Getting home safely: a discharge planner’s guide to home support
The patient is medically ready. The family is in the corridor. The bed is needed this afternoon. You need to know which pathway applies, and a provider who answers honestly about capacity. This guide covers the NDIS, aged care and private pathways, Transition Care and the Restorative Care Pathway, with a checklist you can print.
- Free, no sign-up needed
- Printable discharge checklist
- Checked against official sources, October 2026
A maybe that falls through lands back on your ward
You’re holding bed pressure, a patient who wants to go home, and a family who may be frightened of what home will look like now. A provider who says ‘probably’ and then can’t staff the first week doesn’t just let the patient down. It undoes your plan.
The first question is always funding. Who pays for support at home decides who can provide it, and how fast. Here are the three pathways, in plain words.
If the patient is an NDIS participant, or might be
- Ask early. With the patient’s consent, hospital staff can let the NDIA know they’re in hospital and that their needs may have changed.
- The NDIA says it will be in touch within 4 days of being told a plan change may be needed, or that the person wants to apply. The person then works with the NDIA’s specialised hospital team, which may include a hospital liaison officer.
- If the patient isn’t a participant but may be eligible, hospital staff can contact the NDIA with their consent.
- Once a plan or plan change is approved, the NDIA tells the hospital which supports are in it. With consent, it shares the plan with the participant’s support coordinator, who can help organise supports for the return home.
- While someone is in hospital, NDIS funding can’t pay their usual support worker for care, except for a complex communication need or managing behaviours of concern.
- The NDIA’s number is 1800 800 110.
If the patient is older and needs help at home
Government-funded aged care starts with an assessment through My Aged Care (1800 200 422). You need the patient’s consent before contacting My Aged Care for them. Two short-term options matter most at discharge:
- Transition Care helps older people recover after a hospital stay. It’s for hospital patients who’ve been told they’re ready to leave and would benefit from short-term services. An assessor visits in hospital, and hospital staff can arrange it. Care can be at home, in the community or in an aged care home, for up to 12 weeks (84 days), with a possible extension of up to six weeks after another assessment. There’s no means assessment. The maximum fee is currently $14.19 a day at home and $68.93 a day in a residential setting.
- The Restorative Care Pathway is part of Support at Home, which replaced the Short-Term Restorative Care Programme in November 2025. It offers up to 16 weeks of care led by allied health and/or nursing, with a budget of around $6,000, and needs an aged care assessment. A recent fall or hospital admission is one of the situations My Aged Care lists for seeking one.
- Longer term, an older person may be approved for the Commonwealth Home Support Program (CHSP) or ongoing Support at Home services.
A person can’t receive Transition Care at the same time as respite care or restorative care. They can receive it alongside existing CHSP or Support at Home services, as long as services don’t double up.
When funding won’t be ready in time
Sometimes the right support exists on paper but won’t be funded by discharge day. A plan change is in progress, an assessment hasn’t happened, or the patient doesn’t qualify for either scheme. Private, fee-for-service support can bridge the gap. Anyone can book it, and it can stop the day funded support starts.
Be upfront with the family about cost, and ask any private provider for a written quote before the first visit.
What to ask a home-support provider before discharge
- Can you staff this suburb, at these times, from the discharge date? Yes or no.
- Who will the worker be, and will the same person keep coming?
- What can your workers do, and what needs a nurse or allied health professional instead?
- Who will you update after the first visit: the family, the GP, the support coordinator?
- If funding is still being arranged, what would private support cost in the meantime?
- Are you registered for the support you’ll provide? (NDIS providers are listed on the NDIS Commission’s Provider Register.)
Discharge checklist: support at home
Tick these off as you go. The same checklist is in the PDF, ready to print or share with your team.
- Funding pathway identified: NDIS, aged care, compensation scheme or private.
- Consent recorded to contact the NDIA or My Aged Care.
- NDIA told (1800 800 110) if an NDIS plan change may be needed.
