Discharge Planning: Arranging In-Home Support Before the Patient Leaves

At some point this week, a nurse handing over a patient to home-based support has asked the question: how much can the support worker do? The care plan includes medications, wound dressings, pressure care and a modified diet. The support worker is able and willing.

Willingness does not equate to being within boundaries, and nurses have a professional responsibility to set the boundaries right, not only for the person's safety but also for their own registration. The answer is multi-layered, and that's part of the confusion. There is no national scope document for support work. The specific activities that a support worker can be safely and legally involved in will vary based on the training received, the type of arrangements in the person's plan, the setting, and in some instances, state-based rules about particular tasks.

This article skims the surface in general terms, just to get the conversation going from a common starting point at handover. It is a guide to the shape of the boundary, and not a substitute for verifying what applies to your setting and state.

The core of the role

Support workers assist with daily living. The tasks that sit comfortably in the role include personal care such as showering, dressing and grooming, meal preparation and assistance with eating, household activities, transport and community access, social and recreational support, prompting and encouraging routines, and implementing non-clinical strategies that have been developed by others, such as a communication approach recommended by a speech pathologist, or the day-to-day aspects of a behaviour support plan delivered by a trained worker.

Assist and report are the two verbs that identify the safe centre of the role. A good support worker helps the individual to do what they would do on their own, and notifies the appropriate person of any changes noticed. They can be the first to see someone eating less, sleeping poorly, developing a pressure area or becoming less mobile. The value of this is extremely large, and it works precisely because the worker doesn't have to make any clinical interpretation of what they observe. They notice and escalate. The clinical judgement stays with you.

The tasks that sit behind a training gate

There is a zone between everyday support and those tasks which are clearly clinical, and it may require certain training and, in most cases, documented competency and clear delegated responsibility for support workers. The most typical example is medication. In many contexts a trained support worker can help a person with medication, such as helping the person with a dose administration aid from a pharmacist, or reminding them to take their medicine. The rules are different when it comes to administering medication, making PRN determinations or any other clinical judgement, however, and they differ by state, setting and the individual's own arrangements. Do not assume the worker in front of you is trained to do medication tasks. Ask specifically what they have been trained to do.

The NDIS also provides recognition for a group of high intensity daily personal activities, such as supports to manage complex bowel care, enteral feeding, severe dysphagia, ventilator support, tracheostomy care, urinary catheter management and subcutaneous injections. Some of these supports can be carried out by support workers; however, they must have extra training against the relevant skills descriptors to perform them, and their provision carries specific obligations. If a task on your handover list is on that list, mark it as "gated" until you are satisfied that training and arrangements are in place.

The other half of this band is delegation. Nurses can delegate some activities to unregulated workers, but the professional standards on delegation still apply: is the activity appropriate to delegate to someone who may be unregulated? Is this person competent to perform this activity? What supervision and review does this need? Delegation is not about passing on responsibility, but responsible passing on.

What sits outside the role entirely

No matter how experienced the support worker is, some things sit outside the role entirely: diagnosing, prescribing or changing medication regimes, doing tasks that are restricted to allied health professionals, and making clinical decisions about deterioration instead of escalating it. Asking a support worker to do any of the above puts the person being supported at risk, and sets the worker up to fail.

How this plays out in practice

Imagine a situation all community nurses know of: a client with paraplegia comes home after surgery, and complex bowel care has been placed on the support schedule. The rostered support worker is not trained in complex bowel care, identifies that, and doesn't attempt it.

The right rework is simple, the nurse keeps the clinical task, the provider arranges training of two regular workers to the appropriate high intensity skill descriptor (and gets them accredited in the process), while the support workers take on the remainder of the programme. That's no failure. The worker that says "I am not trained for that" is the exact worker that you want in the home.

Making the boundary work day to day

It is best to have the scope written and shared. A one-page summary for each client, indicating which tasks are support tasks and which are gated and held by named trained workers, removes the daily ambiguity that leads to overreach and underuse. Use an escalation line: what should the support worker escalate, to whom, and how quickly? Support workers use the full extent of their role with confidence when they are clear about what they can and can't do.

Next steps

Ask three questions before you move on to the next support arrangement: what does this worker have the training in, what does the written support plan allow, and who does that plan leave the tasks to? If the answers are not known, then that is the first place to begin.