To support the safe and timely discharge of NDIS participants from hospital, we have committed to contacting every participant (or their authorised nominee or representative) within 4 days of being notified that they have been admitted to hospital.
We have increased the number of NDIA staff nationally who work directly with the health system, called health liaison officers (HLOs).
HLOs work with hospital staff to ensure communication between the hospital and the NDIA is as fast as possible. They also make sure that we receive the right information to plan for discharge.
HLOs will also help NDIS participants apply for Home and Living supports such as Specialist Disability Accommodation if needed.
We have also increased the number of specialised planners who focus on planning for participants who are admitted in hospital.
Our specialised planners work closely with HLOs and participants to create urgent NDIS hospital discharge plans where required.
Information for hospital staff
Where an NDIS participant is admitted to hospital, hospital staff should notify the NDIA by contacting the HLO connected to their hospital.
Where a patient is admitted to hospital who is not an NDIS participant but has or has recently acquired a permanent and significant disability, hospital staff should refer them to the NDIA to begin the access application. NDIA HLOs can support people with an access application. We will assess their eligibility as a priority, usually within 7-10 days.
The NDIA has developed an optional Discharge Assessment template for hospital staff. They can use the template to provide information to help us understand the participant’s needs upon discharge, such as personal care, daily living supports, and Home and Living supports.
Hospital staff can request the template by contacting the HLO connected to their hospital. Alternatively, we will provide the template to hospital staff when they refer the participant to the NDIA. The use of this template is not mandatory, but it provides guidance on the information we may need to approve the participant’s NDIS plan with the appropriate supports.
While the NDIA will fund any assessments needed once a participant returns home, hospitals are responsible for providing health information to support discharge and planning prior to discharge.
The NDIA has also developed a Discharge Assessment for Psychosocial Participants as their information, history and care needs can be different from other patients. This template is also optional and we will provide it to hospital staff when they refer the participant to us.
Hospital discharge process
The below steps represent the process for an NDIS participant (or prospective participant) to discharge from hospital in a timely manner.
The process in indicative of the full hospital discharge process as per the NDIA Hospital Discharge Operational Plan agreed at the Disability Reform Ministerial Council (DRMC) meeting in July 2022. There may be other potential steps that are not covered in this process.
The NDIA and State and Territory health services share information in compliance with respective privacy legislation and with consent of participants or their authorised representatives.
1. Participant identified in hospital
- Existing participant - Hospital staff identify the patient as an existing NDIS participant.
- Prospective participant -Hospital staff identify the patient as someone potentially eligible for the NDIS.
2. NDIA notified of the participant
- Existing participant - With the participant’s consent, hospital staff notify the NDIA when the participant is admitted to hospital.
- Prospective participant - With the prospective participant’s consent, hospital staff help them to lodge an access request and notify the NDIA Hospital Discharge team of the prospective participant.
NDIA Hospital Discharge team completes the access request within 7-10 days of being notified.
3. Contact participant
NDIA Hospital Discharge team contacts the participant, prospective participant or their authorised representative within 4 days of being notified of their admission to hospital.
4. Contact the hospital
NDIA health liaison officer (HLO) contacts hospital staff within 4 days of being notified to discuss the participant’s circumstances and reassessment needs.
HLO identifies and requests any further information to facilitate the planning activity.
5. Hospital provides information
Hospital staff provide information and evidence to help the NDIA Hospital Discharge team to understand participant needs upon discharge (the Discharge Assessment template can be used for guidance and consistency).
Health information is needed before the planning meeting.
6. Home and living assessment
If required, the NDIA Hospital Discharge team will conduct a home and living assessment. The Discharge Assessment template provides information about if a home and living assessment is needed.
7. Planning meeting
NDIA Hospital Discharge team conducts the planning meeting with the participant.
NDIA Hospital Discharge team may request further information during the planning meeting.
8. Plan approval and implementation
NDIA Hospital Discharge team prepares the plan.
NDIA Hospital Discharge team approves and implements the plan, including Request for Service (RFS).
9. Health alignment meeting
NDIA Hospital Discharge team notifies hospital staff of the approved plan and specific supports relevant to the hospital discharge planning process.
10. Support coordinator engagement with key people
Support coordinator engages with the participant, HLO, NDIA Hospital Discharge team and other key people in the participant’s life.
Support coordinator understands the participant’s current and usual living situation, including informal supports, who they usually/may live with, and history of their living situation and suitability.
11. Plan implementation
Support coordinator engages with the participant and scopes market options, including home and living supports, and supports the participant to transition to the selected option.
12. Discharge planning meeting
Support coordinator conducts a discharge planning meeting with the hospital staff, if required, as the support coordinator transitions the participant to their selected option.
13. Hospital discharge summary
Hospital staff undertake comprehensive discharge planning to facilitate the participant’s exit from hospital.
14. Discharge participant from hospital
Supports are in place and suitable for the participant.
NDIA Hospital Discharge team hands the plan back to the participant’s usual planner for future planning.
Support coordinator follows up with the participant, so they are stable and settled.