Hospital to Home Care
Supporting Safe Transitions from Hospital to Home
Transformative Nursing & Support Services provides nurse-led community care for people transitioning from hospital to home across Townsville and North Queensland. Our clinical team works collaboratively with hospitals, families, Support Coordinators and allied health professionals to ensure continuity of care and a safe recovery.
Many people leaving hospital need extra support to manage complex health needs at home. Our services provide short-term and ongoing assistance that promotes recovery, reduces avoidable readmission, and supports independence — with nursing expertise available within the same organisation.
What Our Discharge Support Includes
A complete clinical pathway — from first assessment through to ongoing complex supports at home.
Hospital to Home Nursing Supports
Our team can provide a range of clinical and personal supports following hospital discharge, including:
- Post-surgical recovery support
- Wound care and dressing management
- Medication management and monitoring
- Catheter and continence care
- Support for complex disability transitions
- Short-term intensive support following discharge
- Ongoing community nursing supports
Who We Support
We regularly work with individuals who require additional support after leaving hospital, including:
- NDIS participants requiring increased supports
- Older people transitioning to in-home aged care services
- Individuals recovering from surgery or illness
- People with complex or chronic health conditions
- Patients requiring short-term clinical monitoring at home
Working with Hospitals & Health Professionals
We value strong communication and collaboration with the wider care team. We provide clear updates and work closely with hospitals, discharge planners, GPs, allied health providers and Support Coordinators to ensure each person receives the right level of care — with nursing oversight at every step.
Referral Process
Referrals from hospitals, families and health professionals are welcomed.
- Submit a referral via our online referral form or contact our team
- Our intake team reviews the referral and confirms service availability
- An intake assessment is arranged to develop a tailored support plan
- Services commence in collaboration with the patient and care team
New referrals acknowledged within 24 hours.
Local Care Across North Queensland
Proudly supporting communities across Townsville, the Burdekin, Charters Towers, Ingham and surrounding regions.
Not sure whether we service your area?
Contact Our TeamDiscuss a Hospital Discharge
Planning a discharge or supporting someone coming home from hospital? Talk to our clinical intake team — referrals acknowledged within 24 hours.