Practice Guide — Hospital Discharge | FOI document library

FOI 24/25-1158 DOCUMENT 1

Disclosure Log

Practice Guide – Hospital Discharge

A guide for Health Liaison Officers, Planners and Administrative Officers in the Health Interface Branch

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Purpose ………………………………………………………………………………………………………… 3
Overview ………………………………………………………………………………………………………. 3
Key Aligned Documents ………………………………………………………………………………….. 3
Key roles in the Hospital Interface Branch …………………………………………………………. 3 4.1 Administration Officer (AO) ……………………………………………………………………….. 3 4.2 Health Liaison Officer (HLO) ……………………………………………………………………… 4 4.3 Hospital Discharge Planner (HD Planner) …………………………………………………… 5 4.4 Hospital Diversion Team …………………………………………………………………………… 6
Hospital Discharge Case Management System ………………………………………………….. 6 5.1 Dashboards …………………………………………………………………………………………….. 6 5.2 Communication in PACE ………………………………………………………………………….. 7
End-to-End Hospital Discharge Process ……………………………………………………………. 7 6.1 New Cases ……………………………………………………………………………………………… 7 6.2 Identification of Discharge Requirements - Notification and Contacting Health …. 7 6.3 Process for Access ………………………………………………………………………………… 10 6.4 Not Ready for Planning …………………………………………………………………………… 11 6.5 Collecting Health Information …………………………………………………………………… 12 6.6 Health Information Collected ……………………………………………………………………. 13 6.7 Plan Meeting …………………………………………………………………………………………. 14 6.8 Follow up Plan Approval …………………………………………………………………………. 14 6.9 Plan Approval and Implementation …………………………………………………………… 15 6.10 Escalations and prioritisations …………………………………………………………………. 17
Appendix …………………………………………………………………………………………………….. 18 7.1 Appendix A – Critical Discharge Requirement Checklist (Contact Guide) ………. 18 7.2 Appendix B – Supporting Evidence ………………………………………………………….. 19 7.3 Appendix C - Wound Care ………………………………………………………………………. 24 7.4 Appendix D - Respiratory ………………………………………………………………………… 25 7.5 Appendix E - Nutrition …………………………………………………………………………….. 26 7.6 Appendix F – Change to H&L Decision …………………………………………………….. 26

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1. Purpose

This Practice Guide (PG) outlines the roles and responsibilities of key staff who support the hospital discharge pathway. This PG further outlines the Hospital Discharge Case Management system and the overall discharge process.

2. Overview

In June 2022, the Australian Disability Reform Ministers made a commitment to streamline hospital discharge for NDIS participants, this PG reflects the processes that have been established to support this commitment.

The NDIA considers a successful discharge to be when a participant has safely left hospital into long term accommodation or medium-term accommodation with sustainable disability related supports. This includes being connected to mainstream and community supports, and the risk of re-admission is mitigated.

3. Key Aligned Documents

This document is to be used in conjunction with the following key resources:

Hospital Journey Map
Health Contact Guide
Supporting Evidence Guide
PACE Guide

4. Key roles in the Hospital Interface Branch

4.1 Administration Officer (AO)

The AO Team is the first point of notification of a participant’s hospital admission. The team receives and processes information from internal and external stakeholders via the intake email address redacted: s22.

4.1.1 AO roles and responsibilities

Create a Hospital Discharge PACE case.
The AO is to make initial contact with a participant within 4 days of notification.
- Call the Participant/Plan Nominee or Authorised Representative.
- Confirm admission details where possible, including admission date and facility name.

