Community Success Stories


Help From Hospital to home

Residents in the Northern Sydney suburbs need not feel alone when returning home after a stint in hospital, thanks to two hospital discharge follow-up services funded by Sydney North Health Network, provided under the Australian Government’s financial support of the PHN program. These short-term ‘hospital to home’ support services (up to 12 weeks), run by Just Better Care and Kincare, help people settle back into their home life after hospital surgery, while helping reduce the risk of re-admittance to hospital. 338 people received help from the services in 2019 alone.

As well as making the transition from hospital to home easier, an equally important aspect of this program is preventing people from needing a hospital stay in the first place. The program helps people who are at risk of hospital admission and may not know how to access at-home supports or have chronic or complex health conditions that require more support.

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How do help from hospital to home services help patients?

When people return home from surgery rehospitalisation can occur for a range of reasons, including not eating well, missing medications, or doing too much on arriving home. This is where the Northern Sydney teams at Just Better Care and KinCare come in – they are passionate about helping people keep their independence and quality of life at home.

Reenay Mishra, Package Manager at Just Better Care, says, “We go into the client’s home to complete an assessment and see what links we can make within the community. … If they are comfortable, they are more likely to work harder towards rehabilitation and wellness, and that means avoiding going back into the hospital.”

Meet Jocelyn

‘Just Better Care offers a transportation service so I can get a driver for myself or my husband to go medical appointments or do the shopping.’

Meet Catherine

‘I don’t know what I would have done without KinCare when I first came out of hospital. I was totally reliant on someone to come in each morning to help me get around.’

Just Better Care’s client Jocelyn is in remission from cancer. She is also the primary carer for her husband, Rob.

Jocelyn says, “It is hard to give up the things you are used to doing yourself, but I have arthritis in my neck and standing at an ironing board is not at all comfortable for me, so Just Better Care helps with the ironing and showering Rob, so he doesn’t fall. They also offer a transportation service, so I can get a driver for myself or my husband to go medical appointments or do the shopping.”

The services funded by Sydney North Health Network enable the Just Better Care and KinCare teams to visit clients in their home on return from hospital, supporting them to live the way they want. From specialist health services such as nursing, falls prevention, and occupational therapy to domestic services, the teams are there to remove the burden of daily tasks and specialised care, helping people put all their effort into recovery.

KinCare client Catherine says, “I’ve always been a very independent person and always have been capable of looking after myself and other people. Now the shoe was on the other foot, and I struggled with that, but KinCare hasn’t made me feel awkward about it, and I think I’ve got better quicker because of that. It’s still an ongoing process, but I’m getting there. I’m feeling better within myself, coping well and getting my social life back.”

Deb Fraser, Central Home Care Package and Health Manager at KinCare, stated, “On the outside, Catherine looks well-presented, but she was feeling quite depressed when she was in the hospital and worried about how she was going to manage at home without any extra supports. Now, her confidence is starting to build up, and she is improving her mobility and becoming more independent.”

The main referrers to these services are health professionals from public and private hospitals in the Northern Sydney region.


ABOUT: Just Better Care
Across Australia, Just Better Care provides in-home aged care and disability support services, supporting people to live independently. They empower customers by putting individual preferences and support needs at the centre of their approach. Every Just Better Care office is owned and operated locally, providing affordable and accessible services that meet local and individual requirements.


ABOUT: KinCare
KinCare is one of Australia’s leading in-home care providers. They are family owned with over 28 years’ experience in delivering home care services. Because this is all they do, their team are experts in in-home care – “We are big enough to help, but small enough to care.” They are committed to improving the quality of life, health, and wellbeing of everyone they provide in-home care for. They know what it takes to help older Australians and people with disabilities live independently in their own homes.

Eligibility criteria of clients for the hospital-to-home discharge referral service include:

  • people who have suspected or diagnosed dementia
  • a person with a chronic or complex health condition
  • a person who is not receiving adequate support and would significantly benefit from post-hospital discharge follow-up at home within 24 hours of arriving home
  • someone who would benefit from short-term follow-up support
  • people not currently enrolled in a Transitional Aged Care Program; and
  • a person who may show health characteristics that deem them to be at high risk of hospital readmission.

If you, or someone you care about, could receive help from these services the northern Sydney area, please talk with your GP or other primary care service providers about referring them to :

  • Just Better Care by phoning 0437 522 258 for those people residing in Hornsby or Kur-ring-gai local government areas or
  • KinCare on 1300 689 741 for people living in the other Northern Sydney local government areas – Hunters Hill, Lane Cove, Mosman, Northern Beaches, North Sydney, Ryde, and Willoughby.


These hospital discharge services – help from hospital to home – have been made possible through funding provided by the Australian Government under the PHN Program.

Find out more about SNHN help from hospital to home services

For a list of SNHN commissioned help from hospital to home services please visit: https://sydneynorthhealthnetwork.org.au/about-us/commissioning/hospital-avoidance-services/