– MARCH 2025 –
Are you supporting a participant who is currently in hospital or recently arrived home?
Heading home from a hospital stay, especially one that has been lengthy or had life-changing consequences, can be exciting, but it can also be challenging and overwhelming.
It’s often difficult to know exactly what support a participant will need to adapt to new functional levels at home. Adding the complexity of starting to use the NDIS can make things feel overwhelming very quickly!
At Active Edge Physio, we understand the complexities of this transition and always aim to help make it as smooth as possible. We believe in getting involved early – whilst the participant is still an inpatient – so we can help tailor a plan that addresses their specific needs and ensures a successful transition home.
How does the hospital system work?
While in hospital, the inpatient medical and allied health teams often assist with completing an NDIS access application and referring to a NDIS Support Coordinator. NDIS Support Coordinators have a crucial and important role in guiding their participants through the complexities of the NDIS, ensuring their community-based care team – including disability support workers, physiotherapists, occupational therapists, speech therapists, psychologists, podiatrists, and others – works together seamlessly to comprehensively support and empower the personal at home.
As a proactive Support Coordinator, you may often be seeking an allied health team that is qualified and trustworthy to provide supports to your complex participants within their own home, particularly during such a vulnerable and critical time after discharging from hospital.
Why should you contact us before your participant discharges from hospital?
The NDIS can be a complex system to navigate, and those working within the hospital may not always be fully aware of the specific needs of NDIS participants in the community. For example, inpatient physiotherapists may request funding for community therapy upon discharge, but this may not fully align with what the participant requires once they’re back home. Without adequate NDIS funding, your participant may not receive the necessary therapy time to maximise their recovery and ease their transition back to daily life.
Inpatient physiotherapists are also often hesitant to recommend specific therapy services due to a potential conflict of interest. It’s thus important to do your research and find a provider that you can be confident meets your participant’s goals and needs.
At Active Edge Physio, we understand the importance of covering not just the therapy time but also additional costs like travel and administrative tasks related to a participant’s care to set them up for success. These tasks can include prescribing equipment, liaising with the care team, and training new caregivers or family members. This is why it’s essential for a community therapy team to be involved in the NDIS application process from the outset, ensuring that your participant has access to adequate funding and support as they transition home.
Our top tips for a successful discharge home
We understand that heading home after a hospital stay can be both exciting and overwhelming, so we’ve compiled our top tips to help make the transition smoother and less stressful.
1. Engage a qualified and invested support team
It’s essential to have a solid and prepared support system in place when a participant returns home. A strong support system can make a big difference to overall well-being and risk of returning to hospital.
Empower the participant and their family to carefully select carers before discharge who can be trained by the inpatient hospital team. Involve the new community physiotherapist early so that there can be an in person handover and continuity of care with ongoing training of disability support workers and to ensure independence is nurtured as much as possible.
Consider involving the participant’s family, friends, and/or carers in the discharge planning process to optimise success. These people will play a crucial role in supporting the participant’s recovery, both physically and emotionally. Make sure everyone understands the plan and knows how they can help, whether it’s assisting with daily tasks, offering emotional support, or providing transportation to appointments.
2. Prepare the home environment
Before your participant heads home, take the time to ensure their living space is ready for their new needs.
Your participant’s Occupational Therapist can assist with making modifications to the home, such as installing grab rails, ensuring there is ramp access if needed, providing toileting aids and rearranging furniture for easier access. It’s important to set up the home environment so that it promotes safety, independence and comfort.
3. Equipment and supplies
Make sure your participant has\ all the necessary equipment and supplies to support their care at home. Be proactive in ensuring everything is ready before your discharge so that they don’t have to worry about it once they’re home.
This may include mobility aids (walkers or wheelchairs), special seating or bedding, and home care supplies (incontinence products, personal hygiene items). Nursing and allied health teams will guide you in determining what is essential and help you source any equipment that may be needed.
4. Encourage the establishment of a routine
Creating a daily routine will help your participant regain a sense of normalcy and independence. A well-structured routine can help them stay on track with their recovery and can make it easier to adjust to any new equipment, therapies, and caregivers they may have.
Work with your participant’s care team to establish a schedule that works for them, keeping in mind that it may need to be adjusted as they settle in or as their condition changes.
Remember, transitioning home is a big step, and it’s normal to feel a little uncertain! By taking these steps, you can help create a supportive and organised environment that will help your participant thrive as they move forward in their recovery.
If you or a loved one is ready to transition out of hospital and back home, our dedicated specialists would be delighted to help. Contact us to book a free 15-minute consultation or complete the referral form online and we’ll be in touch within 24 hours (on weekdays) to explore the best way forward.
Author | Amanda Lieblich – Senior Physiotherapist