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Explain NDIA processes where applicable. Advise further contact will be made regarding a planning meeting if it is required.
- If speaking to the Participant or Plan Nominee, we ask the following questions.
- “Are you happy for us to share information with The Hospital to consider any changes to support needs and your NDIS plan?”
- “If your plan only requires a minor update, are you happy for us to make the change to your plan without doing a full reassessment?”
- If they are yet to meet access and are an Applicant, we follow the above process but tailor the language to explain that if they’re found eligible for the NDIS, further contact will be made regarding a planning meeting.
Organise planning meetings.
Upload inbound documentation to the Business System (CRM and/or PACE)
Perform other administrative work as required.
AO will issue the Request For Service (RFS) once the Support Coordinator (SC) has been chosen for cases where the participant had not made a choice of Sc at the planning meeting. If a non-registered Support Coordinator is chosen a manual template will be completed by the Planner.

4.1.2 Closing a PACE case

When the PACE case is closed by the HLO, the AO will re-assign the participant to the relevant State/Territory Service Delivery Branches (National Delivery (ND)). The State/Territory Branches will take over booking future check-ins and allocation to ND Planners in line with National Delivery practice.

4.2 Health Liaison Officer (HLO)

The primary role of the HLO is to drive the hospital discharge process from notification to discharge. They are to ensure participants have their disability support needs met for a safe discharge from Health settings and a transition to the community.

4.2.1 The HLO roles and responsibilities

Provide a single point of contact for the health facility whilst the participant is an inpatient.
Provide clear and regular communications to promote understanding of NDIS process and policy to external stakeholders in Health settings.
Manage an assigned portfolio comprising:
- Whole Health District or Health Network
- Facility
- Unit
- Or a mix of the above
Work closely with the key contacts in Health. Each Health facility will have a nominated health lead or complex care coordinator appointed as the key contact.

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Attended regular weekly or fortnightly meetings with their Health facilities and key leads.
Work closely with the SC throughout the case from the outset or as soon as one is engaged to facilitate timely discharge. Identify any skills gap or capacity building opportunities with SC.
Maintain accurate records for all required information and case notes, ensuring it aligns with Health facility data. For further information see Pace Guide.
Ensure consent for information sharing is recorded and covers all required parties.
Ensure all formal guardianship and nominee arrangements are reflected and adhered to. Identify and gather the information required to support the NDIS actions to facilitate discharge – For further information see section 6.5.
Lodge relevant internal requests (Home and Living (H&L), Mandatory TAB in PACE, monitor and escalate as required.
Identify and resolve barriers to planning and discharge.
Identify and assist to resolve challenges or delays in access or planning decisions or the Implementation of critical supports.
Confirm with all stakeholders that long term supports are in place to stop unnecessary re-admission.
Ensure all stakeholders are provided with clear and precise communication of NDIA decisions.

4.3 Hospital Discharge Planner (HD Planner)

The HD Planner is usually involved for a short two-week period when the participant is ready for planning. It is a priority to complete the planning process as quickly and efficiently as possible, while ensuring an appropriate discharge plan is implemented.

4.3.1 HD Planner roles and responsibilities

The HD Planner role incorporates the following functions:

While the HLO will identify and obtain all information from Health for the planning meeting, the planner will work with the HLO to obtain any further information requirements identified during the planning process.
Meet with participants and/or representatives (and other invited stakeholders) for the first plan, plan reassessment or variation meeting.
Keep the HLO up to date with planning progress via notes and updates reflected in PACE.
Build the NDIS plan.
Implement the NDIS plan with the participant and/or representative and the SC, including submitting the RFS for SC where a new referral is to be made.

NB while the Guardian is required to be invited to attend planning meetings, they do not need to be present for the planning meeting to occur. The Guardian is required however to confirm the goals, participant statement and the plan

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management type prior to plan approval. This can be completed via phone call or email.

4.3.2 HD Planner exceptions

Planning activities for Hospital Discharge will be assigned to planners in the Hospital Discharge planning team with the following exceptions:


Existing CSN participants	Current CSN Planner
Existing YPIRAC participants	Current YPIRAC planner
Participants at risk of entering aged care	YPIRAC Diversion planner

Note: An indication prior to planning that a participant has a palliative condition, they will be referred to the HD palliative planning team. Please contact your Line Manager for further directive.

