A family's guide to arranging supports after hospital discharge
Reviewed by the My Care Link Australia Editorial Team · Last reviewed
Hospital discharge moves faster than anyone expects. This guide is for families who have just been told a discharge date and need supports in place at home — what to organise first, who pays for what, and how to get providers moving in days rather than weeks.
The first conversations to have
- Ask the ward for the hospital social worker or discharge planner by name — they coordinate the whole thing
- Ask for the expected discharge date in writing, and ask to be told if it moves
- Ask the treating team what support is needed at home, in specific terms: personal care, transfers, medication, mobility
- Ask whether an occupational therapist has assessed the home, and request one if not
- Ask whether equipment is being arranged, and by whom
Write down who said what and when. Discharge involves many people and things get lost between them.
Who pays for what
There are several pathways and they do not all apply at once. Which one fits depends on age, existing plans and whether the need is temporary.
- Existing NDIS plan — supports may already be funded, and a change of circumstances request can be made if more is needed
- New to the NDIS and under 65 — an access request can be started, but it will not be decided in time for discharge
- Over 65 — My Aged Care, including short-term restorative care and Home Care Packages
- Short-term recovery — state health services often fund transition care or post-acute support for a limited period
- Private — sometimes the only way to cover the first few weeks while funding is arranged
Ask the hospital social worker directly which pathway they are pursuing, and whether interim funding exists for the gap.
What to arrange first
- Personal care for the first mornings — showering, dressing, medication prompts
- Equipment that must be in the home before arrival: bed, shower chair, rails, walking aids
- Transport home and to the first follow-up appointments
- Meals for the first week
- A cleaner or help at home if nobody is staying over
- A phone list on the fridge: GP, treating team, providers, after-hours numbers
Getting providers moving quickly
Availability is the constraint, not paperwork. Providers with capacity at short notice exist, but finding them by ringing around takes days most families do not have.
Tell us the suburb, the discharge date and what is needed, and we come back with providers who can actually start. We do this regularly for hospital discharge teams and families, and it is free.
The first fortnight at home
- Expect the support plan to need adjusting after the first few days — nothing survives contact with the real house
- Watch for fatigue: the first week home is harder than the hospital expects
- Keep a short log of what worked and what did not — it is evidence for any funding request
- Book the GP follow-up in the first week
- Check in with the family member doing the most; they are usually the one who breaks
About this guide. Written and reviewed by the My Care Link Australia team as general information for NDIS and aged care participants, families and support coordinators. Read our editorial guidelines and provider review process.
This guide is general educational information only. It is not medical, legal or financial advice. For decisions about your individual situation, please speak with the appropriate qualified professional.
Frequently asked questions
Who arranges support when someone leaves hospital?
The hospital social worker or discharge planner coordinates it, but families usually need to chase providers, equipment and funding themselves.
Can the NDIS fund supports straight after discharge?
If there is an existing plan, supports may already be funded and more can be requested through a change of circumstances. A new NDIS application will not be decided in time for a discharge date.
What if the person is over 65?
My Aged Care is the pathway, including short-term restorative care and Home Care Packages. State health services may also fund short-term post-acute support.
How quickly can support workers start?
Some providers can start within days if they have capacity in the area. The hard part is finding who does — that is what our free matching service checks.
What equipment needs to be at home before discharge?
Whatever the treating team or occupational therapist recommends — commonly a bed, shower chair, rails and mobility aids. Confirm who is arranging and delivering each item.
Related services
NDIS Personal Care
Help with showering, dressing, grooming, toileting and daily personal hygiene.
NDIS Help at Home
Cleaning, gardening, meals, laundry and household tasks under your NDIS plan.
NDIS Nursing Supports
Clinical care at home including wound care, medication and health monitoring.
NDIS Occupational Therapy
OTs help build skills for daily living, work, study and play.
NDIS Transport
Help getting to appointments, work, study and community activities.
Get free help finding a provider
Tell us what you need — we'll come back within 24 hours.
Tell us what you need
We'll use this information to connect you with suitable providers.
Sources and further reading
Rules, funding amounts and wait times change. We check these primary sources when we update this page, and you should confirm current details directly with them.
- National Disability Insurance Scheme (NDIS)(opens in a new tab) — National Disability Insurance Agency. Official scheme information, eligibility and current processes.
- NDIS Pricing Arrangements and Price Limits(opens in a new tab) — National Disability Insurance Agency. The current price limits that govern what providers can charge.
- NDIS Quality and Safeguards Commission(opens in a new tab) — NDIS Quality and Safeguards Commission. Provider registration, practice standards and complaints.
- NDIS Commission provider register(opens in a new tab) — NDIS Quality and Safeguards Commission. Check whether a provider is registered.