Discuss the request
Share the preferred start date, location and broad support requirements.
Home / Hospital to home
Hospital to home
Coming home.
With support around you.
For discharge teams, rehabilitation services and support coordinators planning community support for a person living with ABI or FND.
A clear handover starts before discharge.
For someone with complex support needs, returning home can involve changes to routines, assistance and the people delivering care. Discuss the proposed support early so requirements and availability can be considered.
Before a service is agreed
- The person’s consent, goals and communication preferences
- Proposed discharge date, home location and access requirements
- Daily tasks, timing and any nursing or high intensity needs
- Current care instructions and relevant rehabilitation guidance
- Worker skills, equipment and other services required
- Funding arrangements and responsibilities for each part of the plan
Clarify the first days at home
Agree who is doing what, which services are confirmed, what information workers need and who to contact if arrangements change. A planned discharge date does not itself confirm service availability.
Keep the care team connected
With the person’s consent, the referral discussion should identify the relevant hospital contact, support coordinator, treating clinicians and family or carers to involve.
The hospital determines clinical readiness for discharge. Core Clinical Care can discuss the community supports being requested; it does not approve hospital discharge or NDIS funding.
Further reading: NDIS: hospital stays and discharge planning ↗
Referral pathway
From initial enquiry
to agreed support.
Review the fit
Clarify care scope, skills, availability and the information needed for review.
Confirm arrangements
Agree on the service, handover, responsibilities and communication before support starts.
Planning a discharge?
Start with a general referral enquiry.