Mum's returning to her aged care facility: Settling back in after hospital

Your mum's been in hospital after a fall. Now she's heading back to her aged care facility.

This transition - hospital to facility - can be unsettling. She's been somewhere different, had medical treatment, and maybe feels weaker or more confused than before. Now she's going back to familiar surroundings, but things might feel different.

You want to help her settle back in smoothly. You want to make sure the facility has what they need. You want to know what to expect.

Here's what actually helps during this transition.

This is for you if:

• Your parent is returning to aged care after a hospital admission

• You want to help her settle back in

• You're wondering what information the facility needs

• You're not sure what to expect in the first few days

• You want to know how to work with staff during this transition

• You're trying to figure out your role right now

 

The discharge information

The hospital should send discharge paperwork to the facility, but it helps to communicate directly too.

Call the facility and let them know:

• When she's being discharged

• What medical treatment your Mum received

• Any new medications or changes to existing ones

• New mobility limitations or equipment needs

• Follow-up appointments scheduled

• Any special care instructions from the hospital

Ask them:

• Is her room ready?

• Do they need anything from you?

• What time works best for readmission?

• Who should you speak with when you arrive?

This isn't checking up on them. It's helping ensure smooth handover.

 

Medical:

• Copy of discharge summary (hospital gives you this)

• List of current medications

• Any new prescriptions

• Follow-up appointment details

Personal:

• Her belongings from the hospital

• Any new equipment (walking frame, etc.)

• Updated glasses or hearing aids if replaced

Practical:

• Your current contact details (in case they've changed)

• Any updates to emergency contacts

 

Your Mum might be different than before

Common changes after hospital:

• More tired or weak

• Confused about where she is (hospital? home? facility?)

• Less mobile than before

• More anxious or unsettled

• Different sleep patterns

• Less appetite

This is normal after hospital stays, especially for elderly people. It doesn't mean something's wrong, it means she needs time to readjust.

Give it a week or two. Most people resettle within 10-14 days.

The facility will reassess her needs

When she returns, expect:

• Nursing assessment of her current condition

• Physiotherapy review of her mobility

• Care plan update based on hospital discharge

• Medication review with new prescriptions

This is good practice, not a concern. They need to understand how her needs might have changed.

Her routine might need adjusting

Before hospital:

• She managed certain tasks independently

• She participated in specific activities

• She had a daily routine

After hospital:

• She might need more assistance temporarily

• She might not feel up to activities yet

• Her routine might need to be gentler initially

The facility will work with her to rebuild confidence and independence gradually.

 

Your presence matters

In the first few days:

• Visit if you can (even briefly)

• Help orient her: "You're back at [facility name]. This is your room."

• Stay for a meal if possible

• Bring familiar items if they went missing during the hospital transfer

You're not checking on the facility - you're providing familiar comfort during transition.

Keep it calm and simple

If she's confused:

• Don't over-explain

• Keep statements simple: "You were in the hospital. You're back now."

• Repeat as needed without frustration

• Point out familiar things: "Look, here's your photo of the grandkids."

If she's anxious:

• Acknowledge it: "I know this feels unsettling."

• Provide reassurance: "The staff here know you. You're safe."

• Don't dismiss: "You're fine" feels invalidating

Work with her rhythm

Don't push:

• If she's tired, let her rest

• If she doesn't want to go to activities yet, that's okay

• If she needs help with things she did before, that's temporary

Do encourage gently:

• "Would you like to sit in the common room for a bit?"

• "Shall we walk to the dining room together?"

• Small steps toward a normal routine

 

Building good communication

The staff know your Mum's daily routine. You know her history and personality. Together, you provide complete care.

Good ways to communicate:

When you visit:

• Say hello to staff on duty

• Ask: "How has she been today?"

• Share what you've observed: "She seems more tired than usual."

• Listen to their perspective: "We've noticed that too."

When you can't visit:

• Call at a reasonable time (not during medication rounds or meal times)

• Ask to speak with the nurse on her wing

• Keep it brief: "Just checking how Mum's settling back in."

For ongoing communication:

• Ask what the best way to stay updated is (phone? email? care app?)

