Complex Hospital Discharge Program in Adelaide

Our Hospital Discharge Program assists Adelaide’s Hospitals in the prompt and successful discharge of vulnerable clients into the community.

Guaranteeing a smooth transition from hospital to home.

At Scarlet Homecare we provide comprehensive support during each stage of the hospital discharge process to ensure our clients experience a seamless transition from hospital care to recuperation in their own homes or other healthcare facilities. Overall, hospital discharge programs aim to enhance patient outcomes, reduce the risk of readmissions, and improve the overall quality of care during the transition from hospital to home or another care setting.

Nurse and patient in a wheel chair looking into the distance on the side of a road.

What is complex hospital discharge planning?

Complex hospital discharge planning provides patients with a safe and measured transition out of hospital. This type of assistance facilitates the recovery process of patients who require ongoing care and is vital to ensure continued support after leaving hospital. At Scarlet Homecare, our highly experienced team of nurses have a strong background in acute care, plus community and mental health nursing.

For a client to be successfully discharged from the hospital, they need to have a housing to go to and, where necessary, they need to have community services in place. In the event where these two conditions are not met, clients are unable to be successfully discharged resulting in suboptimal usage of an acute care hospital bed, increased risk of hospital acquired infection to the client and furthermore, prolonged time in the hospital distances the client, both emotionally and mentally, from the community environment, making it harder for their discharge into the community.

How does the Hospital Discharge Program work?

At Scarlet Homecare, we believe there are 3 key facts to successful client discharge: Housing, Services in the community, and, Transition into home or long-term accommodation. These facets can be divided into 2 phases:

  • Phase 1: Organising housing and community services for prompt discharge into the community.
  • Phase 2: Identifying permanent housing and service solutions and assisting in this transition.


A lack of suitable housing in the community can delay a client’s discharge which can take up a acute care bed and can cost the hospital thousands of dollars. Scarlet Homecare, has an inventory of housing scattered across Adelaide, including Prospect, Vale Park, Campbelltown, Elizabeth and Munno Para, that have been designed/modified to accommodate clients with varying care needs hospital discharge.

Services in the community

In addition to housing, clients often require wide range of services in the community. This service can vary in complexity, from driving a client to their appointments to monitoring and managing a client’s wounds. Without the appropriate and well- coordinated services in the community, the client may at risk of clinical deterioration. By taking a holistic approach, we tailor each service to suit the client’s current needs.

Transition into home or long-term accommodation:

Housing and services in the community are the two key facets of successfully hospital discharge. However, in the event where the client does not get discharged to their home or a long-term accommodation, then a practical plan is required to ensure smooth transition to this accommodation. For some client, this may entail modifying their home prior to transition, whereas for others, it may entail sourcing a Specialist Disability Accommodation that has been designed to fit the client’s significant physical needs. Scarlet Homecare understands the importance of smooth transition. We work closely with the clients’ Support Coordinators, Family/Guardian and Healthcare team to establish a transition plan and where necessary, work with other NDIS and Aged Care Providers to assist in this transition.

What it’s like to work with our compassionate registered nurses.

Scarlet Homecare have been invaluable to my participants. They have provided excellent care, they are professional, caring, thorough and very knowledgeable. I highly recommend Scarlet Homecare for all your NDIS and nursing needs.

Carmen Sharkey

As an NDIS Support Coordinator, I have engaged the services of Sobhan and Scarlet Come Care for almost a year now. The service is reliable and professional. I can not say enough about the quality of their nursing and personal care staff.

Johanna Bradley

Need assistance with complex 
hospital discharge?

Our experienced team is here to help make your loved one’s transition from hospital to home or long-term accommodation as smooth as possible.

Why settle for less?
98% of our clients partner with us for life.

Providing your loved ones with the safest and highest quality complex hospital discharge planning is our top priority. Our team of kind, respectful and experienced nurses are here to ensure that your loved one is cared for properly, helping them to recover at the pace right for their needs. As a team, we truly care about our patients. Everything we do is to ensure their recovery process and help improve their lives after their stay in hospital. We take the feedback of our patients and their carers very seriously, and regularly review and adapt to client feedback. All Scarlet Homecare processes are continually developing to provide the best support for our patients.


