What is post-hospital care?
Post-hospital care covers the support an older person needs in the days and weeks after a hospital admission. The right care here prevents readmission, restores independence and gives families peace of mind.
The four pathways out of hospital
- Transition Care Programme (TCP) — short-term, government-funded, designed to help you regain independence after hospital. Lasts up to 12 weeks.
- Short-Term Restorative Care under Support at Home — up to 8 weeks of intensive multidisciplinary support to restore function.
- Residential respite — short stay in an aged care facility while you recover.
- In-home recovery support — privately-funded or via your Home Care Package / Support at Home budget.
What we provide
- Hospital discharge coordination — we attend the discharge planning meeting where appropriate
- Same-day or next-day in-home start
- Registered nursing — wound care, medication management, drains and catheters
- Allied health at home — physio, OT, podiatry, dietetics
- Personal care — showering, dressing, mobility
- Domestic support — cleaning, meal prep, laundry, shopping
- Transport to follow-up appointments
- 24/7 on-call clinical contact
Hospitals we coordinate with
My Evervale takes referrals from public and private hospitals across Melbourne. We have established discharge pathways with:
- Western Health — Footscray, Sunshine, Williamstown campuses
- Eastern Health — Box Hill, Maroondah, Angliss campuses
- Northern Health — Northern Hospital Epping, Broadmeadows
- Monash Health — Clayton, Dandenong, Casey, Moorabbin campuses
- Alfred Health — Alfred, Sandringham, Caulfield campuses
- Peninsula Health — Frankston, Rosebud campuses
- Royal Melbourne, Royal Women’s, Royal Children’s
- Private hospitals: Cabrini, Epworth, St Vincent’s Private, Knox Private, John Fawkner, Brighton Private
How to start post-hospital care
- Inpatient referral — ask your hospital social worker, discharge planner or aged care liaison nurse to refer to My Evervale.
- Family-initiated referral — call our team on Phone — coming soon or use the online referral form — we’ll coordinate with the hospital.
- Self-referral after discharge — if you’re already home and struggling, we can start within 24 hours.
Funding pathways
- Transition Care Programme — fully government-funded, no cost to you
- Short-Term Restorative Care — under Support at Home, funded
- Existing Home Care Package or Support at Home Plan — can expand temporarily
- Private pay — typically $60–$95 per hour for in-home support, depending on time of day and service type
- Insurance / DVA — we coordinate with private insurers and DVA Gold/White Card
Related pages