Community Nursing Care
Registered and enrolled nurses delivering clinical care in your own home, on a schedule that fits your life.
Specialist clinical care
Hospital Discharge & Transition Home
Discharge delays are rarely clinical. They happen because supports at home are not ready. We work directly with hospital discharge planners, social workers and allied health teams to get supports in place quickly — including complex care — so participants go home on the day they are medically ready, with a clinical handover that does not drop anything.
How it's funded
Delivered through Core Supports, and Capacity Building where nursing assessment or coordination is required. We can begin with interim supports while a plan review or change of circumstances is being processed.
What's included
What hospital discharge covers
- Rapid response to discharge referrals, including short-notice requests
- Attendance at discharge planning meetings, in person or online
- Clinical handover from the hospital team to our nursing staff
- Nursing care plan written before discharge, not after
- Worker training completed ahead of discharge where complex care is involved
- Interim supports while a plan review or change of circumstances is processed
- Home set-up coordination, including equipment and consumables
- Personal care, nursing and community supports from day one at home
- Close monitoring through the first weeks home, when readmission risk is highest
Who this is for
- Hospital discharge planners and social workers arranging supports for an NDIS participant
- Participants whose support needs have changed during a hospital admission
- Support coordinators managing a hospital-to-home transition
- Families bringing a relative home with new clinical needs
How we work
Our clinical process
No mystery, no drawn-out intake. You know what happens at each stage and who is responsible for it.
- 1
Referral and same-week response
Send us the referral and we respond quickly, with a clear yes or no on capacity — not a maybe that wastes a week of a discharge plan.
- 2
Assessment in hospital
Our nurse attends the ward or discharge meeting to take clinical handover directly and assess what home will require.
- 3
Ready before discharge
Care plan written, workers trained and rostered, equipment and consumables confirmed — all before the discharge date, not after it.
- 4
The first weeks home
We monitor closely through the highest-risk period, escalate early to the treating team, and adjust supports as recovery progresses.
Safeguards
How we keep this safe
Clinical supports carry real risk. These are the controls that sit behind the care, and we are happy to walk any of them through with you or your support coordinator.
- Clinical handover is documented, not verbal-only
- A registered nurse reviews every discharge referral involving clinical or high intensity care
- Where complex care is involved, worker competency is signed off before the participant comes home
Related supports
Often needed alongside this
High Intensity & Complex Care
High intensity daily personal activities delivered by trained, nurse-supervised workers — the supports many providers decline.
Assistance with Life Stage, Transition & Supports
Help navigating the NDIS and the big transitions, so decisions get made with information rather than pressure.
Hospital discharge
Need hospital discharge in Melbourne?
Send a referral or call us and we will tell you honestly whether we can help and how quickly. We respond within one business day.
Or email admin@expert2care.org
Expertise, led with kindness