Hospital Discharge and the NDIS: Who Does What, and How Long It Should Take

There’s a particular kind of stuck that families only learn about from the inside.

The treating team says the words “medically ready for discharge”. Everyone exhales. And then nothing happens. A week passes. Then a fortnight. The person is occupying an acute hospital bed they no longer clinically need, losing confidence and muscle tone by the day, while somewhere in the background a plan is being written, or an assessment is being waited on, or a piece of equipment hasn’t been approved.

Nobody is being negligent. The problem is that discharge for an NDIS participant requires two large systems — health and the NDIS — to hand off cleanly, and neither of them owns the whole process. In the gap between them, people wait.

This guide is about closing that gap. It sets out what the NDIA has publicly committed to doing and how quickly, who is responsible for which part, what a Hospital Liaison Officer is and why you want one involved on day one, and what to do when things stall anyway.

It’s written for participants, families and support coordinators. Nothing here is clinical advice — the treating team owns the medical decisions. This is about the process around them.

The commitments the NDIA has published

Start here, because almost nobody knows these exist, and knowing them changes the conversation from “please hurry” to “this was due four days ago”.

The NDIA publishes specific commitments for participants in hospital:

• Within 4 days of being notified of a hospital admission, the NDIA will contact the participant, or their authorised nominee or representative.
• Within 4 days of notification, a Health Liaison Officer will contact hospital staff.
• For prospective participants — people not yet in the scheme — access requests are completed within 7 to 10 days of notification, and eligibility is usually assessed in the same 7 to 10 day window.
• Where required, specialised planners create urgent discharge plans.

Read those again, because there’s a condition buried in all of them: of being notified. Every clock starts when somebody tells the NDIA that the person is in hospital. If nobody does, no clock starts at all, and the first anyone hears about a discharge is when a family rings in a panic at week six.

So the single most useful thing in this entire guide is this: make sure the NDIA is notified on day one of the admission. Hospital staff are meant to identify existing participants and, with consent, notify the NDIA. They often do. They also often don’t, particularly in a busy emergency admission where nobody has asked whether the person has an NDIS plan.

Don’t assume it happened. Ask directly: “Has the NDIA been notified of this admission, and when?” If the answer is vague, ask the ward’s social worker to do it, and ring the NDIA yourself on 1800 800 110 as well. Duplicate notification costs nothing. Missing notification costs weeks.

Who is actually responsible for what

The NDIA publishes a division of responsibility across three parties. It’s worth knowing in detail, because most delays happen when everyone assumes someone else is doing something.

The NDIA’s responsibilities

• Contacts the participant and liaises with the hospital through Health Liaison Officers
• Requests any further information needed for planning
• Conducts a home and living assessment if one is required
• Holds the planning meeting
• Prepares, approves and implements the plan, including the Request for Service
• Notifies hospital staff once the plan is approved
• Hands the plan back to the participant’s usual planner after discharge
• Funds any assessments needed once the participant has returned home

Hospital staff responsibilities

• Identify existing NDIS participants and, with consent, notify the NDIA
• Help prospective participants lodge an access request
• Provide health information and evidence before the planning meeting — there’s a Discharge Assessment template available for exactly this purpose
• Undertake comprehensive discharge planning
• Prepare the discharge summary

The support coordinator’s responsibilities

• Engages the participant, the HLO, the NDIA team, and the key people in the participant’s life
• Understands the current living situation and what informal supports exist
• Scopes the market — which providers can actually deliver what’s needed, and when
• Supports the transition itself
• Runs a discharge planning meeting with hospital staff if one is required
• Follows up after discharge to make sure the person is stable

Look at that third list closely. A great deal rests on the support coordinator, and a participant without one — or with one who is overloaded and reactive — is at a significant disadvantage. If there’s no support coordination in the plan and a hospital discharge is looming, that is itself worth raising with the NDIA urgently.

What a Health Liaison Officer actually does

This is the role families most often have never heard of, and it’s the one that can unstick things fastest.

Health Liaison Officers — sometimes called Hospital Liaison Officers, and usually just HLOs — are NDIA staff whose job is the interface between hospitals and the scheme. They work directly with hospital teams, help identify participants, chase the information the NDIA needs, and keep a discharge moving through the planning process.

They are, in effect, the person inside the NDIA whose job it is to care that someone is stuck in a bed.

Practical things to know:

You can ask for one. If your hospital team hasn’t mentioned an HLO, ask the ward social worker or discharge planner whether one has been engaged. If nobody has, ask for it directly.

They talk to the hospital, not usually to you. The HLO’s primary relationship is with hospital staff. Your route to them is normally through the social worker, the discharge planner or your support coordinator rather than directly — though the NDIA contacting the participant within four days is a separate commitment.

They can escalate. An HLO who understands that a person has been medically ready for three weeks can push internally in ways a family phone call cannot.

