What to Arrange Before You Leave Hospital: An NDIS Discharge Checklist

Discharge day is the wrong day to discover that the bathroom doorway is four centimetres too narrow.

Yet that’s roughly how it goes for a lot of families. The hospital’s job is largely finished at the front door; the NDIS world picks up somewhere after it. In between sits a list of practical things that nobody formally owns — and if nobody checks them, they get discovered on the first night home, usually at the worst possible moment.

This is that list. It’s organised by when to do each thing, because sequence matters more than completeness here: several items have lead times measured in weeks, and starting them in the wrong order is how a discharge slips a month.

It’s written for NDIS participants and the people supporting them. It covers process and logistics, not clinical care — the treating team owns the medical side.

Week one of the admission: the things with long lead times

Start these immediately, even while recovery is uncertain. Every one can be stood down if it turns out not to be needed. None can be accelerated retrospectively.

Confirm the NDIA has been notified. Hospital staff should identify existing participants and notify the NDIA with consent. Ask directly whether this has happened and on what date. The NDIA’s published commitments — contacting the participant within four days, a Health Liaison Officer contacting hospital staff within four days — all start from notification. No notification, no clock.

Ask for a Health Liaison Officer to be engaged. Most families have never heard of HLOs. They’re NDIA staff whose job is the hospital interface, and they can escalate internally in ways a family phone call can’t.

Book the occupational therapy home assessment. This is the keystone item. An OT needs to assess whether the person can safely return home as it stands, and that assessment determines everything downstream — equipment, modifications, support hours, whether home is viable at all. OT waitlists are the most common hidden delay in the whole process. Book it in week one.

Tell your support coordinator. Not next week. Today. A great deal of the discharge sits with them — scoping providers, convening a discharge planning meeting, supporting the transition — and they can’t start on information they don’t have. If there’s no support coordination in the plan and a complex discharge is looming, raise that with the NDIA as a priority.

Tell your existing providers. If the person already receives SIL, respite or in-home support, their provider needs to know on day one. Rosters get reallocated during an absence, and a provider told nothing for three weeks cannot produce a trained worker on Friday.

Start the equipment conversation. Ask the treating team what the person is likely to need at home. Hospital bed, pressure mattress, hoist, commode, shower chair, wheelchair, walker. Approval is one timeline; supply, delivery and installation are separate ones. Some items run to several weeks.

Weeks two and three: evidence, funding and the plan

Get the evidence written properly. The hospital provides health information to the NDIA before the planning meeting, and there’s a Discharge Assessment template available for exactly this. Reports that describe function concretely — what the person can and can’t do, hour by hour, on a good day and a bad one — carry far more weight than clinical summaries. If a draft report reads as generic, it’s reasonable to ask for more detail.

Work out whether the plan still fits. A plan written before a stroke bears little relation to life after one. If support needs have changed materially, a plan variation or reassessment is needed, and it needs evidence. Ask your support coordinator to start this as soon as the change in needs is clear, not after discharge.

Ask for an urgent discharge plan if it’s warranted. The NDIA uses specialised planners to create urgent discharge plans where required. If the person is occupying an acute bed they no longer clinically need, say so explicitly and ask for escalation by name.

Confirm what the hospital funds versus what the NDIS funds. This boundary causes more delay than almost anything. In broad terms the health system is responsible for treatment, hospital-based rehabilitation and discharge planning; the NDIS funds disability supports once the person is home. The edges are genuinely contested and vary by state. Rather than assume, ask both sides directly and get the answer in writing, particularly for equipment and any short-term rehabilitation.

Request a discharge planning meeting. One room, everyone in it: treating team, social worker, support coordinator, family, HLO if possible. This single meeting surfaces more assumptions than a month of phone calls.

Three to four weeks out: the home itself

Walk the home with the OT report in hand. Not from memory — physically walk it. Measure doorways if a wheelchair is now involved. Check the path from the car to the front door. Check bathroom access, bed height, light switches, whether the person can reach the kettle.

Decide: modifications, equipment, or a different home. If modifications are needed, start them now. Assessment, quotes, approval and building work is a multi-week sequence, and it’s the single biggest cause of long discharge delays.

If home won’t be ready, raise MTA. Medium Term Accommodation funds up to 90 days of accommodation while the permanent arrangement is sorted. Critically for this situation: where someone is being discharged from hospital and is eligible for SDA, SIL, an ILO or home modifications, the NDIS states you don’t need a confirmed long-term home — the usual requirement is waived for hospital discharge. MTA funds accommodation only, so the support has to be arranged alongside it. Our guide to medium term accommodation covers the mechanics.

Sort the practical household things. Is there food in the house? Is the power on? Has the mail piled up? Is the place clean and warm? If the person lived alone, somebody needs to physically open the house before they arrive. This sounds trivial and it is routinely forgotten.

