New service supports patients transitioning from hospital to home

Clinical Nurse Consultant Lynette Smith

A new nurse-led service at Caboolture Hospital is helping patients transition safely from hospital to home, improving continuity of care and reducing unnecessary hospital visits.

Clinical Nurse Consultant Lynette Smith is leading the rollout of the Discharge Support Service, which officially commenced on 30 March 2026.

The service provides a single phone-based point of contact for patients following discharge from both medical and surgical wards.

“Patients can contact the service within 30 days of leaving hospital to receive advice and support from our nursing team,” Lynette said.

“We’re helping with all aspects from wound care and pain management to answering questions about recovery and coordinating referrals to GPs or outpatient services.”

Caboolture Hospital is the first site in Queensland to implement the Medical Discharge Support Service model.

The initiative aims to streamline the patient journey, enhance the overall patient experience, and reduce avoidable emergency department presentations and readmissions.

Lynette said the service builds on the success of the Post-Operative Discharge Support Service (PODSS), an award-winning model that has already demonstrated strong outcomes for patients recovering at home.

“PODSS has been incredibly successful in supporting patients after surgery and reducing the need for hospital readmission,” she said.

Originally piloted at Metro North Health’s Surgical, Treatment and Rehabilitation Service, the model has since expanded across Queensland, supporting patients in multiple regional and metropolitan locations.

For Lynette, leading the implementation of the Discharge Support Service at Caboolture Hospital has been a rewarding milestone.

“I’m passionate about making a positive difference in our patients’ recovery journeys and ensuring they feel supported once they leave hospital,” she said.

Metro North Health’s continued investment in innovative, nurse-led models of care is helping to deliver safer, more connected healthcare for patients across the region.