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.
Overview
At a glance
- We support NDIS participants transitioning from hospital back into community living or Supported Independent Living
- We work with discharge planners, social workers, support coordinators and allied health professionals
- Referrals can be submitted online, by phone or email at any stage of admission
- We aim to respond to all referrals promptly and give honest capacity updates
- We are registered to implement behaviour support plans for participants with behaviours of concern
Our process
How the transition process works
Early referral
Refer as early as possible during admission so we can begin planning. We accept referrals from support coordinators, discharge planners, social workers, mental health clinicians and allied health.
Multidisciplinary planning
We work with the hospital team, support coordinator, participant and family to understand the participant's needs, goals and risks.
Environment and staffing readiness
We prepare the home or SIL environment and confirm appropriate support staffing is in place before discharge.
Day-of-discharge execution
We coordinate a planned, supported move on discharge day with clear communication to all parties.
Post-discharge monitoring
We monitor closely in the early weeks and stay in contact with the care team to ensure supports are working.
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. Several participants have been living stably in our homes for multiple years.
What you can expect
Our commitments
- We aim to respond to referrals promptly
- Where feasible, we attend discharge planning meetings
- We provide post-discharge review in the early weeks
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.
Hospital to Home referral form
For your privacy and a faster page, the secure online form loads when you’re ready. You can also call or email us using the details below.
If you have difficulty using this form, call 1300 332 433 or email cx@careable.com.au.
Explore more
Related services
After a Mental Health Admission
Step-down support for people transitioning from mental health settings into community and SIL.
Supported Independent Living
SIL homes in Melbourne with on-site support for daily living and independence.
Psychosocial Support
Recovery-oriented support for NDIS participants with psychosocial disability.
Get in touch
Ready to refer?
Submit a referral online, or call our team to discuss a participant's needs and our current capacity.