Briefings for support coordinators · Complex Care Continuum · September 2026

A participant with complex needs is on a ward in Perth, medically ready to go home, and the ward wants the bed. The next ten days decide whether they go home with a roster that holds, or bounce back through the emergency department within a fortnight. This is the sequence we use with coordinators when we take a discharge referral. It is written for Western Australia, where the hospital side runs through WA Health’s discharge planners and the NDIA’s Health Liaison Officers.

Before you start: the two NDIA clocks

Since September 2022 the NDIA has held itself to two commitments for participants in hospital: it will contact the participant (or their nominee) within four days of being told about the admission, and it will approve a discharge plan within 30 days. Both clocks start when the hospital notifies the Health Liaison Officer (HLO) connected to that hospital. If nobody has notified the HLO, neither clock is running, and that is the single most common reason a discharge drifts. Your first question on any admission is therefore not “what supports do they need” but “has the HLO been told, and on what date”.

Day 1 to 2: get the facts and the consent

• Confirm the HLO notification. Ask the ward social worker or discharge planner for the date the HLO was notified and the HLO’s name. If it has not happened, ask them to do it today and confirm back to you in writing.
• Get consent for information sharing. The hospital cannot send clinical information to the NDIA or to a provider without the participant’s (or nominee’s) consent. A signed consent on day one saves a week later.
• Establish “medically ready” versus “discharge ready”. These are different. Medically ready means the treating team has no further acute reason to keep the person. Discharge ready means the supports, equipment and home are in place. Write both dates down and keep them separate in every conversation, because the hospital will talk about the first and you are responsible for the second.
• Ask for the clinical picture in provider terms. Airway and breathing, feeding and swallowing, medications and how they are given, continence, transfers and manual handling, skin, behaviour, communication. A provider can give you a capacity answer within the hour if you can tell them these seven things. They cannot if all you have is a diagnosis.

Day 2 to 3: does the plan fund what going home needs?

Compare what the ward says the person needs with what the current plan funds. The gaps are usually one of three kinds: the plan funds daytime support but the person now needs active overnight; the plan funds standard support but the person now needs high-intensity daily personal activities (tracheostomy, PEG, ventilation, complex bowel care, seizure management, subcutaneous injections); or the plan has no community nursing and the person now needs a registered nurse’s oversight. If there is a gap, the discharge plan the NDIA approves within 30 days has to close it, and the evidence for that comes from the hospital. Ask the treating team for a letter that states the functional impact and the support required in hours, not just the diagnosis. The NDIA’s optional Discharge Assessment template, which hospital staff can get from their HLO, is a good structure for that letter.

Day 3 to 4: capacity, honestly

Now ring providers, and ask each one the same question: can you staff this roster, with these clinical competencies, from this date, and will you put that in writing. A provider who says yes without asking about the overnight, the transfers or the competencies is guessing, and a guessed yes is what produces the missed first shift. Ask specifically whether the workers who will be rostered have been assessed as competent for the clinical tasks involved, and who signs that off. For high-intensity supports the answer should be a registered nurse.

If you are talking to us, this is the point at which you use the capacity check on our support coordinator page. Initials and suburb are enough; we call back within the hour with a yes, a no, or a yes-from-a-date.

Day 4 to 6: the provider meets the participant on the ward

Insist on this. A provider’s nurse or clinical lead should meet the participant, the family and the ward team before discharge, not after. That visit is where the mealtime plan, medication chart, transfer method, equipment list and any behaviour support plan are reconciled with what the home actually looks like. It is also where the family meets a face that will be on the first shift. In our experience the discharges that fail are almost always the ones where the first time the provider met the participant was at the front door.

Day 5 to 8: equipment, home and the roster

• Equipment. Hoist, bed, pressure mattress, suction, feeding pump, commode. Confirm delivery dates in writing and who is training the workers on each item. Equipment that arrives the day after discharge is the second most common reason for readmission.
• Home. Can a worker get the person in and out, is there somewhere for an overnight worker to be, is there power for the equipment, are there pets, is there anyone else living there who needs to be part of the plan.
• Roster. Ask the provider for the named workers for the first fortnight and the date each was inducted to this participant. Named workers, not “a team”.
• Medications. The hospital’s discharge medication list, reconciled by the provider’s nurse against what is actually in the house. Webster packs ordered before discharge, not after.

Day 8 to 10: the handover and the first 72 hours

On the day, the provider should have a worker at the hospital for the handover or at the house when the ambulance or transport arrives, and a nurse contactable for the first 72 hours. Ask the provider what their escalation path is if something goes wrong at 2am on night one, and who you will hear from. Then diarise a call with the family on day three, because that is when the small problems surface: a feed that is running late, a worker who has not been shown the hoist, a medication that was not in the pack.

What to keep for the plan reassessment

Everything above is evidence. The hospital’s letter, the dates the HLO was notified and responded, the gap between medically ready and discharge ready, the equipment and roster that were needed to make home safe, and the readmissions that did not happen. Keep it in one place, because the next plan has to fund what this discharge proved was necessary, and the provider’s monthly summaries and plan-review report should build on it rather than start again.

If you have a participant on a ward now, the capacity check is on our support coordinator page, and the full picture of how we handle a transition is in the hospital discharge guide. Or ring (08) 9515 8000; it is answered around the clock and hospital referrals are called back within the hour.

Makena, Registered Nurse, Clinical Lead, Complex Care Continuum. This briefing is general information for support coordinators and is not clinical or legal advice for an individual participant.