Differentials and investigations

Discharge Planning

Overview and approach

Discharge planning starts early: confirm the patient is medically stable, identify complex needs, agree the plan with the patient and (with consent) family, and arrange follow-up before they leave (1).

  • Introduction and consent: "Before I explain your mother/father/partner's current treatment, can I clarify that I have your mother/father/partner's consent to discuss this with you?" Explain the patient is medically stable and does not need to stay unnecessarily in hospital.
  • Safe transition depends on a verified medication list and clear communication to the GP and My Health Record (2)(3).
Assessment and clinical features

Explore ideas, concerns and expectations of the patient and family.

  • Moving back with the family, or living alone? Why?
  • Are the family happy to have the patient home? Will it affect their social life or finances?
  • Acknowledge distress: "I can see that the decision to discharge your has upset you, and you have spoken about the stress you have at home due to _. Please can I ask further about these stressors, so I can help you?"
Differentials and investigations

Checklist (HOPS PPC) to find what could make discharge unsafe.

  • H Home situation: involve relatives and supports; can they cope by themselves? Organise a home assessment, with OT for home equipment (5).
  • O ADLs: cleared by physiotherapy?
  • P Community services: cleared by the social worker?
  • S Medications: checked by pharmacist (regular, added and ceased; PRN analgesic and antiemetic) (2)(3).
  • P Management plan: how the condition is managed.
  • P Preventative issues: smoking, alcohol, diet.
  • C CRISF.
Management and follow-up

Hand over to the community team and give the patient a clear plan.

  • Send a complete medication list explaining changes to the GP promptly and upload to My Health Record; the GP reviews and reconciles medicines after discharge (2)(3)(4).
  • Communicate any in-hospital falls or fall risks and medication changes in the discharge summary; arrange an occupational therapist home safety intervention for older people at increased risk (5).
  • If relatives are not happy: "***, thank you for meeting with me today. I understand the situation is very frustrating, and you do not feel happy that your ***_ is being discharged. Would it be possible to arrange a meeting with myself, the senior doctor, and maybe some other team members (OT and social worker)."
Red flags and clinical pearls

Do not discharge when the home plan, medicines or follow-up are unresolved.

  • Check capacity and consent before sharing information with family.
  • Escalate disagreement to the senior doctor early and document the meeting.
  • Poor medication transitions are a common cause of readmission (3)(4).
References
  1. ACSQHC: Comprehensive Care Standard, Action 5.04
  2. Australian Government Department of Health: Guiding principles to achieve continuity in medication management
  3. Australian Prescriber: Achieving safe medication management during transitions of care from hospital
  4. ACSQHC: Medication Management at Transitions of Care Stewardship Framework
  5. ACSQHC: Preventing falls and harm from falls in older people, hospitals (2025)

Last updated from Sen’s notes on 9 October 2026.