When someone with complex needs is ready to leave hospital, the hard part is often not the medicine. It is getting the right supports funded, trained and standing in the home before the discharge date. Complex Care Continuum is a registered NDIS provider (4050153886) based in Girrawheen that specialises in exactly this handover. This guide explains how discharge works for NDIS participants in Perth, who to contact at each major hospital, and how to refer someone to us so support is ready when they are.
Need to place someone now? Call (08) 9515 8000 or use the referral form below. Our referral line is answered 24 hours a day, 7 days a week, and hospital referrals are called back within one hour.
How hospital discharge works with the NDIS
The National Disability Insurance Agency (NDIA) runs a dedicated hospital discharge process. Knowing the steps lets families and ward staff push things along rather than wait.
- Tell the hospital the patient is an NDIS participant (or may be eligible). With the patient’s consent, hospital staff notify the NDIA. Families can also notify the NDIA directly on 1800 800 110 or through the participant’s my NDIS contact.
- The NDIA commits to making contact within four days of being notified. A Hospital Liaison Officer (HLO) is assigned to work with the ward, the participant and their support coordinator.
- The hospital provides evidence of the participant’s needs on discharge. Where a new home-and-living arrangement is needed, the NDIA carries out a home and living assessment.
- The NDIA creates or changes the plan, then shares the approved plan with the hospital and support coordinator so providers can be engaged before discharge.
- A plan implementation meeting connects providers, and support starts on the day the participant leaves.
If the patient is not yet on the NDIS but has acquired a permanent and significant disability, hospital staff can refer them to the NDIA for an access request, which the NDIA treats as a priority, usually deciding within 7 to 10 days.
Where Complex Care Continuum fits
Our job is to remove the gap between “medically ready” and “safely home”. From the first call we work in parallel with the ward and the NDIA rather than waiting for each step to finish:
- Bedside assessment at the hospital, usually within two business days of referral, with the participant, family and treating team
- A written support proposal the support coordinator and HLO can use as evidence for plan funding
- Recruiting and training a consistent team on the participant’s specific care plan before discharge, including high intensity supports such as PEG feeding, tracheostomy care, ventilation, complex bowel care and seizure management
- Registered nurse oversight of clinical tasks and competency sign-off
- Home readiness: equipment, access, routines and emergency plans checked before discharge day
- A support worker present at the hospital handover on discharge day, then daily check-ins for the first week
Perth hospital contacts
Every public hospital in Perth has social work and discharge planning staff who coordinate with the NDIA. There is no separate public phone line for them; call the switchboard below and ask for the social work department or discharge coordinator for the patient’s ward. Numbers are the hospitals’ published general enquiry lines, checked August 2026.
| Hospital | Switchboard | Ask for |
|---|---|---|
| Royal Perth Hospital, Wellington St, Perth | (08) 9224 2244 | Social work / discharge coordinator for the ward |
| Sir Charles Gairdner Hospital, Nedlands | (08) 6457 3333 | Social work / discharge planning |
| Fiona Stanley Hospital, Murdoch | (08) 6152 2222 | Social work / complex discharge |
| Fremantle Hospital | (08) 9431 3333 | Social work |
| Joondalup Health Campus | (08) 9400 9400 | Social work / care coordination |
| Osborne Park Hospital, Stirling (rehabilitation) | (08) 6457 8000 | Rehabilitation social work / discharge planning |
| St John of God Midland Public Hospital | (08) 9462 4000 | Social work |
| Perth Children’s Hospital, Nedlands | (08) 6456 2222 | Social work / disability liaison |
| Rockingham General Hospital | (08) 9599 4000 | Social work |
| Armadale Health Service | (08) 9391 2000 | Social work |
| NDIA (National Disability Insurance Agency) | 1800 800 110 | Hospital discharge / Health Liaison Officer |
What to have ready when you refer
You do not need all of this to make contact; the first call can be two minutes. But discharge moves faster when we can get these from the ward or coordinator early:
- Participant’s name, date of birth and NDIS number (if they have one)
- Hospital, ward and the name of the treating team or social worker
- Expected discharge date and whether the patient is already medically ready
- Current NDIS plan, or the status of the plan review or access request
- Support coordinator’s name and contact details
- Discharge summary, nursing care plan and any allied health reports (OT home assessment, physiotherapy transfers plan, speech pathology mealtime plan)
- Behaviour support plan, if there is one
- Where the participant will live on discharge and who else is in the home
For families
If you are reading this at a bedside, three things help most. First, tell the ward social worker today that your family member is an NDIS participant and that you want the NDIA notified; ask for the name of the Hospital Liaison Officer once one is assigned. Second, ask for the expected discharge date in writing, because plan changes are prioritised around it. Third, call us. You do not need to know the NDIS rules; we will talk you through what is fundable and speak with the coordinator and ward on your behalf if you want us to.
Frequently asked questions
How quickly can support start after discharge?
Where the plan already has funding and we are contacted a few days before discharge, support can start on discharge day. Where a plan change is needed, timing depends on the NDIA, but our assessment and support proposal usually shortens that wait because it gives the HLO the evidence they need.
Can you support someone who is not yet on the NDIS?
We can take part in planning and be ready to start once access and funding are approved. Ask the hospital to lodge the access request as a priority.
Which hospitals do you work with?
Any Perth hospital. Most of our discharges come from Royal Perth, Sir Charles Gairdner, Osborne Park, Joondalup and Fiona Stanley, and the participant usually returns to a home in Perth’s northern suburbs.
Do you provide 24-hour support at home after discharge?
Yes, where the plan funds it and the home is safe for workers, including active overnight support.
What if the participant needs somewhere to live first?
We support participants in supported independent living and short-term accommodation, and we work with SDA providers where specialist housing is needed. The NDIA’s home and living assessment during the admission is the key step; tell the HLO early that housing is a concern.
Discharges across Perth and Peel
We take hospital discharges from every major public and private hospital in the metropolitan area and Peel, and we have local pages for Joondalup, Osborne Park and Stirling, Nedlands and the western suburbs, Perth city and the inner east, Midland and the hills, Bentley and the south-east, Murdoch, Fremantle, Armadale, Rockingham and Kwinana and Mandurah. Once someone is home, the same team continues with complex care, high-intensity daily personal activities, community nursing, supported independent living and respite, so there is no second handover. Support coordinators can check our capacity and see what happens after a referral on the support coordinator hub.
Refer a patient
Call (08) 9515 8000 any time, day or night, email info@complexcarecontinuum.com.au, or complete the form below. Hospital referrals are called back within one hour, including evenings and weekends. If discharge is imminent, ring rather than wait for the form.