Mum's going home after a fall: Your first week action plan

The hospital says your mum can go home. That should feel like good news.

So why does it feel terrifying?

Because home is where she fell. Because you're not sure it's safe enough. Because someone mentioned "support services" and "equipment" and you have no idea where to start. Because discharge might be tomorrow and the house isn't ready.

Here's what matters: she doesn't need a perfect setup. She needs a safe-enough setup for this week. The rest you can figure out as you go.

Let's get you through the next seven days.

This is for you if:

• The hospital is discharging her home (maybe in a few days, maybe sooner than you'd like)

• She was living independently before the fall

• The plan is for her to return to her own home (or back to living with a partner)

• You're trying to figure out what needs to change to make home safe

• Someone's mentioned ACAT assessments, home care packages, equipment

• You're worried about her falling again

• You don't know what support services exist or how to access them quickly

• You're managing this from another city and can't be there to check everything yourself

• The occupational therapist said things you didn't quite understand

• You need to know what to do this week - not a comprehensive six-month plan

 

This isn't a guide to long-term aged care planning. This is about the next seven days.

We'll cover:

• Understanding the discharge timeline (and what "medically cleared" actually means)

• Making home safe enough for this week (not perfect, just safe enough)

• Equipment you might need fast (and how to get it)

• Setting up support services quickly (what can start this week vs what takes months)

• Preventing the next fall (practical changes that actually work)

• What the ACAT assessment means and why you should ask for it

• Who can help right now (and what to ask them)

What we won't cover:
Long-term residential care decisions, selling the house, major home renovations. If you're thinking those things might be necessary, you might be in Scenario B or Scenario C instead.

 

When is "discharge"?

The hospital will give you a discharge date. Sometimes it's several days away. Sometimes it's "tomorrow." Sometimes it's "today if you can arrange transport."

Key questions to ask the discharge planner:

• What's the earliest discharge date?

• What needs to happen before she can leave? (Tests? Physio assessment? Equipment arranged?)

• Can discharge be delayed if we need more time to prepare the house?

• What support will be in place before she goes home?

• Who is arranging that support—us or the hospital?

What "medically cleared" actually means

"Medically cleared for discharge" means the hospital has treated her acute injury and she doesn't need hospital-level medical care.

It does NOT mean:

• She's back to how she was before the fall

• She can safely manage everything at home alone

• The house is safe for her new mobility level

• All support services are organized

The gap between "medically cleared" and "actually ready for home" is where families struggle. This is normal. You're not being difficult if you're concerned.

The 48-hour reality check

If transition care is delivered at home, you have 48 hours from discharge to receive care. But for regular home support, services often can't start for days or weeks.

This means: The first 48-72 hours after discharge are often the hardest. 
Plan for someone to be there or check in frequently during this time.

 

You don't need to renovate. You need to remove immediate fall risks and set up what she needs to move around safely right now.

The essential safety check (do this before Mum comes home)

Walk the path she'll take most often: Front door → bedroom → bathroom → kitchen.

Remove from this path:

• ✓ Loose rugs or mats (roll them up, don't just tuck edges)

• ✓ Electrical cords across walkways

• ✓ Clutter, boxes, shoes

• ✓ Furniture jutting into pathways

• ✓ Anything she might trip over in the dark

Add to this path:

• ✓ Night lights (hallway, bathroom, bedroom)

• ✓ Clear lighting for stairs

• ✓ Non-slip mats in bathroom (only if they're properly secured)

The bathroom (highest risk room)

Immediate changes:

• Can she get in and out of the shower safely? If not, she might need to use a washcloth at the sink for a few days while you arrange equipment.

• Put non-slip mat INSIDE the shower/bath (check it's secured)

• Move toiletries within easy reach (no stretching or bending)

• Clear the floor completely - no bath mats that can slip

Equipment that helps:

• Shower chair or stool (she can sit while showering)

• Grab rails beside toilet and in shower

• Raised toilet seat if she has trouble getting up

Don't buy anything yet until the occupational therapist (OT) assesses. But if discharge is immediate and you can't wait, a basic shower stool is a safe bet.

The bedroom

Immediate changes:

• ✓ Can she get in and out of bed safely?

