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Leaving hospital with the NDIS
Discharge for an NDIS participant needs two large systems — health and the NDIS — to hand off cleanly. Neither owns the whole process, and in the gap between them, people wait in beds they no longer clinically need. These guides set out what the NDIA has actually committed to, who is responsible for what, and how to keep a discharge moving.
Every clock starts at notification
The NDIA's commitments all contain the same condition: of being notified. The four-day contact window, the Health Liaison Officer engagement, the seven-to-ten day access decision — none of them begin until somebody tells the NDIA that the person is in hospital.
Hospital staff are meant to identify existing participants and notify the NDIA with consent. Often they do. Often they don't, particularly after a busy emergency admission where nobody thought to ask whether the person has an NDIS plan.
Don't assume it happened. Ask directly: "Has the NDIA been notified of this admission, and on what date?" If the answer is vague, ask the ward social worker to do it, and call 1800 800 110 yourself as well. Duplicate notification costs nothing. Missing notification costs weeks.
The role nobody mentions: Health Liaison Officers
HLOs are NDIA staff whose entire job is the interface between hospitals and the scheme. They work directly with hospital teams, chase the information the NDIA needs, and can escalate internally in ways a family phone call cannot. They are, in effect, the person inside the NDIA whose job it is to care that someone is stuck in a bed.
Most families have never heard of them. 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 — and if not, request it.
Who is responsible for what
The NDIA publishes a division of responsibility across three parties. Most delays happen when everyone assumes someone else is doing something — so it's worth knowing which list each item sits on.
| Who | Responsible for |
|---|---|
| The NDIA | Contacting the participant · liaising with the hospital through HLOs · requesting further information · conducting a home and living assessment if needed · holding the planning meeting · preparing, approving and implementing the plan including the Request for Service · notifying hospital staff of the approved plan · handing back to the usual planner after discharge · funding assessments needed once home |
| Hospital staff | Identifying existing participants and notifying the NDIA with consent · helping prospective participants lodge access requests · providing health information and evidence before the planning meeting, optionally using the Discharge Assessment template · comprehensive discharge planning · preparing the discharge summary |
| Support coordinator | Engaging the participant, HLO, NDIA team and key people · understanding the current living situation and informal supports · scoping market options · supporting the transition · running a discharge planning meeting with hospital staff if required · following up to ensure the person is stable |
Note how much sits with the support coordinator
A participant without one — or with one who is overloaded and reactive — is at a real disadvantage during a discharge. If there's no support coordination in the plan and a complex discharge is looming, that itself is worth raising with the NDIA as a priority.
Guides to the discharge journey
Written for participants, families and support coordinators. These cover process and logistics — the clinical decisions rest with the treating team.
Hospital Discharge and the NDIS: Who Does What
The NDIA's published commitments and timeframes, what a Health Liaison Officer does and how to get one involved, the full responsibility split, a realistic four-week timeline, the seven things that actually cause delays, and what to do when it stalls anyway.
What to Arrange Before You Leave Hospital
The practical checklist, sequenced by when to start each item — the OT home assessment, equipment lead times, support rosters and competency, medication, paperwork, transport, and the first 72 hours at home.
Who Pays for What: Health System vs NDIS
The funding boundary that causes more discharge delays than anything else — what the health system funds, what the NDIS funds, where the edges are genuinely contested, and how to get an answer in writing.
Equipment, Home Mods and Assistive Technology
The single most common cause of a long discharge delay. Assessment, quotes, approval, supply and installation — and how to run them in parallel rather than in sequence.
When You Can't Go Home: MTA, SIL and Interim Options
The discharge-specific MTA rules including the confirmed-home exception, how support is funded alongside accommodation, and what the 90 days should be used for.
Recovery at Home: Rebuilding Capacity
Allied health, capacity building and the plan reassessment nobody requests — how to use the months after a hospital stay to rebuild rather than just stabilise.
When home isn't ready: the MTA exception
If the pre-discharge home is unsuitable and the long-term solution isn't ready, Medium Term Accommodation funds up to 90 days while the permanent arrangement is finalised.
There's a detail here that a lot of provider content gets wrong. 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 a confirmed long-term home.
That matters enormously, because it means a family doesn't have to solve the permanent housing question before getting someone out of an acute bed. The two problems can be sequenced instead of stacked.
Two caveats. MTA funds accommodation only — the support has to be arranged and funded in parallel. And it isn't emergency or crisis housing.
Six things to do today
If someone you support is in hospital at the moment, this is the order that saves the most time.
- Confirm the NDIA has been notified, and get the date. Every commitment runs from here.
- Ask whether a Health Liaison Officer has been engaged. If not, request one.
- Ask whether an OT home assessment is booked. If not, ask for it this week — it's the keystone item that everything downstream depends on.
- Tell your support coordinator and existing providers today, not when a discharge date appears.
- Ask what will be needed at home — equipment, modifications, support hours, clinical competencies — and start each in parallel.
- If home won't work, raise MTA now, not when the discharge date is set.
The thing families say most often afterwards
"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 began the paperwork. The discharge process can always be stood down if it turns out not to be needed. It can't be accelerated retrospectively.
If a discharge date has been mentioned, call us
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. The earlier we're involved, the more options exist. We'll tell you honestly what's realistic, including when the answer isn't us.
Or enquire online and we'll call you back within one business day.
