Hospital to Aged Care in NSW: A Discharge Plan

Hospital teams plan for a patient to leave as soon as that person is medically ready. That is good news for your parent's recovery, but it can leave a family feeling rushed. Many families meet this moment after a fall, an infection or a stroke, with no assessment done and no home chosen.

The calendar adds pressure in November and December. Some offices run reduced hours between Christmas and the first week of January, so forms, calls and approvals can take longer. If you begin in the second week of November, you have about five weeks of normal business days before the holidays. Our guide for finding a Sydney aged care home before Christmas covers the wider holiday timing.

The first rule is that you are allowed to ask questions and ask for time. You can ask the social worker which options are available, who decides on discharge timing and what happens if a bed is not ready. Write the answers down, because several people will give you information over a few days. Ask for a named contact on the ward, plus a direct phone number, so you do not have to explain the whole story each time you call.

Every government-funded aged care service starts with an assessment arranged through My Aged Care. According to My Aged Care, you can ask hospital staff to arrange the assessment, or you can call 1800 200 422 before discharge. The line is open Monday to Friday 8am to 8pm and Saturday 10am to 2pm.

The assessor decides which services your parent is eligible for. The outcome might be an aged care home, residential respite, transition care or support at home, and sometimes more than one. Our ACAT assessment guide explains what the assessor asks and how to prepare.

After the assessment, you will receive an outcome letter, sometimes called a Notice of Decision, with a support plan and referral codes. Keep that code handy. A provider needs it to see your parent's record and accept a referral.

Transition care is short-term recovery support after a hospital stay. The Department of Health, Disability and Ageing says it includes social work, nursing support, personal care and allied health, and it can run for up to 12 weeks in an aged care home, at home or both. To qualify, your parent must be a hospital patient, be ready for discharge and be likely to benefit from a short period of restorative care.

The timing rules are strict. Care must start within 24 hours of discharge if it is in an aged care home, or within 48 hours at home. You can ask once for an extension of up to 42 days, and you must ask within the first 12 weeks.

This matters for families who are not ready to choose a permanent home. Transition care can give your parent time to get stronger, and give you time to compare homes, check fees and decide whether going home with support is realistic. It is not a free pass to stay indefinitely, so ask the hospital team early whether your parent might be eligible.

Residential respite is a short stay in an aged care home. My Aged Care says it can give your parent a room, meals and care, and it gives the family a chance to see how a home feels from the inside. Subsidised respite is available for up to 63 days in a financial year, and it can be extended by 21 days at a time with approval from the assessor.

Respite is not the same as a permanent place. Your parent needs an assessment for it, though in an emergency a provider may be able to arrange an urgent assessment. Approval also does not guarantee a bed, so ring each home to confirm availability for your dates. Our guide on respite versus permanent care sets out the differences in cost and rights.

If the main carer has collapsed under the strain, call Carer Gateway on 1800 422 737 for emergency respite. It is a federal service for carers, and the call can start support quickly. Many Sydney families use a respite stay over Christmas as the first step before a permanent decision.

Your parent's approval lets them choose from any home with a vacancy. You do not need to accept the first bed offered, although a short stay may make sense while you look. The My Aged Care Find a provider tool lets you save up to 16 homes to a shortlist and compare three side by side.

Start with location. A home within 20 minutes of the person who visits most will matter more than a nicer foyer an hour away. On our February 2026 extract of government data there are 445 residential aged care homes across Greater Sydney. You can compare aged care homes in Sydney by suburb and rating, or look at aged care homes in Western Sydney if your family lives out near Blacktown or Parramatta.

Then check quality. The government's Star Ratings give each home an overall score from one to five, plus four sub-categories: Residents' Experience, Compliance, Staffing and Quality Measures. The latest service-level data on the department's site is dated October 2026. Our Star Ratings explained guide shows how to read the breakdown.

A bed offer can arrive with very little warning, often by phone and with a short deadline. Keep a list by the phone so you do not forget the basics. The right home will answer clearly and will not rush you into signing.

Bring our aged care checklist to a visit if you can. Walk the corridors, look at the bedrooms and see how staff speak to residents. If a home is vague about fees or staffing, treat that as information.

Costs worry families more than anything else. My Aged Care says the means assessment takes time, so the sooner you start, the better. For most people it is done by Services Australia, which then sends a fee advice letter explaining what your parent can be asked to pay.

Under the fee arrangements that apply from 1 November 2025, residents may pay a basic daily fee, a hotelling contribution, a non-clinical care contribution and an accommodation cost. My Aged Care lists the maximum basic daily fee at $68.93 a day under current rates. Everyone pays the basic daily fee, including on days spent in hospital after entering care. Our guide on aged care costs in Australia breaks down each charge, and the new Aged Care Act article explains what changed.

A home cannot ask for a higher everyday living fee before your parent enters care, and it cannot make that fee a condition of entry. The accommodation payment can be a refundable deposit, daily payments or a mix. Read our refundable accommodation deposit guide before you sign anything, and consider free advice from Services Australia's Financial Information Service on 132 300.

You do not have to do this alone. The hospital social worker can explain discharge options, and My Aged Care can walk you through the assessment and referral steps. If you feel pressured or confused, the Older Persons Advocacy Network offers free, independent advocacy on 1800 700 600.

If you are worried about a loved one's safety, the national helpline 1800 ELDERHelp is on 1800 353 374. It is not an emergency service, so call 000 if someone is in immediate danger. Keep a notebook with names, dates and phone numbers from every conversation.

Also check legal paperwork early. Ask whether your parent has an enduring power of attorney or enduring guardianship in place. Without those, decisions about money and care can take longer to arrange, particularly if your parent has memory problems.

You do not need to solve everything in a day. A simple schedule keeps the work in order, and each step builds on the one before. Here is a plan you can print and stick on the fridge.

The most useful thing you can do today is ask the hospital for the assessment and write down the answer. Then pick the Sydney region closest to the person who will visit most, and open our aged care comparison tool to see homes side by side. One call at a time is enough.

When you have a shortlist, use Nursing Home Match to compare official Star Ratings, request a tour and ask for pricing straight from each home's page. A calm, step-by-step start this month can mean a far gentler January for your whole family.