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 once the means assessment is finalised. Our guide to RAD or DAP explains the choice.
• Another move: each move means a new room, new staff and a new routine, so weigh this up carefully for 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 cannot move a patient into an aged care home against their will. NSW Health's guideline says transfer can only happen if the person is approved for that level of care and does not object. A person who is able to make their own decisions can refuse a particular home, or refuse residential care. If they cannot decide, their appointed decision maker decides. If no one has been appointed and it becomes necessary, a state or territory tribunal, board or court can appoint a guardian to decide for them.

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.

Staying in hospital while waiting for aged care can cost money, 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 the older person has a correspondence nominee with Services Australia, that person can apply for them. The assessment works out the contributions the older person pays and whether they get help with accommodation costs. What they pay also depends on what they agree with the provider. 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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