Ensuring Safe Transitions Between Hospital and Home: What NDIS Providers and Support Coordinators Need to Know
- Anna Latifi
- Jul 28
- 2 min read
When an NDIS participant transitions between home and hospital, the risk of miscommunication and service gaps can significantly increase. Whether the admission is planned or unexpected, the responsibility lies with providers and coordinators to ensure these transitions are managed safely and in line with the NDIS Practice Standards.
In January 2025, the NDIS Commission released a Practice Alert to remind all providers of their obligations during transitions of care. This blog outlines what’s required and how you can strengthen your practices.
Why Transitions of Care Are High Risk
Transitions of care are more than just a change in location—they are critical risk points for participants.
When communication breaks down, the consequences can be severe. According to the Commission, risks include:
Medication errors
Lack of appropriate follow-up with specialists
Inadequate support upon discharge
Missed changes in health or personal support needs
These risks are especially serious for participants with complex or high-intensity support needs.
What Are Your Responsibilities as a Provider?
The NDIS Practice Standards clearly outline your obligations. If you are a registered provider, you must:
Plan and coordinate hospital transitions with the participant and their support network
Keep health-related documentation up to date, including medication charts and support plans
Conduct a risk assessment before discharge to confirm you can meet any new care requirements
Communicate any limitations in service delivery early and clearly (e.g., if your team is not trained or registered for HIDPA tasks)
Ensure staff are competent and trained as per the High Intensity Support Skills Descriptors
These responsibilities aren't just good practice—they're required under the NDIS Code of Conduct and Practice Standards.
Support Coordinators: Your Role Is Critical
Support coordinators play a vital part in managing transitions:
Linking with hospital case managers and discharge planners
Organising new equipment, allied health referrals, or assistive technology
Coordinating staff training for any new procedures or risk areas
Ensuring a clear, timely flow of information between services, participants, and their families
Participants with support coordinators tend to experience smoother discharges and fewer readmissions. Your involvement makes a measurable difference.
Practical Tips to Improve Transitions
Here are a few strategies to help your organisation meet best practice standards:
Develop and use a hospital transition checklist (we can help with this)
Include a summary of support needs in Easy Read or visual formats
Ensure you have a medication summary, discharge plan, and care instructions ready to pass on
Use tools like Manage My Care, A2D Together, and My Health My Communication to streamline documentation
Need Help Getting It Right?
At Explicit Consulting, we specialise in making complex compliance obligations simple and practical. Our Hospital to Home Transition Pack includes:
Customisable checklists
Easy-to-use templates for pre-admission, admission, and discharge
Training guidance for high-intensity support delivery
Policy and procedure updates that align with the January 2025 NDIS Practice Alert and new participant person-centred framework.
Whether you're a new provider or a seasoned coordinator, having a structured transition framework reduces risk—and improves outcomes for the people we support. NDIS consulting and guidance are provided for Australia-wide.
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