Community Success Stories




Help From Hospital to home

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 PCCS, 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.

Disclaimer: The story and video on this page refer to KinCare, an organisation that formerly delivered a hospital discharge service in the Northern Sydney region. As of 1 July 2021, the hospital discharge service is now being delivered by Primary and Community Care Services (PCCS). For more information on the hospital discharge services, contact PCCS or Just Better Care.

Watch the video...

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 PCCS 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.’

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 PCCS 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.

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.


PCCS is all about providing practical supports to your health and wellbeing. They design innovative health and wellbeing services that make a real difference. As a leader in Social Prescribing, their programs are developed with the client, carers, family and friends at the centre, keeping within their vision of optimising health and wellbeing for local communities.


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
  • PCCS on 02 9477 8700 for people living in the other Northern Sydney local government areas – Hunters Hill, Lane Cove, Mosman, Northern Beaches, North Sydney, Ryde, and Willoughby. View referral form here.


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/