• ✓ Is the bed too high or too low? (Feet should touch floor when sitting)

• ✓ Is her phone charger within reach?

• ✓ Is there a clear path to the bathroom at night?

• ✓ Is there lighting she can turn on without getting up?

Quick wins:

• Move the bed away from the wall if she needs to get out both sides

• Put a sturdy chair beside the bed she can hold while standing up

• Clear everything off the floor (no shoes, clothes, clutter)

Stairs: the biggest decision

If she lives in a two-storey house:

Option 1: Set up downstairs temporarily

• Move bedroom downstairs (couch, spare room, dining room)

• This is temporary until she's steadier on her feet

• It's not forever, it's for this week

Option 2: Make stairs safer (if she must use them)

• Handrails on BOTH sides if possible

• Good lighting at top and bottom

• Clear stairs completely (no items stored on steps)

• She should never carry anything heavy up/down stairs

• Consider a basket at top and bottom to move items

Reality check:
If stairs feel unsafe, don't force it. Downstairs living for a few weeks is better than another fall.

What if you can't check the house yourself?

If you're managing from another city, deputise someone local:

• A neighbour she trusts

• A friend who has a key

• A sibling who lives closer

• A paid home organizer if necessary

Give them this checklist:

• Take photos of each room so you can see what they're seeing

• Walk the main path and remove trip hazards

• Set up night lights

• Check bathroom safety

• Make sure basics are stocked (food, toilet paper, medications)

 

 

What the OT (occupational therapist) does

The hospital should arrange an OT assessment before discharge or shortly after. The OT will:

• Visit the home (or assess in hospital)

• Recommend specific equipment for her needs

• Sometimes arrange equipment through the hospital

• Show her how to use equipment safely

If the OT hasn't contacted you yet, ask the discharge planner to arrange this.

Common equipment after falls

Mobility aids:

• Walking frame (most common): Four-legged frame she pushes in front of her. More stable than a walking stick.

• Walking stick: Only if she's steady enough. Must be the right height.

• Wheelchair: Sometimes needed temporarily for longer distances.

The hospital might provide these or tell you where to get them. Don't guess which one she needs—wait for the OT recommendation.

Bathroom equipment:

• Shower chair: She sits while showering (reduces fall risk)

• Over-toilet frame: Rails either side of toilet to help sit/stand

• Raised toilet seat: Makes it easier to stand up

• Grab rails: Permanently installed in shower/beside toilet

Other useful items:

• Bed rail: Helps her pull up to sitting

• Reacher/grabber: Pick things up without bending

• Non-slip socks: Better than bare feet or slippery socks

• Personal alarm pendant: Can call for help if she falls

Where to get equipment quickly

Free or subsidised (but slower):

• Through hospital OT

• Through My Aged Care services (once approved)

• Red Cross equipment loan

• Community health centers

Fast but costs money:

• Pharmacy (basic items like walking frames, shower stools)

• Mobility equipment stores

• Online delivery 

Budget roughly:

• Walking frame: $50-150

• Shower chair: $40-100

• Over-toilet frame: $60-150

• Grab rails: $30-80 (plus installation)

What to prioritise:
Mobility aid first (walking frame), then bathroom safety (shower chair, grab rails), then everything else.

This is where it gets complicated. Some support can start quickly. Some takes months. Here's what you need to know.

The Aged Care Assessment: Start this nOW

The Aged Care Assessment determines eligibility for government-funded aged care services.

Why you need it:

• Opens access to subsidised home care

• Required for most aged care services

• Can be fast-tracked through hospital

• Takes weeks to organise if you wait until your Mum is home

How to get it:

• Ask the hospital discharge planner to arrange it while she's still in hospital

• Or call My Aged Care: 1800 200 422 and say "My mother is being discharged from hospital after a fall and needs a comprehensive assessment urgently"

What the assessment covers:

• Her ability to manage daily tasks

• What support she needs

• Eligibility for home care packages, respite, residential care

Timeline:
Hospital can fast-track. Community assessments can take 2-6 weeks.

The assessment doesn't commit her to anything. It just opens doors to services.

