Residential In Reach Post Hospital Support

The service focuses on supporting older adults with dementia or recent delirium, helping to reduce the chance of readmission and making sure they receive the right care in the right place.

What we offer

As part of this service, we provide:

• Collaborative discharge planning with patients, families, carers and the aged care home
• A personalised support plan tailored to the patient’s medical, cognitive and functional needs
• Two to four weeks of follow-up after discharge, with regular contact through:  up after discharge, with regular contact through in-person visits, phone check-ins and Telehealth appointments
• Access to geriatrician review if clinically required
• A final safety net appointment and a summary sent to the resident’s GP and aged care home net appointment and a summary sent to the resident’s GP and aged care home

Our team works closely with aged care staff and families to help residents settle safely back into familiar surroundings with the right support in place.

Who can use our service

Our Post Hospital Support service is designed for older adults, aged 65 and over (or 50 and over for First Nations people) who:

• are moving from a hospital stay into a new Residential Aged Care Home
• have dementia or delirium and are at risk or readmission
• are likely to experience a challenging transition

Referrals

Referrals can only be accepted from a person's treating team at the RMH.