Not every hospital has a good relationship with one. Larger metropolitan hospitals generally have established HLO contacts; smaller and regional hospitals sometimes don’t. If you’re in a smaller facility, the HLO connection may need to be actively created rather than assumed.

A realistic discharge timeline

Here’s how a well-run NDIS discharge actually sequences. Compare it against what’s happening in your situation to find where things have stalled.

Day 1 — Admission. Hospital identifies the person as an NDIS participant and notifies the NDIA with consent. Family confirms this has happened. If the person is not yet an NDIS participant but may be eligible, hospital staff help lodge an access request immediately — don’t wait to see how recovery goes.

Days 1–4 — Contact established. The NDIA contacts the participant or nominee. An HLO makes contact with hospital staff. The support coordinator, if there is one, is engaged and starts building a picture of the current living situation.

Week 1–2 — Evidence gathering. The treating team assesses what the person will need on discharge. Occupational therapy assessment of the home. Allied health input. Any changed clinical needs documented. The hospital provides health information to the NDIA, ideally using the Discharge Assessment template.

This is the stage where delays most often begin, and the usual cause is an OT home assessment that hasn’t been booked. Ask in week one whether it’s scheduled.

Week 2–3 — Planning. The NDIA holds the planning meeting. Where the discharge is urgent, a specialised planner should be creating an urgent discharge plan rather than queuing it behind routine work. If your discharge is being treated as routine and the person is in an acute bed, say so explicitly and ask for it to be escalated.

Week 3–4 — Plan approved and implemented. The plan is approved, hospital staff are notified, and the Request for Service goes out. The support coordinator starts securing actual providers — which is a different job from having funding approved, and takes its own time.

Before discharge — Everything in place. Equipment delivered and installed. Home modifications completed or an interim arrangement agreed. Support workers recruited, trained for this person’s specific needs, and rostered. Medication supply sorted. Follow-up appointments booked.

After discharge — Follow-up. The plan returns to the participant’s usual planner. The support coordinator checks the person is stable. The NDIA funds any further assessments now needed at home.

Four weeks is a good run. Many take longer. But a timeline you can point at makes it visible where the blockage is, and visible blockages get fixed faster than vague frustration.

The seven things that actually delay discharges

From the pattern of cases we see, delays almost always sit in one of these. Check them early rather than discovering them at week five.

1. Nobody notified the NDIA. Covered above, and genuinely the most common. Every NDIA commitment is conditional on notification.

2. The OT home assessment hasn’t been booked. An occupational therapist needs to assess whether the person can safely return to their home as it is. Until that’s done, nobody knows whether you need equipment, modifications, or a different home entirely. Book it in week one.

3. Equipment lead times. A hospital bed, a hoist, a pressure mattress, a commode — approval is one timeline, supply and delivery is another, and installation can be a third. Some items take weeks. Ask early what’s needed and start the process before the plan is finalised where possible.

4. Home modifications. A ramp, a bathroom modification, door widening. These involve assessment, quotes, approval and then actual building work. This is the single biggest cause of long discharge delays, and it’s the one where interim accommodation most often becomes necessary.

5. Support worker recruitment and training. Funding approved is not the same as support available. If the person needs high intensity supports — enteral feeding, complex bowel care, tracheostomy support — workers need to be recruited and assessed as competent for that specific person, which takes real time. Tell any prospective provider the clinical detail at first contact so they can tell you honestly how long they need.

6. The plan doesn’t match the new reality. A plan written before a stroke bears no relation to life after one. A plan variation or reassessment is needed, and it needs evidence. Start this the moment it’s clear the person’s needs have changed materially.

7. There’s nowhere to go. The home is unsuitable and can’t be made suitable quickly, or there was no home to begin with. This is where Medium Term Accommodation enters the picture, covered below.

When the person can’t go home

If the pre-discharge home is unsuitable and the long-term solution isn’t ready, Medium Term Accommodation is the NDIS support designed for exactly this gap. It funds up to 90 days of accommodation while the permanent arrangement is finalised.

There’s an important detail here that’s widely misunderstood, including in a lot of provider content. MTA normally requires that a long-term housing outcome is confirmed. Hospital discharge is the exception. The NDIS states that where you’re being discharged from hospital and are eligible for SDA, Supported Independent Living, an Individualised Living Option, or home modifications, you don’t need to have a confirmed long-term home.

That matters enormously. It means a family doesn’t have to solve the permanent housing question before they can get the person out of an acute bed. The two problems can be sequenced instead of stacked.

Two caveats worth knowing. MTA funds accommodation only — support is funded separately, and must be arranged in parallel. And you must have a home you can move back into; MTA is not emergency or crisis housing.