What Can Start This Week

Immediate support (possibly within days):

1. Transition Care Programme (TCP)
If she's being discharged from hospital, she might be eligible for transition care:

• Up to 12 weeks (84 days) of subsidised care, can be extended up to 6 weeks with another assessment

• Can be at home or in residential setting

• Includes therapy (physio, OT), nursing, personal care

• Hospital arranges this - ask the discharge planner

2. Hospital outreach programs

• Some hospitals provide 1-2 weeks of follow-up support after discharge

• Nurses visiting home to check wounds, medications

• Not available everywhere - ask what your hospital offers

3. Private services (you pay)

• Cleaners can start this week

• Meal delivery services (Meals on Wheels, private providers)

• Private home care workers (if you can afford it)

• Uber/taxi for appointments

What Takes Longer (Weeks to Months)

Commonwealth Home Support Program (CHSP), or the new Support at Home Program:

• Low-level home support (cleaning, shopping, personal care)

• Usually 1-4 weeks wait after assessment

• Limited hours per week

Home Care Package:

• More comprehensive support

• Packages don't expire once approved, but wait times vary

• Can take months to be assigned a package after approval

• You're put on a national queue

Support at Home (new program):

• Gradually replacing Home Care Packages

• Ask My Aged Care for current information

Making a Plan for the Gap

The reality: Your Mum is coming home Thursday. Services won't start for 2-4 weeks. What do you do?

Bridge options:

1. Family roster: Who can visit daily for the first two weeks?

2. Pay for private help: Can you afford a cleaner once a week and meal delivery?

3. Neighbours: Can someone pop in daily to check she's okay?

4. Technology: Video calls twice daily?

5. Delay discharge: If it's genuinely unsafe, tell the hospital you need more time

 

 

In Australia, one in three people aged 65 and over fall at least once a year.After one fall, the risk of falling again increases.

Why do older people fall?

Common causes:

• Balance/mobility issues: Weakness, unsteady gait

• Medications: Some cause dizziness, low blood pressure

• Vision problems: Can't see obstacles clearly

• Home hazards: Loose rugs, poor lighting, clutter

• Medical conditions: Arthritis, dementia, Parkinson's

• Rushing: Hurrying to the toilet, moving too fast

Often it's a combination of several factors.

What You Can Do This Week

1. Medication review

• Ask the GP to review ALL her medications

• Some medications increase fall risk (blood pressure meds, sleeping pills, pain meds)

• GP might adjust doses or timing

2. Vision check

• When did she last have her eyes tested?

• Are her glasses the right prescription?

• Book an optometrist appointment this week if overdue

3. Footwear check

• Proper enclosed shoes with non-slip soles (not slippers)

• No loose-fitting shoes

• No walking in socks or bare feet

• Shoes should be easy to put on (slip-ons or velcro if bending is hard)

4. Strength and balance

• Ask if physiotherapy has been arranged

• Even simple exercises help (GP or physio can recommend)

5. Slow down

• This sounds simple but it matters

• No rushing to answer the phone or get to the toilet

• It's okay to let the phone ring

• Use the walking frame even for short distances

Warning Signs to Watch For

Call the GP or hospital if:

• She's dizzy or lightheaded when standing up

• She's more unsteady than before the fall

• She's afraid to move around (this increases fall risk)

• She's in more pain than expected

• She seems confused or not herself

Call 000 if:

• She falls again and can't get up

• She hits her head

• She's in severe pain

• She loses consciousness

 

Hospital discharge planner or social worker

What they do:
Coordinate discharge, connect you to services, arrange equipment and assessments.

When to contact:
Before discharge, while she's still in hospital.

What to ask:

• "Can you arrange a comprehensive aged care assessment while she's still here?"

• "What support can be in place before she goes home?"

• "Who arranges equipment - do we buy it or do you provide it?"

• "Is she eligible for transition care?"

• "What's the process if we feel home isn't safe enough yet?"

Occupational therapist (OT)

What they do:
Assess home safety, recommend equipment, sometimes provide equipment, show how to use it safely.

When to contact:
Hospital should arrange. If they haven't, ask discharge planner.

What to ask:

• "Can you do a home visit before discharge?"