Two weeks out: supports and people

Confirm the support roster in writing. Not “we’ll have someone there” — an actual roster. Which worker, which hours, starting which day. Get it in writing and read it against what the OT report says is needed.

Check competency for any high intensity supports. If the person now needs enteral feeding, complex bowel care, catheter support, tracheostomy care, wound care or subcutaneous injections, support workers must be assessed as competent for that person’s specific plan, not merely trained in general. That assessment takes time.

Ask any provider two questions: how many of your workers are currently assessed competent for this, and who assessed them? A provider with one competent worker has a roster that collapses the first time someone is unwell. Our high intensity supports guides cover what to look for.

Make sure the clinical plans exist. Every high intensity support needs a written plan from the appropriate clinician — a dietitian for feeding, a continence nurse for catheter care, and so on. These plans govern what workers do. They should exist, be current, and be physically in the home, not filed in an office.

Sort medication supply. Who writes the scripts now? Which pharmacy? Is a Webster pack being set up? Does the first week’s supply go home with the person, or does someone need to collect it? If medication is given via a feeding tube, has a pharmacist specified the method for each one?

Book the follow-up appointments. Outpatient reviews, GP handover, community nursing, allied health. Book them before discharge — ringing for appointments in the first chaotic week at home rarely happens.

The final week

Do a trial run if you can. Many hospitals support a day leave or an overnight before formal discharge. This is worth pushing for. A few hours at home reveals the problems that a checklist never will, while there’s still a hospital bed to return to.

Confirm equipment has physically arrived and is installed. Not ordered. Not approved. Delivered, assembled, and working, with somebody shown how to use it.

Get the discharge summary and read it. It should set out the diagnosis, what happened, medications, follow-up and any changed care needs. Your GP needs a copy. So does your support provider, with consent.

Confirm the transport. How is the person physically getting home? Is a standard car workable, or is wheelchair-accessible transport needed? Who’s driving, and when?

Agree who to call. In the first fortnight, something will come up at an inconvenient hour. Write down, on paper, on the fridge: the provider’s after-hours number, the GP, the community nursing service, the relevant hospital ward or outpatient contact, and when to simply call 000. Guessing at 2am is how people end up back in emergency unnecessarily.

Paperwork and admin worth sorting before you leave

Unglamorous, and it causes a disproportionate number of problems in the first month.

Consent and information sharing. Decide who the hospital and the NDIA are permitted to speak to, and get it recorded. Families routinely hit a wall in week two because a sibling who is doing all the coordinating isn’t listed anywhere as an authorised contact. If the person has a nominee, guardian or plan nominee arrangement, make sure everyone involved knows who holds which authority — and where the person themselves makes their own decisions, which is most of the time.

Copies of everything. Discharge summary, current medication list, clinical plans for any high intensity supports, the OT report, equipment documentation and warranties, follow-up appointment letters. One folder, physical or digital, that travels with the person. Hospital systems and NDIS systems don’t talk to each other, and the family folder is frequently the only complete record in existence.

Check the plan dates. If the NDIS plan is due to expire in the next few months, flag it now. A reassessment landing six weeks after a major change in circumstances is actually good timing — but only if someone is preparing for it rather than being surprised.

Centrelink and income. A long hospital stay can affect payments. If the person’s circumstances have changed materially — particularly if they’re moving to a different living arrangement — Services Australia needs to know, and Commonwealth Rent Assistance eligibility may change with a change of address.

Insurance and compensation. If the admission followed a motor vehicle accident or a workplace injury, a compensation scheme may be the primary funder rather than the NDIS, and the interaction between the two systems is genuinely complicated. Get advice early; this is one of the few areas where getting it wrong creates months of untangling.

When the person is going somewhere new

Not everyone goes back to the home they left. Where discharge is to a different address — a SIL house, an MTA placement, a family member’s home — a few extra things apply.

Visit before move-in day. Even briefly. Arriving somewhere entirely unfamiliar on the same day you leave hospital is a lot to absorb. Where the destination is a shared home, meeting housemates beforehand matters more than almost anything else for how the placement settles.

Set the bedroom up in advance. Belongings, photographs, familiar things, in place before the person arrives. Walking into their room rather than a room changes the first night measurably.

Brief the receiving team properly. The new provider needs the discharge summary, the clinical plans, the medication list, and a conversation about what the person was like before the admission — not just their current clinical state. A support team that only knows the hospital version of someone is working with half a picture.

Agree the family contact rhythm out loud. Daily calls the first week? Visits on Sundays? Making it explicit prevents both the person feeling abandoned and the family feeling shut out.

Common mistakes worth avoiding

Waiting to see how recovery goes before starting anything. The most expensive mistake available. Every item on this list can be stood down. None can be back-dated.

