Hospital discharge support
Hospital to Home — Safe NDIS Transitions in Melbourne and Victoria
Careable supports safe, structured transitions from hospital back into community living or Supported Independent Living. We work alongside discharge planners, social workers, support coordinators and allied health professionals to ensure each participant has the right supports in place before and after leaving hospital. We have supported discharges from Austin Health, Northern Health and St Vincent's Melbourne.
Referrals can be submitted online, by phone or email at any stage of admission.
- Acknowledged within one business day
- Capacity answer within two business days
- Austin · Northern · St Vincent's
Referrals are handled by our leadership team on 1300 332 433 or cx@careable.com.au.
Our process
How the transition process works
- Meet the participantWe ask to meet the person face to face, usually on the ward, and complete our initial risk assessment. Where a Behaviour Support Plan exists, we go through it with the practitioner.
- Familiarisation shiftsCareable staff do a small number of shifts alongside the participant before discharge — on the ward, on leave, or in the community — so the person gets to know the workers who'll be supporting them.
- Transition planTogether with the participant, the family, the treating team and the support coordinator, we agree a written transition plan: discharge date, roster of care, overnight model, medications, equipment, who's on the first shift, and what happens if something goes wrong in the first week.
- Discharge dayA named support worker the person has already met collects them from the ward or meets them at the front door — whichever the hospital prefers. The first-week roster is confirmed with the family that day.
- Day-7 status noteOn day 7, a written status note goes to the family and the referrer: how the person has settled, the routine in place, any concerns and what we're doing about them.
Alongside the process
- Where feasible, we attend discharge planning meetings
- We provide post-discharge review in the early weeks
For discharge teams
What we need from the discharge team
To assess a referral, it helps to have:
- Discharge summary
- Medication chart
- NDIS plan and funding categories
- Any behaviour support plan
- Equipment needs
- Risk assessment
- Preferred discharge date
You don't need all of these for a capacity check. A first name, the ward and the likely discharge date are enough to start; we'll ask for the rest once we've said yes.
Safety and quality
Clinical governance and safety
- Registered with the NDIS Quality and Safeguards Commission
- Alignment with NDIS Practice Standards
- Registered to implement behaviour support plans for participants with behaviours of concern
- Awareness of the NDIS Commission's guidance on transitions of care between disability services and hospitals
- Our process covers discharge summary review, medication information, risk assessment, equipment needs and staff readiness
Our experience
Our experience
Careable has experience supporting participants with psychosocial disability transitioning from acute and sub-acute mental health settings into Supported Independent Living, including complex cases where an earlier transition had broken down.
Referrers
Who can refer
- Support coordinators
- Hospital discharge planners and social workers
- Allied health professionals
- Mental health clinicians
- Families and participants
Make a referral
Refer a participant
Use the form below to refer an NDIS participant for Hospital to Home support. You can also call us on 1300 332 433 (1300 DECIDE) or email cx@careable.com.au.
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If it doesn’t appear, call 1300 332 433 or email cx@careable.com.au.
If you have difficulty using this form, call 1300 332 433 or email cx@careable.com.au.