Professional referral guide
A safe hospital discharge for an NDIS participant depends on early role clarity, current evidence and an accommodation pathway that can support the person’s actual needs. This checklist helps support coordinators, hospital social workers and allied health teams prepare a referral.
Who is responsible for what?
The health system is responsible for medical treatment, discharge planning, clinical evidence and confirming that the person is medically ready to leave hospital. The NDIS may fund reasonable and necessary disability supports that meet its criteria. A support coordinator helps the participant understand options, organise evidence, connect providers and coordinate implementation.
An accommodation or SIL provider assesses whether it can safely deliver the requested service. That assessment should be participant-led and should never be reduced to “a bed is available.”
First-call information
A concise first call helps a provider decide whether a detailed review is appropriate. Be ready to explain:
- the participant’s name, consent and authorised decision-makers
- current hospital and expected medical-readiness date
- why the person cannot return to their previous home
- requested pathway: MTA, SIL, SDA, individual support or another option
- preferred location and non-negotiable accessibility needs
- daily and overnight support requirements
- known risks and urgent equipment needs
- current NDIS plan dates, funding and management type
- the intended long-term housing goal.
Clinical and functional documents
Only share information with the participant’s or authorised representative’s consent and through an agreed secure method. Useful documents may include:
- hospital discharge summary or current medical summary
- social work report and discharge plan
- occupational therapy functional assessment
- mobility, transfer and manual-handling plans
- mealtime-management or swallowing plan
- continence plan and personal-care routines
- medication list and administration arrangements
- behaviour support plan and restrictive-practice information
- skin integrity, pressure-care or wound-care instructions
- communication profile and supported decision-making preferences
- risk assessments, emergency plan and escalation contacts
- equipment list, prescriptions and delivery dates.
Funding and service documents
- current NDIS plan or relevant funding breakdown
- plan-management or NDIA-management information
- approved home-and-living decision, if available
- SIL budget and proposed typical schedule of supports, where relevant
- MTA funding dates or evidence request status
- SDA eligibility, design category and property requirements
- service agreement decision-maker and invoicing contacts
- support coordinator, plan manager and NDIS contact details.
Accommodation and equipment readiness
Before the move, confirm that the proposed environment matches the participant’s needs. Check bedroom and bathroom access, circulation space, hoist or transfer requirements, emergency exits, assistive technology, power needs, transport access and any environmental triggers.
List every item that must be available on day one. Record who will supply it, who will fund it and the delivery date. A transition should not rely on equipment “arriving soon” when the missing item is essential for safe care.
Staffing and handover
Translate assessments into an actual support roster. Clarify:
- hours of active support and whether support is shared or individual
- active overnight, sleepover or on-call arrangements
- two-person support or manual-handling requirements
- required competencies and participant-specific training
- medication, epilepsy, diabetes, enteral feeding or other delegated support arrangements
- behaviour support and restrictive-practice authorisations
- hospital-based shadow shifts, introductions or transition visits
- who can answer clinical questions after discharge.
Training should be completed before commencement when a delay would create avoidable risk.
Choosing the correct temporary pathway
| Situation | Possible pathway to explore |
|---|---|
| Participant needs temporary accommodation while an approved long-term home or supports are being prepared | MTA, subject to NDIA criteria |
| Participant and primary informal supports need a planned short break from usual care arrangements | Short-term respite, subject to plan funding and current rules |
| Participant needs ongoing high-level daily support at home | SIL or another home-and-living support, depending on assessment |
| Participant requires a specialist-designed dwelling | SDA eligibility and enrolled dwelling, with supports funded separately |
| Person has nowhere safe to stay tonight or is in immediate danger | Emergency, crisis-housing or mainstream response—not MTA |
Common causes of delayed discharge
- unclear long-term housing goal
- outdated functional evidence
- funding that does not match the proposed roster
- equipment not ordered or no confirmed delivery date
- provider selected before suitability is assessed
- missing behaviour, mealtime or medication plans
- unclear consent or decision-making authority
- clinical responsibilities incorrectly shifted to disability support workers
- no owner for each action and no escalation date.
A practical transition meeting agenda
- Participant’s goals, preferences and consent.
- Medical-readiness date and outstanding health actions.
- Accommodation pathway and environmental assessment.
- Daily and overnight support roster.
- Equipment, medication and clinical handover.
- Funding, agreements and responsible contacts.
- Move-day plan and contingency arrangements.
- First review date and long-term transition milestones.
Frequently asked questions
Can a hospital refer directly to an NDIS accommodation provider?
Yes, with the participant’s or authorised representative’s consent. The provider must still complete its own suitability, safety, capacity and funding review.
Does the NDIS fund support while someone is admitted to hospital?
In general, the health system is responsible for supports during an inpatient admission. NDIS-funded supports after discharge must meet the applicable NDIS criteria.
Can MTA be used when no long-term address is confirmed?
Current NDIS guidance says a participant being discharged from hospital may not need a confirmed long-term home, but they must meet the relevant home-and-living pathway and funding criteria.
What is the fastest way to get a provider decision?
Provide clear consent, current assessments, the expected discharge date, requested pathway, funding information, actual daily and overnight needs, equipment requirements and the long-term housing goal.
Refer to Eden Ability
Support coordinators, hospital teams, social workers and allied health professionals can review our hospital-discharge and accommodation referral pathway and call 1300 22 88 56 to discuss suitability and current capacity.
This guide is general information, not clinical, legal or funding advice. The participant’s hospital, NDIA contacts and qualified professionals remain responsible for their respective decisions.