4.4 Hospital Diversion Team

If support networks breakdown, participants may be admitted to hospital when they have no identified medical needs. When Health becomes aware of a risk of a non-medical admission, some immediate variations to the plan or collaboration with support teams can prevent unnecessary non-medical hospital admissions. Diversionary support to stop participants entering a Health setting, may be referred to the Health Interface Branch AO Team. These cases will be referred to ND/CSN/YPIRAC for urgent attention via agreed pathways. The HLO involvement with HD Diversion cases will predominantly be to assure health stakeholders that the case is assigned for priority planning.

5. Hospital Discharge Case Management System

The Hospital Discharge PACE application is used to capture, monitor and report on all hospital discharge cases. All relevant information and notes regarding the progress of the case are required to be captured in PACE. Additionally, CRM is used to capture and complete all NDIS access and planning activities, and to capture documents and interactions reflecting general communication actions and progress.

5.1 Dashboards

The Team HLO dashboard drives the work of the hospital discharge process. The dashboard will provide a view of your cases and put the work into segments so you can easily see where things are up to and what you need to action for each participant. HD-TEAM/HLO Dashboard | Salesforce

The DQ dashboard will identify any cases which is missing required data or have contradictory data. Hospital Discharge - Data Quality Dashboard | Salesforce

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5.2 Communication in PACE

All team members should use CRM and PACE to capture all relevant information as per agency documentation standards.
PACE should be used as the single source of truth for progress and requirements for the hospital discharge case.
HLOs and planners should use PACE wherever possible to replace ‘off system’ requests and updates that are otherwise currently occurring by email. This ensures all information is securely captured and available for anyone who may need to engage with the case.
It is expected that if a HLO or a planner needs to have a more detailed communication on a case, that this would occur by phone/teams.
HLOs and planners have access to and are expected to use and check the notes in the PACE case. The notes field is available in the HLO view and planner view reports in the dashboard.
If any team member has an urgent update, they should ensure the update is reflected in PACE and reach out in person to ensure the update is observed.

6. End-to-End Hospital Discharge Process

The end-to-end process refers to the commencement of the hospital discharge process from the point of notification through to the completion of discharge plan and reflects the use of PACE throughout.

6.1 New Cases

Notification of a participant in hospital is sent directly to the email address redacted: s22 inbox (HLO inbox) or the HLO may receive notification directly through the hospital or Support Coordinator (or other avenues). In this latter instance, the HLO will forward this notification onto the HLO inbox. The HLO referral form is the preferred form used by stakeholders when making a notification of admission.

Once notification is received, the AO will create a Hospital Discharge case on PACE, upload any relevant documents to the business system and assign this to the relevant HLO. Private Hospital referrals will be accepted where they occur and assigned to the HLO who services the closest Health network to that private hospital.

6.2 Identification of Discharge Requirements - Notification and Contacting Health

Notification is the date Health confirms the admission with the Agency. This may be through a direct referral from Health notifying of an admission or through the Agency

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contacting Health in response to a notification of admission from a third party (i.e. SC, participant, or other).,

The Agency commits to contact the Participant within four days of being notified of an admission. This is a DRMM agreed Key Performance Indicator (KPI). The AO Team is responsible for contacting the participant. If the contact due date falls on a weekend the due date is moved to five days. The AO will obtain consent from the participant for the NDIS and Health to share information. The AO will complete in PACE the date contact is made with Participant.

The Agency also commits to contact Health within 4 days to confirm the admission and identify the discharge requirements. The HLO is responsible for contacting Health. This initial contact and discussion with Health are critical for ensuring we start on the right path.

If there is no consent to share information with health, the HLO must follow this up to obtain it for the NDIS and Health to work together. If the participant chooses not to provide consent, the HLO will work directly with the participant rather than Health.

The HLO validates and updates information in PACE including the date contact is made with health.

