Service
Post-Discharge Support
The days and weeks after hospital care are where plans quietly fall apart. This service keeps the discharge plan moving.
What this service helps with
Post-discharge support turns discharge instructions into a workable plan: follow-up appointments booked, medicines clarified with the prescriber, home support arranged where needed, and structured check-ins so problems surface early.
Who it is for
- Patients recently discharged after serious illness or surgery
- Families receiving a relative home with new care needs
- Diaspora relatives coordinating recovery from abroad
- Anyone discharged with instructions that are hard to execute
Situations we see
A discharge summary lists three follow-ups and nobody has booked any of them.
The medicine list changed in hospital and the family is unsure what to continue.
Recovery at home needs wound care and nobody has arranged a nurse.
What BRIDGE will do
- Review the discharge plan with you and identify the actions in it
- Book follow-up appointments and reviews
- Raise medication questions with the prescribing provider
- Coordinate home nursing or physiotherapy through selected partners
- Run scheduled check-ins across the recovery window
- Escalate to the appropriate provider when something is deteriorating
What BRIDGE will not do
- Change, stop, or start any medicine
- Provide nursing or clinical care ourselves
- Assess wounds, symptoms, or recovery progress clinically
- Act as an emergency response when someone deteriorates suddenly
What we need from you
- Membership, identity, and consent in place
- The discharge summary and medicine list
- The treating facility and clinician details
- Who at home will be present and available
- Authorised contacts for updates
How fees work
Usually scoped as a time-bound pathway rather than single tasks, because continuity is the point. The window, the number of check-ins, and the cost are agreed before we start.
Response standard
Check-ins follow an agreed rhythm — commonly around day 3, day 7, and day 30 — adjusted to the clinical plan.
We aim to respond to enquiries within 30 minutes to 24 hours. Staffed hours are still being finalised. [CONFIRM BEFORE LAUNCH] Staffed hours and tier-specific response windows.
Clinical boundary
Follow-up is coordination, not clinical monitoring. If symptoms worsen, contact the treating provider, or call 112 in an emergency. BRIDGE is not an emergency service. For emergencies, call 112 or go to the nearest emergency facility.
Questions
Is this the same as home nursing?
No. Nursing is delivered by partner providers. We coordinate and follow up.
Can you tell us if recovery is going well?
No. We report what we observe and raise it with the clinician; interpretation is theirs.
Can a relative abroad receive the updates?
Yes, once the patient has authorised that person and identity has been verified.
Arrange post-discharge support
Join BRIDGE to open a case. If you are not sure this is the right service, start with a few questions instead.