Assuming the hospital is coordinating the NDIS side. They’re not, and it isn’t their job. Hospital discharge planning covers the health system’s responsibilities. The NDIS side needs the support coordinator, the HLO and usually a family member pushing.

Accepting “we’ll sort it when you’re home.” Occasionally reasonable for small things. Usually it means a gap nobody has resourced, and the person discovers it on night one.

Taking a verbal commitment about support hours. Get the roster in writing. Providers are generally acting in good faith, but “we’ll have someone there” has a wide range of meanings when a worker calls in sick.

Not asking what happens if the date moves. Discharge dates slip, both ways. Ask every provider and every supplier what happens if the date changes by a week in either direction. The answer tells you how much slack is in the arrangement.

The first 72 hours at home

The checklist doesn’t end at the front door. The first three days are where most readmissions get set up.

Expect it to feel harder than hospital. In hospital there was a call button and someone always nearby. Home is quieter, and for many people that’s frightening before it’s a relief. This is normal and it passes, usually within a fortnight.

Watch for the things the hospital was managing invisibly. Hydration. Pain relief timing. Pressure care and repositioning. Bowel routine. These were happening on a ward schedule that nobody at home has inherited. Make them explicit in the support plan for the first fortnight.

Keep a simple log. What happened, when, what helped, what didn’t. Two weeks of notes is worth more at the first follow-up appointment than anyone’s recollection, and it reveals patterns — a medication timing problem, a support gap at a particular hour — that nobody would otherwise spot.

Expect to adjust the roster. The plan built in hospital was a best guess. A week at home will show where the hours are in the wrong place. Good providers expect this and build in an early review; ask for one at the two-week mark rather than waiting for a scheduled review months away.

Know the readmission triggers. For most conditions, the treating team can tell you specifically what to watch for and what to do about it. Ask for that list in writing before discharge. A clear escalation pathway prevents both unnecessary trips to emergency and dangerous delays.

Who does what in your family

One more thing worth settling before discharge day, because it causes friction that nobody anticipates.

A hospital discharge generates a surprising amount of work: phone calls, appointments, chasing equipment, collecting medications, being present for deliveries, managing the paperwork folder. In most families this lands on one person by default, usually whoever answered the phone first, and it lands on top of their existing job and life.

Two things help. Name the coordinator explicitly rather than letting it fall to someone by accident — and make sure that person is listed as an authorised contact with both the hospital and the NDIA, or they’ll spend the first fortnight being told nobody can speak to them.

Then split the list deliberately. Someone manages clinical appointments. Someone handles the house — cleaning, food, utilities, opening the place up. Someone deals with the NDIS paperwork. Someone is the point of contact for the provider. It doesn’t matter how it’s divided; it matters that it’s divided, and that everyone knows which part is theirs.

And a note for the person doing most of it: the fortnight after a discharge is genuinely exhausting, and it arrives directly after however many weeks of hospital visiting. Carer Gateway (1800 422 737) is free, national, and exists precisely for this. Using it early is considerably more useful than using it after you’ve run out of capacity.

If the discharge is being rushed

The opposite problem to a stalled discharge, and it happens: bed pressure means someone is pushed out before the supports are genuinely ready.

You’re entitled to say so. A discharge that happens before equipment arrives, before workers are trained, or before the home is safe tends to produce a readmission within weeks — which serves nobody, including the hospital.

If you’re in that position, put the specific gaps in writing to the treating team and the discharge planner: what is missing, why it’s unsafe, and what date it would be resolved. Specifics are much harder to override than general reluctance. Ask for the discharge to be reviewed, involve your support coordinator, and if needed bring in a disability advocate — free, independent services operate in every state and territory, and they carry weight in exactly this conversation.

Equally, be honest with yourself about whether the gap is genuinely a safety issue or whether it’s anxiety about the transition. Both are real; they need different responses. The OT report and the clinical team can usually tell you which one you’re dealing with.

The printable version

If you take nothing else, take these ten:

1. Confirm the NDIA was notified, and when
2. Ask for a Health Liaison Officer
3. Book the OT home assessment in week one
4. Tell the support coordinator and existing providers on day one
5. Start equipment and home modifications before the plan is finalised
6. Request a discharge planning meeting with everyone in one room
7. Get the support roster in writing, and check competency for clinical supports
8. Sort medication, scripts, transport and follow-up appointments
9. Write the after-hours contact list on paper and put it on the fridge
10. Book a two-week review with the provider before you leave

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We support hospital discharges across NSW — medium term accommodation where home isn’t ready, supported independent living, high intensity supports and out of hospital care. If a discharge date has been mentioned, call 1300 271 824. The earlier we’re involved, the more of this list is already done by the time you leave.

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