6.2.1 Key information to collect within 4 days of notification.

Admission date
Admission type
LHD and facility
Hospital Status (Medically Ready/Not Ready)
Expected Discharge Date
Confirm nature of admission
Are there any new disability diagnoses.
Does the participant have the capacity to make independent decisions?
Is there a plan nominee in place?
Plan requirement (how are the disability supports going to change as a result of the current admission?)
- This requires a conversation to understand if the participant requires a change to their plan and what information is required to support this.
- HLO to review current plan if they are an existing participant.
- HLO to determine the needs of the participant with plan variation, plan reassessment, or no plan change needed. If the participant has just met access, a First Plan is required and reflected in PACE.
Planning Barriers (reflected in PACE)
- If health advise they are unable to identify the participants discharge support needs, the participant is marked as ‘not ready for planning’.

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If the required evidence to progress planning is already available complete the health info collected date as the date that this was confirmed.
- If further information is required –awaiting health information barrier must be reflected.
- Add any other planning barriers that are relevant in PACE.
- Update Home and Living (H&L) support required field y/n as soon as it is apparent that a new H&L decision is required.
If there is an active s100, the s100 needs to be finalised before subsequent actions can be confirmed. No participants with a s100 barrier will progress to planning meeting.
If there is an active AAT matter, participant cannot progress to planning without expressed approval of the AAT case manager.

6.2.2 Health Contact Guide

When you contact health, you must ensure the following information is gathered or confirmed:

Confirm information in the referral form HLO Referral Template (including consent) to ensure it is accurate. a. Is the admission type correct (what is the nature of the admission) b. Is the hospital status correct (i.e. medically ready/not medically ready) c. If relevant, has rehabilitation been undertaken, what is the timeframe of rehabilitation? d. What is the estimated discharge date (what is the expected date the participant will be complete their medical treatment). e. What is the discharge destination?
Consider Access status. a. if relevant, provide info on access process and requirements and if relevant update on any active access requests.
Consider NDIA planning requirement: a. Confirm nature of admission b. Confirm primary and or secondary disabilities. i. Has there been an additional disability diagnosis? Do we have supporting evidence to support a change of primary disability or addition of secondary disability? (Delegate can make a decision on change/additional disability if evidence supports this in line with eligibility criteria). ii. Is there going to be an ongoing impact to function in relation to disability? c. If relevant, discuss palliative factors. d. Consider the discharge support needs and confirm whether the current plan provides the required supports. i. Does the current NDIS plan require a reassessment/variation to support discharge? e. Is there a dispute in progress (s100 or AAT) in regard to the current plan.

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f. Does the participant have or require behaviour supports?
g. Discuss the expected discharge plan for the participant, including the supporting information required using the Supporting Evidence Guidance and the Discharge Requirement Checklist.
h. Will the participant require a formal or graduated discharge plan.

Is it a complex discharge requiring a coordinated response across multiple stakeholders?
Consider other discharge requirements. a. Is compensation relevant to the admission requiring Compensation advice? b. Is a Support Coordinator already engaged? c. Is a Psychosocial Recovery Coach already engaged (where required)? d. Is there a provider in place for core supports? e. Is any new Assistive technology required for discharge? f. Does the participant require any mainstream supports post discharge? g. Does the participant have capacity to make independent decisions? i. Is there a current Guardianship order? Is there a Guardian or an application for a Guardian needed as part of Health admission? What does the Guardianship Order cover? ii. Is there a Plan Nominee in place? iii. Where there are no formal representatives is there anyone else who assists the participant with decision making?

Health Contact Template:

HLO to copy and paste responses into Hospital Discharge Case:

00/00/0000 LOGON ID

HLO has confirmed all information in referral form: Yes/No (if no, add details to explain).

Do NDIS funded supports need to change: Yes/No -In what areas? or unable to assess – what is the follow up date?

Supporting Information: What information has been requested/date and when is supporting evidence required by.