• "What equipment do you recommend specifically for her?"

• "Where do we get this equipment?"

• "How do we make sure she's using it correctly?"

• "What are the biggest fall risks in her home?"

General practitioner (GP)

What they do:
Ongoing medical care, medication management, referrals for allied health.

When to contact:
Book appointment for within one week of coming home.

What to ask:

• "Can you review her medications - anything that might increase fall risk?"

• "She needs physiotherapy - can you refer her?"

• "When should I be concerned and bring her back?"

• "Can you arrange ongoing wound care if needed?"

My Aged Care (1800 200 422)

What they do:
Government gateway to aged care services and assessments.

When to contact:
This week, while she's in hospital or as soon as she's home.

What to say:
"My mother has just been discharged from hospital after a fall. We need to arrange a comprehensive assessment and look at home support options urgently."

What they'll do:

• Start the assessment process

• Explain what services she might be eligible for

• Connect you with local assessment team

Have ready:

• Her Medicare number

• Brief description of her needs

Physiotherapist

What they do:
Work on strength, balance, mobility - key for preventing future falls.

How to get one:

• Hospital might arrange

• GP referral

• Private physio (you pay)

Why it matters:
Regular physical activity can improve strength, balance, and coordination—activities like tai chi or gentle yoga under proper guidance can be particularly beneficial.

Family and friends (specific asks)

Do ask: "Can you [specific task] on [specific day]?"

Specific tasks to delegate:

• Visit her house and do the safety check (use the checklist above)

• Install grab rails in bathroom

• Set up night lights

• Stock her fridge before she comes home

• Drive her to GP appointment next week

• Visit daily for first week to check she's okay

• Water her plants

• Collect prescriptions from pharmacy

• Bring her dinner twice a week

• Call her every morning to check in

 

 

By the end of this week, you should have:

✓ Discharge date confirmed (or she's already home)

✓ Home safety check done (main pathway clear, bathroom safer, lighting improved)

✓ Essential equipment arranged (walking frame, shower chair at minimum)

✓ Comprehensive aged care assessment started 

✓ GP appointment booked (for medication review and ongoing care)

✓ Support plan for first 2 weeks (who's checking in, what services are starting)

✓ Family communication system (who knows what, how you're updating everyone)

 

But you don't need to solve those things this week.

This week, you need to:

1. Get her home safely

2. Remove immediate fall risks

3. Arrange essential equipment

4. Start the assessment process

5. Set up short-term support

That's it. That's enough.

 

You've done the safety check. You've talked to the discharge planner. And you're still not sure home is safe.

Trust your gut.

You can:

• Ask for the discharge to be delayed while you arrange more support

• Request transition care, or respite care in a residential setting temporarily (gives you time to set up home properly)

• Ask for a frank conversation with the medical team: "I'm concerned home isn't safe. What are our options?"

If you're thinking "I don't think she can live at home anymore," you might be in Scenario C instead of Scenario A. That's okay. Plans change as you learn more.

It's better to pause and get it right than to rush home and have another crisis in two weeks.

What You Need to Remember

Your mum's coming home after a fall. The house that was fine last month might not be safe enough now.

This is what matters:

You don't need to make her house perfect. You need to make it safe enough for this week.

You don't need to understand the entire aged care system. You need to start the Aged Care Assessment and arrange immediate equipment.

You don't need to solve the next six months. You need to get through the first two weeks.

And for what it's worth - you're here. You're reading this. You're trying to get it right.

That counts for a lot.

Next Steps

If you need to understand the aged care system better:
→ Read: Support at Home: What Does That Actually Mean? 

→ Read: CHSP, HCP, NDIS, DVA: Decoding the Alphabet Soup 

If you're managing this from another city:
→ Read: When You Can't Be There in Person 

If family communication is getting messy:
→ Read: The Siblings Who Disappeared All Year Suddenly Have Opinions (existing)

If you're wondering if home is actually viable long-term:
→ Read: She Can't Go Home Yet: Understanding Your Bridge Options (Scenario B article)

If you're already burnt out:
→ Read: You're Not Just Tired. This Is What Burnout Actually Feels Like. (existing)