• Let them know your preferred contact method

• Respond when they reach out

 

Things staff find helpful to know:

About her personality:

• "She gets anxious at night - a nightlight helps."

• "She's always been a morning person."

• "She worries about being a burden - needs reassurance."

About her preferences:

• "She likes her tea weak with one sugar."

• "She prefers showers in the evening."

• "She loves talking about her garden."

About changes you notice:

• "She seems less interested in reading - are her glasses okay?"

• "She's not eating much - is that what you're seeing too?"

• "She seems more settled today."

 

 

Normal concerns to raise:

• "I noticed her walking frame wasn't in her room - can we make sure it's accessible?"

• "She mentioned she didn't sleep well - is there anything that might help?"

• "I'm worried she's not eating much - what are you observing?"

How to raise them:

• Matter-of-fact tone, not accusatory

• "I noticed..." not "You didn't..."

• Ask questions rather than make demands

• Listen to their perspective

 

What these are

Regular meetings (usually every 3-6 months, or after significant changes like hospital stays) where you, staff, and sometimes your mum discuss her care.

Purpose:

• Review the current care plan

• Discuss any changes in needs

• Update goals and preferences

• Address any concerns

Making the most of these meetings

Before the meeting:

• Think about what's working and what isn't

• Note any specific concerns or observations

• Consider her quality of life and well-being

During the meeting:

• Listen to staff perspective - they see daily patterns you might miss

• Share what you observe during visits

• Ask questions about anything unclear

• Discuss her preferences if she can't participate

After the meeting:

• You should leave with a clear understanding of the current care plan

• Know who to contact about what

• Have any changes documented

 

Medical follow-up

Make sure you know:

• What follow-up appointments are scheduled

• Who's responsible for arranging transport

• What specialist or GP visits are coming up

• What tests or monitoring are needed

The facility usually coordinates medical appointments, but confirm this.

Medication changes

After hospital, medications often change.

Check:

• Does the facility have an updated medication list?

• Do they have new prescriptions?

• Has anything been stopped?

• Are there new timing requirements (with food, etc.)?

This is critical for safety. Verify handover happened correctly.

Equipment or room modifications

If she needs new equipment:

• Walking frame or wheelchair

• Shower chair or toilet rails

• Bed rails or a pressure mattress

Ask:

• Does the facility provide this, or do you need to arrange?

• When will it arrive?

• Who will show her how to use it?

If room modifications help:

• Better lighting

• Furniture rearrangement for safer movement

• Personal alarm system

Discuss with staff what's possible.

Her emotional adjustment

Hospital stays are disorienting, especially for people with dementia or confusion.

She might:

• Ask repeatedly where she is

• Not remember going to hospital

• Feel anxious or unsettled

• Seem more withdrawn

• Be clingy when you visit

This usually improves with time and routine.

What helps:

• Consistent daily routine

• Familiar faces (regular staff if possible)

• Your visits (even short ones)

• Familiar objects in her room

• Patience with repetitive questions

 

You're not the care provider anymore - the aged care facility staff are.

Your role is:

• Being a daughter, or a son.

• Visiting and connecting

• Monitoring her wellbeing generally

• Communicating observations and concerns

• Participating in care decisions

• Being her advocate when needed

• Bringing joy and family connection

This is enough. This is important.

You don't need to:

• Be there constantly

• Question every care decision

• Perform care tasks (unless you want to)

• Feel guilty about not doing more

 

 

Your mum's returning to her aged care facility after a hospital stay. This transition needs a bit of attention, but mostly it just needs time.

This is what matters:

She'll likely be more tired, confused, or weak initially. This is normal. Give it two weeks.

The facility needs good information from the hospital. Help ensure handover is smooth.

Your presence in the first few days helps her feel safe and oriented.

Good communication with staff makes everything easier. Be collaborative, not adversarial.

Your role is connection and advocacy, not care provision. That's enough.

 

If family communication is complicated:
→ Read: The Siblings Who Disappeared All Year Suddenly Have Opinions (existing)

If you're managing from far away:
→ Read: When You Can't Be There in Person (new)

If you're feeling overwhelmed:
→ Read: You're Not Just Tired. This Is What Burnout Actually Feels Like (existing)

 

---

 

Let Vera help you navigate this transition.