🌟 After Hospital Support & Transition Care — Safe, Compassionate Recovery at Home

Leaving hospital is an important milestone — but it can also be a challenging and uncertain time, especially when ongoing care and support are needed. At Scout Nursing, we understand that the journey doesn’t end at discharge. The right support during this transition can make a powerful difference to recovery, wellbeing, safety, and independence.

As an NDIS registered, nurse-led provider, we deliver After Hospital Support and Transition Care tailored to the unique needs of each participant — ensuring continuity of care, clinical oversight and compassionate assistance as you move from hospital back into your home or community.

We proudly support NDIS participants with a wide range of complex and chronic conditions, including renal failure, cancer, heart disease, cystic fibrosis, dementia, end-stage liver disease, kidney failure, lung disease, Parkinson’s disease, neurological conditions and stroke.

Our goal is simple:

To make the transition home safe, supported and stress-free — for both participants and their families.

⭐ What Is Transition Care?

Transition Care provides short-term, goal-focused support for people leaving hospital, helping them recover safely while regaining independence and confidence. This support is particularly valuable for participants with ongoing clinical, functional or mobility needs.

At Scout Nursing, we ensure your transition is carefully coordinated — so you never feel “left on your own” after discharge.

🏥 Our After Hospital & Transition Care Services

Every participant receives a personalised and clinically informed care plan. Support may include:

🔍 Post-Discharge Assessment

Our healthcare professionals complete a comprehensive assessment to understand your medical, functional, emotional and environmental needs — ensuring your supports are both safe and appropriate.

📋 Individualised Care Planning

We design a tailored plan in collaboration with:

✔ you

✔ your family or carers

✔ hospital teams

✔ your healthcare providers

✔ your Support Coordinator

Every plan is focused on dignity, independence and wellbeing.

💊 Medication Support & Health Monitoring

We assist with safe:

✔ medication reminders & administration (where clinically appropriate)

✔ prescription coordination

✔ side-effect monitoring

✔ health observations & symptom changes

This helps reduce avoidable risks and hospital readmissions.

🏃 Rehabilitation & Functional Recovery

We support participants to regain strength, confidence and mobility, and work closely with allied health teams such as physiotherapists and occupational therapists where required.

🏡 Support with Daily Living

We help make daily life manageable through respectful assistance with:

✔ personal care

✔ dressing & hygiene

✔ meals & nutrition

✔ transferring & mobility

✔ continence support

✔ daily routines

So you can recover safely — in the comfort of your own home.

🤝 Healthcare Coordination & Advocacy

Our team collaborates closely with:

✔ hospitals & discharge planners

✔ GPs & specialists

✔ allied health

✔ families & guardians

to ensure your care remains connected, consistent and coordinated.

💬 Emotional & Psychosocial Support

Returning home after hospital can be overwhelming. We provide reassurance, encouragement and compassionate listening — supporting both participants and families during adjustment.

👨‍👩‍👧‍👦 Family & Caregiver Guidance

We help families feel confident by providing education, training and ongoing support — because care works best when everyone feels informed and included.

🔁 Ongoing Review & Follow-Up

Your needs may change — and we adapt with you. We provide regular reviews and continuous support, ensuring you remain safe, stable and supported throughout recovery.

💜 Why Transition Support Matters

Research shows that strong post-hospital support helps:

💜 reduce stress on participants and families💜 prevent avoidable hospital readmissions💜 improve recovery and functional outcomes💜 support independence💜 maintain safety and dignity💜 ensure continuity of clinical care

And most importantly — it supports a smoother, safer, more confident return home.

🌟 Why Choose Scout Nursing?

As a trusted, NDIS registered and nurse-led provider, we offer:

✔ highly skilled community nursing

✔ strong clinical governance & oversight

✔ person-centred & culturally respectful support

✔ experience with complex and chronic health needs

✔ collaborative communication with healthcare teams

✔ flexible, compassionate care

✔ 24/7 support availability where needed

We believe in treating every participant as a person — not just a patient or a plan number.

📍 Who We Support

We assist NDIS participants of all ages transitioning from:

🏥 hospitals🏨 rehabilitation facilities🏘 residential care🏠 into home or community living environments

including those with:

✔ complex medical needs

✔ disability-related support needs

✔ declining health

✔ chronic illness

✔ mobility or cognitive challenges

📞 Get in Touch

If you or someone you care for is preparing to leave hospital, we’re here to help make the transition safe, supported and stress-free.

📧 info@scoutnursing.com.au

📞 (03) 8740 3028

📞 0415 680 258

🌐 www.scoutnursing.com.au

Scout Nursing — Always Caring 💜

📌 Important Note

This article is intended as general information only. NDIS funding and eligibility for After Hospital Support and Transition Care depend on individual circumstances and NDIS approval. For personalised advice, please speak with your Support Coordinator, Local Area Coordinator, Planner, healthcare team, or contact Scout Nursing for guidance.