Coming home from hospital: Margaret's Support at Home story
About this story: this is a composite story based on situations our team commonly supports. Names and identifying details have been changed to protect privacy.
After three weeks in hospital with a leg wound that wouldn't heal, Margaret wanted one thing: to go home to her own bed in Wentworthville. Here's how a nurse-led Support at Home plan made that possible, and safe.
The worry: "Will Mum cope at home?"
Margaret is 84. She lives alone, has type 2 diabetes, and had been admitted after a small cut on her shin became infected. By the time the hospital was ready to discharge her, the wound was clean but still open, she was unsteady on her feet, and her daughter Priya was worried.
"The ward kept saying she was medically fine to go," Priya told us. "But who was going to check the wound? Who was going to notice if it got worse? I work full time in the city."
This is one of the most common calls we take. The hospital part is over, but the risky part, the first few weeks at home, is just beginning.
Step 1: An RN assessment before day one
Margaret already had a Support at Home classification and had chosen Trilogy Care as her provider, so the family asked for Good Nurse to deliver her care. One of our Registered Nurses visited the day after discharge. We looked at:
- The wound itself, the hospital's dressing plan and what supplies she had
- Her blood glucose readings, because high sugar levels slow healing
- Her medications, including the new antibiotics
- How she moved around the house, especially the bathroom
- What Margaret wanted, which was to keep cooking her own dinner
We wrote her care plan that afternoon and shared it, with her consent, with her GP, her Trilogy care partner and Priya.
Step 2: The right person for each job
Not every visit needs a nurse, and not every visit should be a support worker. We split the work:
- Nursing (RN/EN), three times a week at first: wound assessment and dressings, glucose review, medication checks and watching for signs of infection.
- Personal care, every morning for the first fortnight: help to shower safely while keeping the dressing dry. From 1 October 2026 personal care sits under clinical supports in Support at Home, so Margaret doesn't pay a contribution for it.
- Domestic help, once a week: vacuuming, changing the bed and a grocery run, so she could save her energy for walking and cooking.
Step 3: Catching a problem early
In week two, our nurse noticed the skin around the wound was warmer and redder than at the previous visit, and Margaret's sugar readings had crept up. Nothing dramatic, but it was a pattern.
We called her GP that morning, sent photos through, and she was reviewed the same day. A change in treatment and closer glucose monitoring followed. No ambulance, no emergency department, no readmission.
Step 4: Stepping care down
By week six the wound had closed. We reduced nursing to a fortnightly skin and foot check (important with diabetes), stopped daily personal care once Margaret was confident in the shower with a rail and stool, and kept the weekly domestic help. Her Trilogy care partner adjusted the budget to match.
"She's back to bossing everyone around," Priya says. "Which means she's well."
What families can take from Margaret's story
- Plan before discharge. Ask the ward for the dressing plan, medication list and follow-up appointments in writing.
- Ask who is checking the clinical side. Cleaning and shopping help is valuable, but someone qualified should be watching wounds, medications and blood sugar.
- Use the Support at Home budget flexibly. Care can start higher and step down as recovery happens.
- Know the warning signs. Increasing redness, heat, swelling, new pain, a bad smell or fever all need a same-day call to the GP or nurse.
If someone you love is coming home from hospital, read our Support at Home Guide or call our nurses on 1300 457 557.
Talk to a nurse
Free, no-obligation chat with one of our Registered Nurses about NDIS or Support at Home care in Western Sydney.