Please see the critical discharge requirement checklist in Appendix A

6.3 Process for Access

If an admitted applicant is seeking Access, Health is to submit the signed Access Request Form (ARF) or supporting evidence to the National Access and Reassessment Branch (NARB) redacted: s22 and redacted: s22 inboxes.

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The AO Team creates a record in CRM (if not already created by NARB). The AO Team creates the case in PACE and emails associated documents to NARB (if not done by Health) with the subject line NAT: PRIORITY HOSPITAL DISCHARGE - NAME NDIS#, to trigger the priority process.

The HLO can support this process directly by sending these forms to the same email boxes as required.

Priority access requests are expected to be completed within 7-10 days. The HLO can support Health on how to lodge an access request and the evidence requirements and legislation. This may include providing advice to health and or the participant/ rep about their prospective eligibility. The AO will monitor the Access request, update pace and progress participant to booking for their first plan meeting.

All new participants will receive a first plan even if they are not ready for planning to meet PSG commitments.

The HLO can refer ineligible patients to their Local Area Coordinator (LAC), or organisations for support.

6.3.1 Process for access (Tasmania only)

When a person with disability is admitted to hospital, who is not a NDIS participant, the hospital staff will assist them to apply to the NDIS. Hospital staff will help gather complete and submit the necessary information via email to redacted: s22.

When we receive the access request, our health liaison officers (HLOs) will liaise with hospital staff to ensure the required information has been received. This information will include identity documents and evidence of impairments.

If needed, the HLO will help the person to gather any further required information. The HLO will then submit the access request. The NDIA will complete the access request decision as a priority (within 7-10 days) and notify the person of the outcome.

When the person is granted access to the NDIS, they will go through the hospital discharge process so they can be discharged from the hospital in a safe and timely manner. For more information visit the NDIS website Hospital discharge process.

6.4 Not Ready for Planning

A plan meeting will NOT be arranged if the Planning Barrier in PACE is ticked for ‘participant not ready for planning’ AND the Health information due date is not populated.

If a participant is not ready for planning:

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Health is temporarily unable to estimate their discharge support needs. The participant may be medically unstable or undergoing active rehab with an uncertain prognosis; HLO must check in weekly to identify when a participant becomes stable enough to progress the planning process – this can be done at the regular Health Key Leads meetings.
Participant ‘not ready for planning’ barrier and Health information collected date unentered in PACE prevents a participant from progressing to plan meeting so they will remain without action if this barrier is not removed at the relevant time.

Where Health advise a participant is expected to have an extended admission (i.e. 6-12 months) where there is no current plan to discharge, the participant will exit the HD pathway until such time as health advise that they are ready to commence discharge planning. This will usually be for participants with long term psychiatric conditions. In these cases, a long-term plan will be implemented to reflect their inpatient supports and an alert will be placed on the file that the HD pathway can be reengaged when they become ready for planning, The HD team will not undertake ongoing monitoring of this group.

6.5 Collecting Health Information

The general rule is that health information is to be provided by health within 15 days of notification. During and subsequent to the initial conversation with Health, the HLO identifies early on what information is required and from who and actively seeks it out. Refer to Appendix A,B,C,D for further information on Supporting Evidence.

When the required information is collected, applications can be submitted for TAB advice (mandatory referrals) and H&L, and a planning meeting can be progressed.

In PACE, the participant will not progress to planning (unless it is their First Plan) when Health info collected date is blank and participant not ready for planning barrier in place.

The HLO must have an awareness and act upon the below if necessary:

Understand if a participant has suffered injury through an accident. It may be necessary to work with the Compensation / Recoveries Team where the participant has connections with other insurers / funders, to confirm supports and funding / recovery of costs, in preparation for the Planner. See Compensation Recoveries Intranet Page for more information.
It is expected that generally, health will provide all of the participants care needs while in hospital. There are some circumstances where a participant may access supports from their plan during admission. Where this occurs the NDIA requests that the health service provide advice on the requirement to access the plan and the adjustments the facility has made to provide an inclusive service. If there is concern or evidence that concurrent supports are being utilised incorrectly, the HLO should discuss this with their manager.

