Leaving the hospital should be a moment of relief and recovery, not a source of stress, uncertainty, or administrative confusion. For NDIS participants, families, support coordinators, and hospital discharge teams, moving from an acute care setting back into the community requires meticulous planning, rapid coordination, and reliable ongoing support.
Whether returning to a private residence, stepping into interim medium term accommodation, or transitioning into a dedicated long-term Supported Independent Living (SIL) home, our service bridges the critical gap between health networks and community care. We ensure that every participant exits the hospital safely, with complete dignity, robust care structures, and the exact clinical, daily living, and long-term accommodation support required to foster lifelong independence.
A delayed or poorly managed hospital discharge can lead to prolonged hospital stays, increased risk of secondary infections, heightened anxiety for families, and unnecessary hospital readmissions. Standard community supports are not always equipped to mobilize at the speed required by hospital discharge boards or coordinate long-term housing arrangements on short notice.
Our dedicated post-acute and long-term care team works directly with hospital discharge planners, social workers, occupational therapists, health liaison officers, and NDIS support coordinators to build an immediate and sustainable care framework. By aligning clinical health requirements with NDIS funding streams—including core daily supports, medium term accommodation, and long-term supported independent living—we remove the operational bottlenecks that keep participants in hospital beds longer than necessary.
Our complete discharge-to-home framework rests on four essential pillars designed to protect participant wellbeing, secure suitable long-term housing, and streamline the administrative workload for hospital discharge teams:
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| 1. Rapid Response & Intake |
| Immediate bedside or virtual consultations within 24–48 hours |
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| 2. Interim Care & Housing Stabilization |
| MTA / STA placements and immediate in-home support deployment |
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| 3. Long-Term SIL & Accommodation Matching |
| Matching with 24/7 Supported Independent Living & SDA homes |
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| 4. Roster of Care & Plan Optimization |
| Evidence collection, NDIA plan reviews, and ongoing stability |
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When a participant is medically cleared for discharge, timing is critical. Our team conducts rapid intake assessments—either bedside in the ward or via urgent conference calls—to evaluate functional capacity, clinical nursing needs, environmental risks, and long-term housing goals.
We deploy qualified Disability Support Workers and Registered Nurses trained in post-acute care. From wound management and complex medication administration to manual handling and hygiene routines, our team delivers high-intensity support from the exact moment of hospital release.
For participants who can no longer reside at their previous home due to newly acquired disability needs, or who require 24/7 ongoing support, we facilitate a direct, structured transition into long-term Supported Independent Living (SIL) homes. We ensure housemate compatibility, accessible home environments, and custom rosters of care tailored to the individual.
If permanent SIL placement or major home modifications are still pending approval, we arrange Medium Term Accommodation (MTA) or Short Term Accommodation (STA) to move the participant out of the hospital environment immediately, providing continuous 24/7 support while long-term arrangements are finalized.
Navigating hospital discharge when a participant requires full-time, ongoing daily support can be complex. Supported Independent Living (SIL) provides 24/7 assistance with daily tasks, personal care, and skill building in a shared or individual home setting.
Our program offers a end-to-end pathway that moves participants smoothly from hospital wards into vibrant, long-term SIL communities:
| Transition Phase | Focus Areas & Action Items |
| Phase 1: Hospital Assessment | Comprehensive review of discharge summaries, allied health functional assessments, and SIL eligibility criteria with hospital social workers. |
| Phase 2: Interim Care / MTA | Placement into fully accessible Medium Term Accommodation with temporary 24/7 active support while SIL funding is processed. |
| Phase 3: Home & Housemate Matching | Exploring available SIL and Specialist Disability Accommodation (SDA) vacancies, conducting compatibility meets with potential housemates. |
| Phase 4: Roster of Care Development | Collaborating with the NDIA and Support Coordinators to create an optimized Roster of Care (RoC) reflecting true 24/7 support needs. |
| Phase 5: Permanent SIL Settlement | Transitioning into the permanent SIL residence with dedicated support staff, personalized goal plans, and ongoing community integration. |
Every discharge and long-term care plan is tailored to the individual. Depending on the participant’s NDIS plan, physical capacity, and long-term goals, our care packages encompass a wide spectrum of continuous supports:
Personal Care and Hygiene: Assistance with showering, dressing, grooming, oral care, bowel and bladder management, and skin integrity maintenance in home or SIL settings.
24/7 Supported Independent Living (SIL): Round-the-clock active or overnight support for daily tasks, household management, meal preparation, and personal safety.
Clinical and Nursing Services: Wound care, complex bowel management, enteral feeding (PEG), tracheostomy management, catheter care, and subcutaneous medication administration by Registered Nurses.
Mobility and Transfers: Hoist operations, slide-sheet maneuvers, standing transfers, and daily implementation of prescribed physiotherapy rehabilitation routines.
Domestic and Nutritional Support: Preparation of nutritious meals adhering to speech pathologist guidelines (including modified textures), grocery shopping, laundry, and house maintenance.
Community Access and Transport: Transport to medical appointments, allied health sessions, vocational training, social outings, and community re-engagement.
NDIS Advocacy and Plan Building: Partnering with Support Coordinators to collect clinical evidence for urgent NDIA plan reassessments, SIL submissions, and SDA funding approvals.
Hospital social workers, Health Liaison Officers, and discharge planners face constant pressure to manage bed flow while ensuring participant safety. We act as an agile, reliable partner that takes the burden out of community and long-term housing transitions.
