Vitalis Health Co-Founder and Director, Alex Chrisment, explains how effective transitional care can transform the Australian healthcare system
Australia’s health and aged care systems are poised to undergo major transformation. At the heart of the Support at Home reform is a growing recognition that a critical part of aged care is healthcare and, increasingly, that care needs to happen where people live: at home.
This convergence of home care and clinical care demands not just better services, but better pathways.
One of the most fragile and overlooked points in the system is the transition from hospital to home, wherever “home” may be: a private residence, aged care facility, or short-term respite setting.
Every hospital discharge marks a critical moment where outcomes can be made… or missed.
Poorly coordinated discharge processes are one of the leading contributors to avoidable hospital readmissions. In Australia, nearly 25% of patients hospitalised for heart failure experience an unplanned readmission within 30 days (University of Queensland, 2024). These readmissions come at a high cost, not just to patients, but to the system. They account for 32% of total admission costs, or approximately $120.9 million annually for heart failure only.
Not all readmissions are inevitable:
– 40.1% of readmission costs are linked to potentially hospital-acquired complications
– 35.6% are due to recurrent heart failure episodes
(Medical Journal of Australia, 2024)
This burden is shared across both public and private healthcare.
Our experience shows that effective transitional care models can also reduce the initial length of hospital stay, a critical benefit as hospitals face growing pressure. This is reinforced by international evidence, particularly for frail older adults and people with chronic disease (American Medical Association Nov 2023).
The effect on patients is profound. Unplanned readmissions and prolonged hospital stays interrupt recovery, diminish quality of life, and erode independence. Nearly 30% of older Australians experience functional decline following hospitalisation, and many never regain their previous level of autonomy (AIHW, 2021). Coupled with muscle loss of up to 5% per day of bed rest, the return to wellness becomes even more difficult.
These problems compound and the real cost to the system goes far beyond what isolated studies can capture.
If we are serious about helping people age safely and independently at home, we must embed transitional care as a core pillar of the Australian healthcare system, supported by:
– Proactive, integrated discharge planning
– Digital tools and remote patient monitoring
– Partnerships between acute, aged care, and community providers
At Vitalis, we’ve been delivering transitional care services for nearly 10 years.
If you’re a hospital, aged care provider, or policymaker looking to strengthen transitional care, we would love to connect with you.
Click here to learn more about partnering with Vitalis.
