Complex Hospital Discharge Support

Tailored complex discharge support to assist individual needs, goals, and circumstances.

Complex hospital discharge is all about helping people with disabilities—especially those with high or complex support needs—transition safely and smoothly from the hospital back into their home or another care setting. It is a vital process that is part of ensuring the person receives the right support at the right time, reducing stress for them and their loved ones, and setting them up for success in their recovery and ongoing care.

Our team at Para Ability Community Care (PACC) works closely with hospitals, support coordinators, families, and NDIS support services representatives to make sure no detail is overlooked. Every person we support is different.

Complex Hospital Discharge process

A successful hospital discharge begins with a thorough assessment of the person’s medical, functional, emotional, and housing needs. It’s a team effort that places the individual at the centre of planning. We involve families and existing support networks at every step to ensure the transition reflects their wishes and goals.

Our approach relies on strong collaboration between hospital teams, support providers, NDIS planners, and community agencies. This coordination ensures that vital services, such as housing, therapy, personal care, and behavioural supports, are lined up and ready to go before discharge occurs.

We also pay close attention to accommodation needs, which means either arranging supported housing or helping someone return to their existing home safely and securely. We work to ensure all care arrangements are in place and that communication stays open and clear among everyone involved. This helps reduce delays, prevent complications, and make the transition as seamless as possible.

Assistance for Complex Discharge Support

When preparing for a complex discharge, we often assist with securing suitable housing or supported accommodation and setting up personal care services to manage daily tasks such as bathing and dressing. Medical needs are also covered, with support for medication, wound care, or nursing as required.

For those with more complex behavioural support needs, we work closely with specialists to develop and implement positive behaviour support plans. Therapy services such as physiotherapy, occupational therapy, or speech therapy may be arranged to support ongoing rehabilitation. Community access is also an important part of the plan, helping people reconnect with their routines, appointments, and social activities once they’re home.

Why is Complex Hospital Discharge important?

By putting the right supports in place before a person leaves the hospital, we help reduce extended hospital stays and free up beds for people in acute need. More importantly, we help people with disabilities regain their independence sooner and safely rejoin their communities. A well-managed discharge improves outcomes, minimises the risk of hospital-related complications, and reduces feelings of isolation by keeping the person connected and supported.

Who is involved in Complex Hospital Discharge?

Complex discharges bring together a wide range of people, each playing a critical role. Hospital staff—such as doctors, nurses, allied health teams, and social workers—provide medical insight and help identify support needs. NDIS planners and health liaison officers assist with funding and ensuring appropriate services are available. Support coordinators and service providers (like our team at PACC) step in to put those supports into action. And, of course, families and carers are key partners in both planning and providing care. When everyone works together, the person at the centre of the discharge plan is well-supported and set up for success.

12 steps to a seamless transition from hospital to home

1. Contact PACC’s Rapid Discharge Team on 1300-OUR-PACC or via email to get started. You can also find our referral form here.
2. Our Hospital Liaison Manager will respond quickly to confirm a meeting with the hospital’s discharge team and the participant or their representative.
   
3. We meet with hospital staff, support coordinators, and allied health teams to understand their needs, identify potential barriers, and establish a realistic discharge timeframe.
   
4. A personalised transition plan is developed, taking into account the participant’s goals, the hospital’s priorities, and the requirements of the NDIS.
5. Service Agreements and consent forms are prepared and reviewed with the participant and their family to ensure clarity and confidence.
6. We collect all relevant documentation, such as medical reports, behavioural strategies, risk assessments, and allied health input, to build a participant-centred plan.
7. If needed, PACC can source short- or medium-term accommodation, including fully supported living options close to family or in preferred areas.
8. A skilled support team is assembled, chosen specifically for their experience with the individual’s medical, behavioural, or mobility needs.
9. The participant has the opportunity to meet their new support workers before leaving the hospital, helping to build trust and ensure a good fit.
10. Our staff may shadow hospital teams or participate in training to learn key care routines such as catheter care, PEG feeding, or behavioural techniques.
11. Before discharge, we conduct a joint review with the hospital and PACC to ensure everything is in place—equipment, care plans, and safety checks—for a smooth transition.
12. The participant is then discharged with wraparound support, ready to go. We can also arrange transport, and care begins the moment they arrive home.

How does Complex Discharge Support ensure safety for people with ongoing care needs?

Ensuring safety during and after discharge starts with early, thorough, and individualised planning. From the beginning, a team of healthcare professionals and support workers come together to create a plan that covers all bases—from medical needs to personal care, housing, therapy, and daily living routines.

We ensure that all necessary services and equipment are in place before the person leaves the hospital. This might include assistive devices, medication management, or home modifications. Equally important is educating and involving the participant and their carers in the process. We take the time to explain routines, demonstrate equipment, and answer any questions so that families feel confident and capable.

Ongoing communication keeps everyone on the same page. Discharge summaries, contact lists, and written care instructions are shared with all involved. And once the participant is home, regular follow-ups help track progress, address any concerns early, and make any necessary adjustments.

With this thoughtful and coordinated approach, complex discharge support helps reduce risks and ensures the individual’s safety and wellbeing as they return to the community.