Outcomes after discharge from acute hospital to residential aged care among long-stay inpatients: a retrospective cohort study using a health service long-stay dashboard

OBJECTIVE: This study aimed to describe pathway timing and 90-day outcomes for long-stay inpatients discharged to residential aged care homes (RACHs), predominantly new entrants, and to explore potentially modifiable factors associated with delays and the composite unsuccessful placement outcome. METHODS: A retrospective cohort study using the Metro South Hospital and Health Service long-stay dashboard was used. Adults flagged as long-stay with a primary reason of awaiting RACH admission (1 January-31 May 2025) and subsequently admitted to a RACH within the health service were included. Key intervals were hospital admission-to-readiness for the RACH pathway and readiness-to-RACH admission (including interim care bed length of stay, where applicable). The primary outcome was the composite of unsuccessful placement within 90 days, defined as emergency department presentation, unplanned readmission, or non-return placement failure. RESULTS: Of 293 flagged patients, 198 were admitted to a RACH and included. Median age was 83 years, and 48% were male; 49% had documented dementia. Median acute length of stay was 28 days; median time from admission to readiness was 10 days, and from readiness to RACH admission was 24 days. Within 90 days, 32% attended an emergency department, 22% were readmitted, and 5% experienced non-return placement failure; 36% met the composite outcome. CONCLUSION: Long-stay inpatients discharged to RACH experience substantial pathway delays and frequent early acute-care utilisation. Strengthening early family engagement and goals-of-care documentation may support safer transitions and help target quality improvement.