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A report of a participant critical incident is any information provided to the NDIA, NCC and Partner staff that alleges that an event occurred involving: Practice Guide – Participant Critical Incident.

6.6 Health Information Collected

When awaiting Health information, the HLO must clearly document what information is required; who the request has been made to; and the expected time frame for it to be provided.

When the supporting evidence has been obtained from Health and uploaded to the NDIS business system, the HLO will:

Ensure the health info collected date is updated in the PACE case.
Lodge any TAB requests where mandatory advice is required, Refer to Mandatory TAB for more information on how to lodge a request.
Prepare and submit the H&L request where required Refer to the Create a Home and Living Application Standard Operating Procedure for more information.
- As soon as TAB and H&L have been lodged, a plan meeting can be triggered. Do not wait for this information to come back first as it is expected any TAB advice or H&L decision will be completed before the meeting date (5/7 days).
- Once a decision is made by H&L and it is marked ‘awaiting build in PACE, the HLO can communicate this decision with Health and support coordinator to allow Health to work with relevant stakeholders to progress discharge planning. It also allows for further discussion, explanation, and information provision if the decision is not aligned with Health and or the Participant /Rep expectations.
- Where the decision supports an SDA and or SIL outcome the outcome and ratios of care can be communicated. Where the decision declines SDA or SIL, the decision can be communicated, and advice should be provided that the planner will determine the volume of supports that will be provided through the planning meeting.
- A Change of Decision request is made when there has been a fundamentally incorrect H&L decision based on both the evidence provided and the NDIS supports policy. See Appendix F.
When the health information date is entered on PACE and the participant is ready for planning (i.e., Participant NOT ready for planning barrier removed on PACE) the planning meeting will be booked by the AO.
The AO will contact the participant/rep and any other required stakeholders to book the planning meeting or schedule a planner to do a variation. If there are persistent issues obtaining information from health, this needs to be raised at the regular Health meeting and prioritised to your Assistant Director (AD) as required. AD will escalate or prioritise to senior leadership team to raise with Health if unable to resolve.

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HLO’s must be proactive to chase info which has not been received in 15 days. If health advise they are unable to provide within that time an estimate of when they can provide it needs to be obtained and documented in notes on PACE.
HLO’s must critically assess what decisions a planner can make with the information already obtained.

6.7 Plan Meeting

The planning meeting is usually between the planner and the participant/rep. Where consent has been provided, the meeting can involve other parties if requested by the participant, such as relevant Health stakeholders who are supporting the participant with their discharge. In principle a planning meeting will only be progressed when all information has been received that is critical to the planning process.

The planning meeting will be triggered when in PACE the criteria of ‘participant NOT ready for planning’ barrier removed AND Health information collection date entered.
It is important that discussions are held with the participant. If the participant is not able to attend or participate in the planning meeting, an alternate rep should be identified. Any formally appointed NDIA nominee or legal Guardian must be invited to the meeting. If there is a Nominee and a Guardian, the nominee is the decision maker. If there is disagreement between the guardian and nominee, discuss with your AD.
A planning meeting should only be cancelled if the Participant or their authorised representative is unable to attend (and not at the request of Health). The Guardian must be invited but does not need to be present at the meeting. They do need to be aware of the participants goals and inclusions in the plan before plan approval.
If the planner is unable to complete the plan this must be updated in PACE with the details and note any barriers. The planner will email the HLO inbox to request the meeting to be re-scheduled if an additional meeting is required.
HLO needs to follow up on any extra information requirements and work with the planner to resolve any barriers.
It is a priority to complete the planning process as quickly and efficiently as possible, while ensuring an appropriate discharge plan is implemented.
The planning meeting can be booked before the H&L or TAB advice is completed. The booking will allow time for the process to be completed and assume the ordinary time frame for these (5-7days)

6.8 Follow up Plan Approval

HLO must monitor the plan meeting dates and approvals.
The plan should be approved within 2 days of the plan meeting. If plan is not approved and there are no notes, HLO must contact the planner to obtain update and then action as required.

