From hospital to home
Hospital Discharge & Transition Support Program
A planned, personalised move from hospital into a Supported Independent Living or Specialist Disability Accommodation home, with the same friendly team beside you from the ward to the front door and beyond.
In short
- Support to move from hospital into a SIL or SDA home.
- We plan the move with you, your family and the hospital team.
- A named coordinator stays with you for the first six weeks.
What it is
Leaving hospital is a vulnerable moment, especially when going back to the old living arrangement isn't an option. Our Hospital Discharge & Transition Support Program works with the hospital team, the person and their family to plan a safe move into a SIL or SDA home, and then stays alongside them through the first weeks so the new routine settles. Nobody makes this move alone.
- Discharge planning with the ward, social work and allied health teams
- Home readiness: equipment, access and the roster of care in place before discharge day
- Escorted transfer and first-day support
- Medication, clinical handover and follow-up appointments managed
- A named transition coordinator for the first 4–6 weeks
- Regular updates to family, support coordinator and treating team
A typical week
Who it suits
People in hospital who can't safely return to their previous home, people waiting on a SIL or SDA placement who are medically ready for discharge, and families and hospital teams who need one provider to coordinate the move. Often involves complex care needs.
How it's funded
NDIS: SIL and SDA funding in the plan, with transition supports from Core or Capacity Building budgets where included. We can prepare the evidence and quotes for a plan change if the current plan doesn't yet cover the move.
Hospital-funded interim arrangements are discussed case by case with the discharging hospital.
Common questions
How quickly can you accept a discharge?
Once a suitable home is available and the roster of care is approved, usually within one to two weeks. We tell the hospital team early if timing is likely to be longer.
Who do you work with at the hospital?
The discharge planner, social worker, OT and treating team. We join discharge meetings and share one plan everyone can see.
What if the NDIS plan doesn't cover SIL yet?
We help gather evidence for a plan reassessment or change of circumstances, and work with the support coordinator on the request. Next step: make a referral and we'll call the same day.
Other ways we can help
Personal Care & In-Home Support
Support with personal care, daily routines, household tasks and complex care, tailored to each person's needs.
Learn moreCommunityCommunity Access & Social Participation
Support to get out, stay connected and enjoy the community through social outings, appointments and recreational activities.
Learn moreDay programDay Program & Group Activities
Engaging centre-based and community activities that encourage independence, friendships and social connection.
Learn moreLivingSupported Independent Living (SIL)
Daily living and overnight support to help people live safely, comfortably and independently in their own homes.
Learn moreHousingSpecialist Disability Accommodation (SDA)
Accessible, purpose-built homes designed for people with significant disabilities, supporting comfort, safety and independence, in the communities people already call home.
Learn moreCall us today
03 8393 8304We'd love to hear from you. Give us a call, Monday to Friday, 8:30am to 5pm, or send an enquiry whenever suits you, and one of our intake coordinators will be in touch within one business day.