- Aged care assessment requested, including Transition Care if suitable.
- Provider has confirmed capacity for the suburb, times and start date.
- First-week supports agreed: personal care, meals, medication prompts, household tasks.
- Patient and family know who is coming, when, and who to call.
- GP and support coordinator (if any) told about the discharge plan.
- Private cost quoted in writing if funded support starts later.
A straight answer on the first call
We’re a registered NDIS provider in Colebee, working in disability and aged care since 2017. When a patient is ready to go home, we can help plan the first weeks with them and their family.
Support at home under their plan
Daily living and personal care, community access, respite, and high intensity supports including complex bowel care, catheter care, wound care, PEG feeding and medication management. The same support worker every visit.
High intensity support →CHSP domestic assistance
For Northern Sydney and the Southern Highlands, with a My Aged Care referral. We’re applying to deliver Support at Home and can’t take Support at Home clients yet.
Aged care →Private nursing and help at home
Booked privately when funding isn’t in place yet, across Greater Sydney wherever we can staff it. For private nursing, send us an enquiry and we’ll talk it through. Personal care and home help: call for a quote.
Private services →If we can’t staff it, we say so
On the first call, not after you’ve told the family.
For referrers →If you have a patient going home who needs support, call us on 0437 733 744 and we’ll talk it through. We’ll tell you on that call whether we can help.
Questions people ask
Who can get Transition Care?
My Aged Care says older people who are patients in a public or private hospital, have been told they’re ready to leave, and would benefit from short-term services. An assessor visits in hospital, and hospital staff can arrange the assessment.
How long does Transition Care last?
Up to 12 weeks (84 days). In some cases it can be extended by up to six weeks (42 days), which needs another assessment.
What replaced Short-Term Restorative Care?
Support at Home replaced the Short-Term Restorative Care Programme on 1 November 2025. Restorative care is now offered through the Restorative Care Pathway: up to 16 weeks, with a budget of around $6,000.
How quickly will the NDIA respond when a participant is in hospital?
The NDIA says it will be in touch within 4 days of being told a plan change may be needed, or that the person wants to apply to the NDIS.
Can NDIS funding pay a support worker while the person is in hospital?
Not for usual care, because hospital staff provide it. The NDIA says NDIS funding can be used in hospital only for a complex communication need or managing behaviours of concern.
Does Kinship provide aged care at home after discharge?
Through CHSP we provide domestic assistance only, in Northern Sydney and the Southern Highlands. We’re applying to deliver Support at Home. Private help is available across Greater Sydney wherever we can staff it.
Is Kinship Uniting Services a registered NDIS provider?
Yes, registration number 4-GWVHCEY. You can check it on the NDIS Commission’s Provider Register.
Sources
Every rule, date, amount and phone number in this guide was checked on these official pages in October 2026. Rules change, so confirm with the source before you act.
- NDIS: Guide to your hospital stay: www.ndis.gov.au/participants/life-transitions/transitioning-other-systems/guide-your-hospital-stay
- My Aged Care: Transition care: www.myagedcare.gov.au/aged-care-programs/transition-care
- My Aged Care: Restorative Care Pathway: www.myagedcare.gov.au/aged-care-programs/restorative-care-pathway
- My Aged Care: Short-term care: www.myagedcare.gov.au/types-care/short-term-care
- My Aged Care: Support at Home program: www.myagedcare.gov.au/support-at-home
- My Aged Care: For health professionals: www.myagedcare.gov.au/health-professionals
- My Aged Care: Commonwealth Home Support Program: www.myagedcare.gov.au/aged-care-programs/commonwealth-home-support-program
General information only. This guide is not legal, financial or medical advice. Check the details with the official agency or scheme for each client’s situation.
Have a client in mind?
Call us and we’ll talk it through. If we can’t help, we’ll say so plainly.
Kinship Uniting Services · Registered NDIS provider 4-GWVHCEY · 39 Victory Road, Colebee NSW 2761