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If the planner is unable to complete the plan, they must update PACE with the details (i.e., discharge support needs cannot be predicted) and note any barriers.
HLO needs to follow up on any extra information requirements and work with planner to resolve any barriers.

6.9 Plan Approval and Implementation

When the plan is approved the planner will communicate the plan to the participant and relevant stakeholders. The HLO will communicate the plan with Health to support their discharge planning.

The purpose of the implementation meeting is to ensure all stakeholders are clear on their role and are actively involved in the implementation of the plan. A plan implementation meeting is to be held by the Planner the same day or within the next business day. It includes the Planner contacting the participant or representative and SC to confirm the plan and next steps. If SIL is part of the approved plan, the Planner needs to have created a SIL Service Booking within five days after plan approval, including all parties being notified.
Where a participant has a plan and is medically ready, HLO must capture the barriers to discharge and work actively with Health, SC and any other relevant stakeholders to resolve them. Implementation barriers are used to inform broader cross government conversations.
If actions are not able to resolve the barriers in a timely manner – escalate/prioritisation to AD. Please see actions to resolve discharge barriers.
Where participants have complex discharge requirements which are unable to be resolved you may need to refer the case to Directors or Branch Manager for case consult/conference. Do this in consultation with your AD.
HLO to follow up delays to a RFS and Support Coordinator onboarding, (the SC needs to be engaged as soon as possible of SC approval).
Monitor and action if the RFS handover meeting is delayed.

6.9.1 Directions on interim plans

An interim plan includes some updates but does not include all the supports required for discharged. This applies for participant who have extended stay in hospital and Health cannot advise what the participant support needs might be to facilitate discharge from hospital.
Interim plans can be completed for 1st plans if the health information is not yet received, this allows for initial support that may be required i.e., Support Coordination, Home modification assessments etc (please note this is not limited to these, it is case by case)
Interim plans can be completed when a person is not ready for discharge, and we have received a request for transition supports i.e., ATHM RFS for wheelchairs for spinal participants or SCCP funding for long-stay MH transition planning.

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Interim plans should not be completed for awaiting information, evidence, or planning decisions i.e., H&L or TAT.

6.9.2 Directions on plan variation and re-assessments

Plan variations should be completed if a person only needs a slight adjustment (as per guidelines of s47) to discharge. HLO’s may complete a plan variation if the requirement is urgent.

No plan reassessment of any type needs to occur if participant has adequate supports in their plan to discharge.

6.9.3 Address Discharge Barriers and Confirm Discharge

Once a plan is approved and implemented, the participant should discharge as soon as they are medically ready to do so.

Estimated Discharge Date (EDD)— this is when a participant’s medical treatment is expected to finish — this is an estimated date and might move around during the admission. The EDD is the expected date the participant will complete their medical treatment and Health are anticipating the participant will no longer have a medical reason to be in hospital.
Medically ready date. — this is an actual date where Health have confirmed the participant became medically ready for discharge.
It is critical to ensure participants with approved plans have a correct hospital status.
The HLO will remain actively engaged with Health during this time to monitor and resolve issues with stakeholders if they arise.

6.9.4 Accommodation Team

If a participant is unable to effectively engage with a Support Coordinator or if their engaged Support Coordinator has exhausted all housing options and a participant is medically ready for discharge with a hospital discharge plan, a referral can be made to the Accommodation team with the template below via the AD to redacted: s22.

