Guide – Psychosocial disability Appendix A – Discharge planning
The contents of this document are OFFICIAL.
This article provides guidance for planner delegate, internal review delegate, national reassessment delegate, local area coordinator, early childhood partner, technical advisors, liaison officers (HLO/JLO), or complex support needs (CSN) planner to understand:
- discharge planning with participants living with a psychosocial disability.
Recent updates
October 2023 Current guidance.
Before you start
You have read and understood:
- Our Guideline – Reasonable and necessary supports (external)
- article Guide – Complex Support Needs (CSN) Pathway.
Appendix A – Discharge planning
This overview is of hospital/secure mental health facility discharge processes. It includes considerations for planning if a forensic order is in place and when a discharge date has been set.
The NDIS and the mental health system work together to plan and coordinate streamlined care for individuals requiring both health and disability services. Planners, recovery coaches, support coordinators and local area coordinators (LACs) consult with their State or Territory’s relevant specialist mental health discharge planning guidelines. The guidelines are used to engage the responsibilities of specialist mental health services during a participant’s transition from rehabilitation or hospital settings.
Keep lines of communication open and provide clear information to the participant and all parties involved in planning for discharge. For advice on reasonable and necessary transitional supports during the discharge processes from either mental health or justice facilities, Technical Advisory Branch (TAB) advice can be sought.
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SGP Knowledge Article Template
For Internal Use Only
Note: Advice may be mandatory in some circumstances. Refer to the technical advice case in PACE and article Understanding when to request for plan advice to understand if you need to request mandatory TAB advice.
Health Liaison Officers
Health Liaison Officers are represented in all states and territories and work within the Complex Support Needs (CSN) Pathway Branch of the NDIA. They provide a single point of contact for health staff to facilitate support for participants (prospective and current) in hospital settings.
For more information refer to the Health Liaison Officer factsheet.
Transition supports
The NDIS is responsible for working with the mental health system during discharge planning to support participants with psychosocial disability who require disability-related functional supports following discharge.
NDIS involvement in transition planning should commence when a participant has stabilised and there is a need for ongoing disability-related supports to maintain or manage functional capacity once the participant returns to living in the community.
The health system is responsible for general discharge planning to support participants through the discharge process and during transition to post-discharge care provided in the community. For example, referral to community mental health team and housing supports.
NDIS plans for participants in hospital or mental health facilities should be developed when a discharge date is available and this date is within 6-12 weeks’ time. However, prior to this time, a community connections plan may be developed.
If the participant has a current NDIS plan, the funding remains active and is available to support the participant to reintegrate into the community and day-to-day living activities following discharge.
Note: The participant or representative may request a plan variation or reassessment or the Agency may commence a plan reassessment when there is a change in the participant’s situation that requires a change in their ongoing support needs.
Effective joint discharge planning ensures:
- the participant’s psychosocial support needs are appropriately identified
- NDIS supports are in place at the time of discharge
- smooth service delivery during transition.
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SGP Knowledge Article Template
For Internal Use Only
A planning meeting involving the recovery coach, specialist support coordinator or LAC, the participant and clinical mental health service should be held before discharge. As part of this meeting, the treating mental health representative should be asked to provide information about what treatments will be put in place post discharge.
Service providers/recovery coaches/support coordinators/LACs should provide supports so the participant is supported through the change, as well as supports that assist participants to develop self-care and self-management capacities.
Article topics and case names – internal use only
Topics
This article relates to the following topics:
- Add: t_complaintsandcriticalincidents
- Add: t_complexsupportneeds
- Add: t_implementation
- Add: t_planchanges
- Add: t_planmanagement
- Add: t_psychosocialdisability
- Add: t_reasonableandnecessary
- Add: t_reviewingdecisions
- Add: t_safeguarding
Case names
You can use this guidance for the:
- Add: dc_case_checkin
- Add: dc_case_evidenceextension
- Add: dc_case_functionalcapacityassessment
- Add: dc_case_hospitaldischarge
- Add: dc_case_internalreview
- Add: dc_case_participantbudgetupdate
- Add: dc_case_participantcriticalincident
- Add: dc_case_participantriskassessment
- Add: dc_case_planapproval
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Version control
| Version | Amended by | Brief Description of Change | Status | Date |
|---|---|---|---|---|
| 0.1 | JJP788 | Draft. Content from article Guide — Psychosocial disability v0.2 | DRAFT | 2022-11-18 |
| 1.0 | CS0074 | Class 1 approval | APPROVED | 2022-11-18 |
| 1.1 | MGC723 | Updated to make sure content is transferred from PG — Psychosocial Disability. Minor updates to change any NDIS Business System language to PACE language. | DRAFT | 2023-08-23 |
| 1.2 | REB563 | Content transferred from PG — Psychosocial Disability. |
Updates to formatting in alignment with new Knowledge Article template.
Minor updates to change any NDIS Business System language to PACE language. | DRAFT | 2023-09-18 | | 2.0 | JS0082 | Class 1 Approval | APPROVED | 2023-09-21 |
V2.0 2023-09-21
WP02-42 — Guide — Psychosocial disability Appendix A
This document is uncontrolled when printed