Referral Submission: The hospital team, support coordinator, or family submits an urgent discharge referral via our online referral form or priority phone line 1300 883 774
Bedside Intake Assessment: Our intake team reviews discharge summaries, therapy reports, and current NDIS funding to identify immediate and long-term care needs.
Service Agreement & Interim Setup: We swiftly draft flexible service agreements utilizing Core supports, Support Coordination, or emergency interim funding lines.
Housing & SIL Matching: If the participant cannot return to their previous residence, we identify suitable long-term SIL vacancies or arrange immediate Medium-Term Accommodation (MTA).
Staff Onboarding and Shadowing: For participants with complex medical needs, our support staff complete clinical training or bedside shadowing with hospital nurses prior to discharge.
Discharge Day and Long-Term Transition: Our team coordinates safe transport from the hospital ward directly to the participant’s home or SIL residence, ensuring immediate care, comfort, and safety.
A participant’s pre-hospitalization NDIS plan may not reflect their new functional realities, or long-term support needs post-injury, surgery, or acute illness. Aligning funding pathways quickly is essential for an efficient hospital exit.
Core – Assistance with Daily Life: Covers daily personal care, domestic tasks, and support worker hours in private homes or temporary accommodation.
Core – Supported Independent Living (SIL): Specifically, funds 24/7 help with supervision and daily tasks for participants living in a shared or individual SIL home.
Core – Medium Term Accommodation (MTA): Covers the accommodation cost for up to 90 days when a participant has a long-term housing solution (like SIL or SDA) confirmed, but it is not yet ready for occupancy.
Core – Short Term Accommodation (STA / Respite): Provides short, intense periods of transitional housing and care support during emergency situations.
Capital – Specialist Disability Accommodation (SDA): Covers the physical brick-and-mortar housing costs for participants with extreme functional impairment or high physical support needs.
Capacity Building – Support Coordination: Funds professional coordination required to navigate complex hospital transitions, submit SIL Rosters of Care, and negotiate NDIA plan reassessments.
Capital – Assistive Technology: Funds temporary hire or permanent purchase of essential mobility aids, hospital beds, hoists, and bathroom modifications required upon exit.
Our team collaborates closely with Support Coordinators, Plan Managers, and NDIA Health Liaison Officers to ensure funding applications are ethically, accurately, and rapidly processed.
In urgent cases, our team can mobilize support workers and clinical oversight within 24 to 48 hours of receiving complete discharge documentation and signed consent forms.
Medium Term Accommodation (MTA) is temporary funding (up to 90 days) used to house a participant safely while their long-term housing is being finalized. Supported Independent Living (SIL) is ongoing, long-term NDIS funding that covers 24/7 support staff and daily living assistance in a permanent home.
Yes. If a compatible SIL vacancy is available and the participant has SIL funding (or an interim funding agreement), we can manage the transition directly from the hospital ward into the permanent SIL residence.
Our service integrates Registered Nurses who oversee complex clinical protocols, including enteral feeding, tracheostomy care, catheter management, and high-intensity mobility transfers, ensuring safe care in both private homes and SIL settings.
We work alongside hospital social workers, NDIA Health Liaison Officers (HLOs), and Support Coordinators to request an urgent plan review or secure emergency transition funding while long-term SIL evidence is compiled.
If you are a hospital social worker, discharge planner, NDIS support coordinator, or family member requiring urgent hospital transition or long-term SIL placement, complete the form below for priority processing:
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| PRIORITY HOSPITAL DISCHARGE & SIL REFERRAL |
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| Participant Name: [__________________________________________] |
| NDIS Number: [__________________________________________] |
| Current Hospital: [_________________] Ward / Bed: [__________] |
| Target Discharge Date: [ DD / MM / YYYY ] |
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| Referrer Name: [__________________________________________] |
| Referrer Role: ( ) Hospital Social Worker ( ) Support Coord. |
| ( ) Family / Carer ( ) Other |
| Referrer Phone: [_________________] Email: [_______________] |
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| Housing & Service Pathways Required: |
| [ ] In-Home Personal & Clinical Care (Return to Existing Home) |
| [ ] Long-Term Supported Independent Living (SIL) Placement |
| [ ] Emergency / Medium-Term Accommodation (MTA/STA) |
| [ ] Specialist Disability Accommodation (SDA) Coordination |
| [ ] 24/7 High-Intensity Clinical Nursing |
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| Brief Medical, Functional & Housing Summary: |
| [ ] |
| [ ] |
| [ ] |
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| [ SUBMIT URGENT DISCHARGE & SIL REFERRAL ] |
+-------------------------------------------------------------------+When a hospital discharge plan transitions smoothly into high-quality, long-term supported living, participants experience better health outcomes, greater stability, and enhanced community connection. We are committed to delivering transparent, highly responsive, and participant-centered care that respects choice and control at every stage of the journey.
Contact our dedicated Post-Acute & Supported Independent Living Team today to discuss participant requirements or organize an immediate ward consultation.
Priority Intake Line: Available 7 days a week for urgent hospital releases and SIL referrals – 1300 883 774 or 0431 566 866
Direct Referral Email: Dedicated discharge and accommodation inbox monitored daily – [email protected]
Regional & Metro Coverage: Supporting hospital networks and community SIL homes across the region
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