Request for assistance to source accommodation


Participant Name:
Referral date:
Referred by:
NDIS No:
Support Coordinator:
Referral required due to:

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6.9.5 Discharge

When Health confirms a participant has discharged, the HLO must capture the date and discharge destination in PACE.
Ordinarily the case will be closed at this point, with information entered for case closed date and closure reason (see PACE Guide on How to Close a case).
The AO will undertake the actions to return the participant to ND for future planning.

6.10 Escalations and prioritisations

Prioritisation refers to when work needs to move through the queue in an accelerated pathway.

Escalation refers to when there is an issue that carries sensitivities or risk.

Requests for prioritisation to your AD include:

H&L decisions that cannot wait the 5-day turn around and/or a case has not received the panel hearing/outcome within the designated time from of 5 days.
TAB decisions that cannot wait the 7-day turn around and/or a case has not received the advice hearing within the designated time from of 7 days.
Access decisions not returned within 10 days.
HDD plan approvals greater than 48 hours
Cases escalated internally where the case is not progressing as expected (encountering internal blockages), or are raised by health due to risk, complexity, or timeliness issues will be managed by the Health Interface Escalations Team redacted: s22 see Escalations Process Guide for further information on internal and external escalations

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7. Appendix

7.1. Appendix A — Critical Discharge Requirement Checklist

(Health Contact Guide)

Note: as per usual process, interactions should be captured in relevant business system.

Critical Discharge Requirements Checklist

Planning	Yes/No
Is a new plan required for discharge?
* Is a new or revised Home and Living decision required?
Is technical advice (TAT) required?
Is consultation with Compensation team required?
Is there an active s100 or AAT case?
Providers	Yes/No
Are new (or change in) providers for critical care needs required for discharge?
Does new Assistive Technology (for critical care needs) need to be sourced for discharge?
Is an update or initial completion of Positive Behaviour Support Plan required for discharge?
Is there a current Support Coordinator involved or does there one need to be engaged?
Is there a current Psychosocial Recovery Coach involved or does there one need to be engaged?
Team Around the Person (TAP)	Yes/No
Are the relevant members of the Team Around the Person (TAP) engaged in the discharge planning for the individual.
* Is a Guardianship appointment required for discharge?
* Has the participant been linked with all required mainstream supports to sustain discharge?
* Is new accommodation required for discharge?
* Is a transition plan required for discharge?

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7.6 Appendix F – Change to H&L Decision

The process for a Change of Decision links with the Home and Living Mandatory Referral Process Home and Living (ndia.gov.au).

New H&L decision received. Decision is in line with the evidence and NDIS guidance documents. a. Implement decision.
- If participant/stakeholder disagree, follow RORD/S48 pathway.
New H&L decision received. Changes required meets H&L Mandatory Referral Criteria Home and Living.

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Examples include:

An alternative / different home and living SDA decision.
Increased daily activities funding of more than an additional *4 hours per day and / or request for an increase to the level of support intensity (i.e., higher from standard).
A change to active overnight supports.
A change to shared support ratio (if relevant) that cannot be covered by the current flexible funding on an ongoing basis.
Participant is under 18 years old.

a. Ensure PACE H&L application status is closed. b. Submit New H&L Application with the new evidence received – NDIS Plan and H&L Application is to be completed by NDIS planner if new evidence is provided during planning meeting. c. HLO or planner to escalate H&L application to AD if required. d. EL1 to place on H&L Escalation tracker.

New H&L decision received. Changes required does not meet H&L mandatory referral criteria Home and Living. Examples include:

<4hrs/day change to Core DA support.
Change to SC&CP Supports.
Change to step-down duration.

a. If PACE H&L status closed. Submit new application. b. If new evidence is received. Submit new application. c. If PACE status is Awaiting Build

No new evidence, discuss with AD.
Complete Request of Change of Decision Form.
AD to endorse the request and determines a decision. Any changes approved by the AD are documented in CRM/PACE/
If request declines, implement original decision. Participant to gather further evidence for review.
HLO or delegate (requestor) to implement change of decision.

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