Podcast highlights: Supporting a person who needs to leave hospital

Kaitlyn King and Linda Hughes

Episode 2 of UpSkill’s Best Practice podcast series talks about how to support a person with complex support needs to leave hospital.
Empty space, drag to resize
In this podcast we hear from Sally and her Mum Jenny about how support coordinators helped Sally leave hospital and achieve what initially seemed impossible. Support coordinators Laura Schutz and Alex Foote from Independence Australia talk about working collaboratively with hospital teams and making it happen.  Below are some key learnings from the podcast, but we suggest you have a listen to find out more.
Empty space, drag to resize


A person in hospital will often tell their support coordinator their main goal is to get out of hospital as soon as possible! Support coordinators can help the person understand what ‘getting out of hospital’ can look like by asking questions. When a person says “I want to go home”,  Laura suggests asking follow-up questions such as: What does that mean to you? What are you going home to? What are your main concerns? This will help the person articulate their wishes and priorities so you can start working together to plan a discharge from hospital. 

There can be a lot of information and actions to work through when a person is in hospital, but it needs to be done at the person’s pace.  Make sure you don’t overload or overwhelm the person with information. 

Support coordinators can ask the person how much information they want, and how they would like to receive it. This might be through a phone conversation, a written update or being included on email correspondence. The support coordinator needs to strike a balance between listening to the person, prompting and supporting them to unpack what they want, and providing important information in a clear and sensitive way. 

Remember, what’s a priority for one person will not necessarily be a priority for another person. Make sure you are listening to the person.

Empty space, drag to resize

Working collaboratively

Building rapport, confidence and respect across teams is an important part of collaboration. Alex and Laura recommend getting together as soon as possible with the person and their hospital team so everyone can understand each other’s roles. With collaboration you can establish timeframes, allocate responsibilities to reduce duplication, assign action items, and agree on how frequently you are going to meet and communicate. Remember to ensure the person is included in these plans and their voice and wishes don’t get lost. 

Sally and her Mum encourage support coordinators to consider how to best include the participant’s voice during meetings with the hospital team. An example they shared is pre-recording a video to communicate the person’s wishes, which the support coordinator can take to a meeting if the person and their family are unable to attend. 

Support coordinators should have a good understanding of NDIS principles, operational guidelines and relevant legislation, as well as showing the person and hospital team just what’s possible with the NDIS.

Hospital teams are busy and Alex and Laura suggest being proactive in learning about hospital processes and roles to help build collaborative working relationships. Working with people in hospital and their hospital team can also present great learning opportunities for support coordinators – so be open to learning lots of new information and skills along the way! 

Sometimes it is not clear whether the NDIS or health is responsible when it comes to disability related health supports. Laura suggests “a good rule of thumb is if the support is directly related to the person’s disability and the support is ongoing, it is likely to be able to be funded by the NDIS”.

Laura and Alex have found getting funding for disability related health supports can involve extra time and obstacles. It can be helpful to work with the hospital team to come up with a solution, so this can be presented to the NDIS in line with reasonable and necessary criteria and COAG principles of responsibility.

Empty space, drag to resize

Help a person understand their housing and support needs and preferences

Sally and Jenny talk about the importance of having the right support in place to not only leave hospital, but to ensure a successful outcome once back living in the community. For Sally, this includes building a community of support and making sure she connects with her support workers.

Alex and Laura encourage support coordinators to help the person think holistically about what their future will look like when they do move out of hospital. This can help the person articulate what they want their housing to look like and what their priorities are. 

Hospital teams do a lot of work to understand  a person’s support needs,  but in hospital a person does not get a lot of say about flexibility over their routine – for example, what time they can have a shower. Part of the support coordinator’s role is to let people know that once they leave hospital, they will have more choice and control  about how, when and who supports them.

Laura and Alex suggest encouraging the person to think about their lifestyle outside of hospital, so a support model can be designed around this. Ask questions like: What’s important to you in your everyday life? Which aspects of this do you need support with? What do you want to be able to do? What role will family and informal supports play? 

Understanding this, support coordinators can build a support model around the person. 

Sometimes a person cannot return to living in their previous home – it might not be accessible or suitable for their support needs. Support coordinators  can help explore  new housing.  Keep the person at the centre, find out what’s important to them: What do they enjoy about their surroundings? Do they want housemates, or would they prefer to live alone? What would they like to be close to? Alex and Laura use a template for this conversation and  record the person’s preferences in how they want to live.
Empty space, drag to resize

Interim plans

Keep in mind the person’s best long-term housing options may not be available or ready to move into from hospital. Sometimes short-term or interim housing may be necessary. In these scenarios, help the person consider the benefits and risks of staying in hospital versus moving into interim housing. If interim housing is required, consider using Medium Term Accommodation (MTA). 

Interim plans are usually for 3-6 months and are a collaborative effort between health and the NDIS. Interim plans can be extremely helpful when put in place early in a person’s hospital admission as they allow the support coordinator to become involved early in the discharge planning process. This means the person, their support coordinator and their hospital team can work together to make sure everything is in place to successfully support the person to transition out of hospital.

In Sally’s case, having an interim plan meant her support coordinator could start working with her hospital team to plan what Sally needed when she was discharged from hospital. It also allowed Sally’s support workers to attend the hospital to complete ‘shadow shifts’ with nursing staff, to learn how to meet Sally’s needs so everyone was confident Sally could be well supported when she transitioned home. It also meant Sally could start spending some time away from the hospital ward with her support team to help her prepare for life after hospital. Both Sally and Jenny agree this was an integral part of Sally’s successful transition out of hospital.

You may also be interested in: