Mum can't go home yet: Understanding your bridge options.

The hospital was supposed to discharge her home. That was the plan.

Now the discharge planner is saying she's "not quite ready" for home. She needs rehab first. Or respite. Or "transition care." Or maybe a few weeks in "residential" to get stronger.

You're nodding as if you understand, but you don't really. What's the difference between these options? How long do they take? Is this temporary or permanent? And the question you're afraid to ask: is this the beginning of her never coming home at all?

Here's what matters: these are bridge options, not final destinations. They buy you time—time for her to get stronger, time to make the house safer, time to figure out what happens next.

Let's understand what you're actually deciding.

This is for you if:

• The hospital says she can't be discharged directly home

• Someone's mentioned "transition care," "rehab," or "respite"

• You don't understand the difference between these options

• She needs more recovery time before home is safe

• You're being asked to make decisions, but don't have enough information

• You're worried this "temporary" placement will become permanent

• You need time to think, but the hospital needs an answer

 

Option 1: Transition Care Programme (TCP)

What it is: Short-term care that helps improve your Mum's health after a stay in hospital. It can be provided at home or in a residential setting for up to 12 weeks (84 days)with a possible extension of up to 6 weeks.

Where it happens:

• In an aged care facility (residential TCP), OR

• At her home with services coming to her (home-based TCP)

What's included:

• Physiotherapy, occupational therapy, speech pathology

• Nursing care (wound care, medication management)

• Personal care (bathing, dressing, eating)

Who arranges it:
The hospital. Hospital discharge staff will liaise with a transition care provider

The goal:
Intensive therapy to maximise your Mum's chances of returning home safely.

Option 2: Residential Respite Care

What it is:
Temporary stay in an aged care facility while you figure out the long-term plan.

Where it happens:
In an aged care facility (nursing home)

What's included:

• 24/7 care and supervision

• Meals, laundry, activities

• Personal care assistance

• Basic nursing care

How long:
Up to 63 days of subsidised care per financial year  - can be extended by up to 21 days at a time.

Who arranges it:
Usually requires assessment first, but emergency admissions can occur.  Hospital discharge staff will liaise with a transition care provider

The goal:
Provide safe care while:

• Mum's home is being modified

• Family arranges longer-term support

• You assess whether the home is actually viable

• Everyone catches their breath

Option 3: Hospital Rehabilitation Ward

What it is:
Intensive rehabilitation program in a hospital setting.

What's included:

• Daily physiotherapy (often multiple sessions)

• Occupational therapy

• Medical supervision

• Focus on mobility, strength, function

How long:
Usually 2-6 weeks, depending on progress

The goal:
Intensive therapy to maximise function before discharge.

 

Choose TCP if:

• The goal is definitely to return home

• Your Mum needs therapy with a clear plan

• You want time-limited support (defined end date)

Residential vs Home TCP:

• Residential: If she needs 24/7 support, intensive daily therapy

• Home: If she's relatively stable, and the house is basically safe

Choose Residential Respite if:

• You're not sure if her home will work long-term

• You need time to assess options without pressure

• Her home needs modifications that take weeks

• Everyone needs breathing room to make better decisions

The advantage:
Can be extended if you need more time. Gives you up to 2-3 months to figure things out.

Important:
Many families use respite to "trial" permanent care without pressure.

Choose Hospital Rehab if:

• Your Mum needs intensive daily therapy

• Short, focused intervention (2-6 weeks)

The reality:
After rehab ends, the same question returns: is home safe?

 

First 2 Weeks: Watch and learn

Observe:

• How is therapy progressing?

• Is she gaining strength or plateauing?

• Can she manage basic self-care?

• Is her thinking clear?

Sort the house:

• Do the safety assessment properly

• Get OT to visit if possible

• List what modifications are needed

• Start arranging equipment

Start services:

• Begin the aged care assessment if not done (call My Aged Care: 1800 200 422)

• Apply for a Home Care Package

• Get on waiting lists

Weeks 3-6: Reality Check

The honest questions:

• Is she making progress or stuck?

• If she came home today, would it be safe?

• What would need to be different?

• Can those things realistically happen?

Ask the therapy team:

• What's realistic for her mobility?

• Can she manage at home with support?

• What level of support would she need?