Accommodation and disability-support coordination for eligible participants who are preparing to leave hospital and need a safe, planned next step.
From hospital to the right support setting
A delayed or poorly coordinated discharge can create stress for participants, families and clinical teams. Eden Ability works with the participant and their support network to understand accommodation, accessibility and day-to-day support requirements before a transition is agreed.
Referral coordination
One point of contact for participants, nominees, social workers, support coordinators and relevant clinicians.
Accommodation review
We consider availability, accessibility, location, staffing and the intended longer-term housing pathway.
Transition planning
Clear responsibilities, support information and move-in arrangements are agreed before discharge where possible.
Who can contact us
- NDIS participants and nominees
- Hospital social workers and discharge planners
- Support coordinators and recovery coaches
- Allied health and clinical teams
- Family members and informal supports, with participant consent
Important information
Eden Ability is not an emergency medical service and cannot replace clinical care, crisis accommodation or emergency response. If someone is in immediate danger or needs urgent medical assistance, call 000.
Accommodation and supports depend on suitability, vacancy, participant consent, funding and the information available to the referral team.
View the discharge checklistInformation we need for an initial review
Current situation
Hospital, expected discharge date, current risks and why the present setting cannot continue.
Disability support
Daily living assistance, mobility, communication, behaviours, overnight support and equipment needs.
Funding and housing
Relevant NDIS funding, support coordination contacts and the planned medium- or long-term housing pathway.
For social workers and hospital discharge teams
What a hospital team needs to confirm before discharge
A safe referral is more than finding a room. These are the practical details we review with the participant, hospital team, support coordinator and treating clinicians.
Discharge readiness and timing
Expected discharge date, current admission status and whether the participant is medically ready to leave hospital.
NDIS and funding pathway
Current NDIS plan, home-and-living status, support coordination contacts and any plan reassessment underway.
Property accessibility
Mobility, transfers, bathroom access, bedroom needs, assistive technology and environmental requirements.
Support capability
Required staffing ratios, active or inactive overnight support, behaviours of concern and specialist competencies.
Clinical and equipment handover
Medication, wound care, continence, mealtime management, equipment delivery, training and follow-up appointments.
Consent and continuity
Participant consent, decision-maker details, discharge summary, risk plans and the contacts responsible after discharge.
Hospital discharge support in Sydney and the Eastern Suburbs
Our team is based in Mascot and can discuss referrals from hospitals across Sydney, including participants returning to Bondi, Randwick, Maroubra, Mascot and nearby Eastern Suburbs communities.
Official guidance: NDIS guide to your hospital stay and NDIS medium-term accommodation information.
How the referral moves forward
Initial contact
Call, email or send an enquiry with the participant’s consent and essential referral details.
Multidisciplinary review
We clarify support, accommodation, clinical and transition information with the relevant people.
Agreed next step
If we have a suitable option, the team develops a practical transition plan and confirms responsibilities.
Questions hospital and social-work teams ask
Can a hospital social worker or discharge planner refer to Eden Ability?
Yes. Hospital teams, support coordinators, participants, nominees and families can make an initial enquiry. Participant consent and the appropriate information-sharing arrangements must be confirmed before sensitive documents are provided.
Can Eden Ability review an urgent hospital discharge referral?
We can review urgent enquiries, but acceptance depends on participant consent, sufficient clinical and functional information, a suitable vacancy, accessibility, staffing, funding and a safe handover. Contact us early and state the target discharge date.
Does a participant need a confirmed long-term home before hospital discharge MTA can be considered?
Current NDIS information says a participant being discharged from hospital may have MTA added if they are eligible for SDA, SIL, ILO or home modifications, and they do not need a confirmed long-term home. The NDIA makes funding decisions and Eden Ability must separately confirm a suitable property and support arrangement.
What does NDIS Medium-Term Accommodation pay for?
Current NDIS guidance describes MTA as accommodation funding for up to 90 days. It does not include food, utilities or personal care supports; approved disability supports are funded separately through the participant’s plan.
What information is needed for an initial discharge review?
Useful information includes consent, current NDIS plan and contacts, discharge date, functional and accessibility needs, daily and overnight supports, equipment, medications and health-support plans, risks, behaviour support where relevant, and the intended longer-term pathway.
Can the participant be discharged before equipment and supports are ready?
A discharge should proceed only when the receiving environment, essential equipment, disability supports, medications, handover and escalation contacts are properly coordinated. Eden Ability will identify outstanding items rather than represent an incomplete arrangement as ready.
Can clinicians send reports directly?
Yes, with appropriate participant consent and secure information sharing. Contact our team before sending sensitive documents so we can confirm the correct recipient and process.
What happens if there is no suitable vacancy?
We will explain that clearly. The support coordinator, hospital liaison officer and discharge team can continue considering other accommodation, home-and-living and community options instead of relying on an unsuitable placement.
Need to discuss a discharge pathway?
Call 1300 228 856 or visit Shop G2/669 Gardeners Rd, Mascot NSW 2020.