Care Specialists

Your well-being should always come first. To us, that means having a team of trained experts ready to ensure your needs are always being met.



You deserve a dedicated support team so you can build lasting relationships that provide the support you need to live with confidence and with dignity.



You should never feel alone. With Scarlet Homecare, you will have 24/7 support from our experienced staff.

No Hidden


We practice transparent pricing and only charge for booked services- never for mileage or extra communications.

Holistic Risk


Our proactive approach to risk assessment means that we address the safety and well-being by seeing the whole person, not just the job at hand.



Your loved ones are part of the team. Scarlet Homecare will make communication easy, and ensure that everyone is always up-to-date with important information.

A woman supporting an elderly man with independent living

Complex hospital discharge planning provided by qualified medical experts.

Each member of our nursing staff is well-equipped to provide patients with more specialised, complex care once they are discharged from hospital, thereby safely managing complex patients in the community. We have the medical and psychosocial knowledge and experience required to properly care for your loved one during their time of need. Scarlet Homecare is registered under NDIS to implement positive behaviour support plans, including restrictive practices for any participant with psychosocial complications. With an extensive team of nurses and support staff on hand, we will organise support for your loved one in the community within a week of being notified. At Scarlet Homecare, we are committed to providing the highest quality complex hospital discharge planning to the people in our care.

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Young lady in a wheel chair.

We specialise in safely managing patients.

When patients are in hospital, they are receiving care on acute care beds. By discharging a patient once they are well enough to receive care in the community or at home, hospitals help to minimise the cost per patient, thereby providing care in a more economical way.

However, it can often be difficult to plan the discharge of patients, as people are in hospital for a number of reasons. People with medical comorbidities and/or psychosocial complications can have different challenges when they are discharged from hospital. Patients in this situation require a variety of services in place to be discharged, this is known as complex hospital discharge planning.

Experience exceptional care with dedicated service coordinators.

When providing complex hospital discharge planning, we allocate a dedicated service coordinator to each person in our care. The service coordinator oversees the patient’s care, including coordinating their services, liaising with other health care providers and advocating for the patient’s requirements.

As a part of our thorough care process, we ensure that each of our patients undergo a comprehensive care assessment, ensuring they receive a service tailored to their needs. At Scarlet Homecare, our team is trained in accordance with industry standards and uses the most up-to-date processes to provide support.

Scarlet Homecare team

Our role in the hospital
discharge process.

Once a client is ready for discharge, Scarlet Homecare’s Service Coordinator starts the first phase of the client’s successful discharge by reviewing the client’s medial discharge summary, nursing discharge summary and allied health report, with the client’s consent.

Our Service Coordinator then speaks with the client, their family/guardian and their healthcare team to identify the barriers to discharge and the long-term goals. Based on the client’s health profile and care needs, the Service Coordinator presents suitable housing and care options to the client and their family/guardian, for them to make an informed decision.

Once the client decides, Scarlet Homecare organises the necessary services in the community and prepares for the client’s discharge to the chosen accommodation.

During Phase 1 of hospital discharge, our Service Coordinator will be working closely with the client and their family/guardian, to ensure that this phase is completed within 1-2 weeks, if not sooner, depending on the complexity of the case.

Following the client’s successful discharge into the community, the Service Coordinator starts the second phase of the client’s successful discharge, which is to find a permanent housing and care solution for the client. This phase would involve liaising the client, their family/guardian, their Support Coordinator and necessary their healthcare team to organise these housing and community services.

A map highlighting the area Scarlet Homecare covers. The map highlights all of Adelaide suburbia from Noarlunga up to Elizabeth.
Kathryn Clifford - Clinical Nurse Coordinator

We provide NDIS services in
Adelaide and surrounding suburbs.

We provide NDIS services in Adelaide and surrounding suburbs.