If this is your situation, raise MTA the week a discharge date is first mentioned. Our guide to Medium Term Accommodation in Sydney covers the mechanics in detail, and our guide on what to arrange before leaving hospital covers the practical preparation.

What to do when it stalls anyway

Sometimes everything is notified, booked and requested, and nothing moves. A graduated approach, in order:

Ask for a discharge planning meeting. A formal meeting with the hospital social worker, the treating team, your support coordinator and — where possible — the HLO. Getting everyone in one room surfaces assumptions fast. The support coordinator can convene this if the hospital hasn’t.

Put the delay in writing. A short email to the NDIA and the hospital setting out the facts: medically ready since this date, this is what’s outstanding, this is who we understand is responsible. Written records change behaviour, and they create a timeline you can escalate against.

Name the acute bed explicitly. Health services have a strong institutional interest in releasing beds that aren’t clinically needed. “This person has occupied an acute bed for 19 days since being declared medically ready” is a sentence that opens doors inside both systems.

Ask for escalation by name. Request that the matter go to a specialised planner for an urgent discharge plan. The NDIA’s own published commitments reference this pathway; asking for it by name signals you know it exists.

Get an advocate involved. Free, independent disability advocacy services operate in every state and territory. They know the escalation routes and they carry weight that a tired family member doesn’t. This is not a last resort — bringing an advocate in early is often what shortens a stuck discharge.

Contact the NDIS directly. 1800 800 110. Ask for the status of the discharge plan, and ask for the reference number of the request. Vague enquiries get vague answers; specific ones get tracked.

Three situations that work differently

If the person isn’t an NDIS participant yet. A sudden injury or illness can make someone eligible for the scheme who never needed it before — a spinal cord injury, a severe stroke, an acquired brain injury. The access request can and should be lodged from the hospital bed, and the NDIA’s published commitment is that access requests for prospective participants are completed within 7 to 10 days of notification.

Hospital staff are meant to help with this. Many will. Some won’t know how, particularly outside major metropolitan hospitals. If you hit that wall, the ward social worker is your best ally, and a disability advocate can lodge on the person’s behalf. The important thing is not to wait for recovery to plateau before applying — permanence can be established with evidence about the likely long-term picture, and starting late costs weeks at the other end.

If the person is over 65. If they were already an NDIS participant before turning 65, they stay in the scheme and this guide applies. If they weren’t, the NDIS isn’t the pathway — aged care is, through My Aged Care on 1800 200 422, and the hospital’s aged care assessment team should be involved rather than an HLO. Families often spend weeks pursuing the wrong system here because nobody said this plainly early on.

If it’s a readmission. Where someone with an existing plan goes back into hospital, the plan usually still exists and the supports are usually still funded — but the provider may have reallocated staff, the SIL roster may have been adjusted during the absence, and the home may need reassessment if the person’s capacity has changed. Tell the provider the day the admission happens, not the day before discharge. A SIL home that has been told nothing for three weeks cannot have a worker ready on Friday.

What families consistently say afterwards

Three things come up again and again from people who’ve been through this.

“I wish I’d started on day one.” Almost everyone describes the first week as lost time — the period when everyone assumed recovery would be straightforward and nobody started the paperwork. The discharge process can always be stood down if it turns out not to be needed. It can’t be accelerated retrospectively.

“I didn’t know I could ask for that.” The HLO. The urgent discharge plan. MTA without a confirmed home. An advocate. None of these are hidden, exactly, but none are offered proactively either. Families who get out faster are usually the ones who learned what to ask for.

“The hospital and the NDIA weren’t talking.” This is the structural problem the whole system has been trying to fix for a decade, and it hasn’t fixed it yet. Until it does, somebody has to sit in the middle and make the handover happen. Ideally that’s your support coordinator. In practice it’s often a family member. Knowing that in advance is better than discovering it in week four.

Where to start today

If someone you support is in hospital right now:

1. Confirm the NDIA has been notified, today, and get the date.
2. Ask whether an HLO has been engaged. If not, ask for one.
3. Ask whether an OT home assessment is booked. If not, ask for it this week.
4. Make sure your support coordinator knows and is actively working the discharge, not waiting to be told.
5. Ask what will be needed at home — equipment, modifications, support hours, clinical competencies — and start each one in parallel rather than in sequence.
6. If home won’t work, raise MTA now, not when the discharge date is set.

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We support participants through hospital discharge across NSW, including medium term accommodation, supported independent living, high intensity supports and out of hospital care. If a discharge date has been mentioned and you’re not sure what happens next, call 1300 271 824 — the earlier we’re involved, the more options exist.

General information only, current at the time of writing. NDIA commitments, timeframes and guidelines are published by the National Disability Insurance Agency and change periodically — confirm current detail at ndis.gov.au or on 1800 800 110. This guide covers process, not clinical care; medical decisions rest with the treating team. In an emergency, call 000.