Hospital Discharge to Home: NDIS Transition Support in Sydney

Leaving hospital is a big step, especially when someone's support needs have changed. Good planning can make the transition from hospital to home safer and less stressful for NDIS participants and their families.

This guide explains who does what at hospital discharge, how NDIS plans can change, short-term accommodation options and what to prepare.

Key takeaways

• In NSW public hospitals, the hospital team leads discharge planning, and planning starts early in the stay.

• The National Disability Insurance Agency (NDIA) has health liaison officers and a hospital discharge team who work with hospitals on NDIS supports.

• Plans can change through a plan variation (urgent, minor or short-term changes) or a plan reassessment (significant, ongoing changes).

• Medium-term accommodation can sometimes bridge the gap while a long-term home or supports are arranged.

• Contacting providers early gives time to have supports ready for the day of discharge.

Who does what when an NDIS participant leaves hospital

Several people and organisations are involved. Knowing their roles helps families ask the right questions.

The hospital team

NSW Health is the lead agency for coordinating discharge from its hospitals. A team of doctors, nurses and allied health staff, such as social workers, occupational therapists (OTs) and physiotherapists, plans treatment and sets an estimated date of discharge. Patients and carers should be kept informed of that date.

Each local health district also has an NDIS lead who helps hospital staff with NDIS processes. The same NSW Health policies apply whether someone is at Bankstown-Lidcombe, Liverpool, Westmead or another Sydney public hospital.

The NDIA's hospital discharge team

The NDIA's health liaison officers (HLOs), also called hospital liaison officers, link hospitals with the NDIA. With the participant's consent, hospital staff let the NDIA know about an admission. The NDIA aims to contact the participant within 4 days of being told.

HLOs can gather evidence from hospital staff if a plan needs to change. They work with specialist NDIA planners who focus on participants in hospital.

LACs and Support Coordinators

A Local Area Coordinator (LAC) can help participants understand and use their plan and connect with services. If a participant has a Support Coordinator, they can keep helping during the hospital stay and should be included in discharge planning.

Support providers

Support providers deliver the supports in the plan once the participant is home. With consent, a provider like Lofty Care Services can talk with the family and the hospital team about what's needed.

Applying for the NDIS from hospital

If someone isn't an NDIS participant but may be eligible, hospital staff can contact the NDIA with their consent and help them apply while they're still in hospital. NDIA health liaison officers can also support the access request.

The NDIA says it assesses eligibility for people in hospital as a priority. Evidence from the treating team about the person's disability and its impact on daily life is central to the application.

Changing an NDIS plan during a hospital stay

Tell the NDIA early if a participant's needs have changed. The hospital can let them know with consent, or the participant or family can call the NDIA on 1800 800 110. The NDIA tells hospital staff which supports are already in the plan.

There are two main ways a plan can change:

• a plan variation, for urgent, minor or short-term changes

• a plan reassessment, for significant and ongoing changes in support needs or living arrangements.

Since 27 August 2026, only the participant, their plan nominee or child representative can ask for an unscheduled plan reassessment, using the NDIA's form and evidence. Families should check whether the participant has a plan nominee.

The two systems fund different things. The health system provides treatment and rehabilitation. The NDIS funds disability-related supports needed to live at home and in the community.

Medium-term accommodation and other short-term options

Sometimes a participant is medically ready to leave hospital before their long-term home or supports are ready. Medium-term accommodation (MTA) may help.

The NDIA can add MTA to a plan when a participant is leaving hospital and is eligible for SDA, SIL, individualised living options (ILO) or home modifications. In this situation, a confirmed long-term home isn't required.

MTA is usually funded for up to 90 days, with extensions only in limited situations. It covers the accommodation only, not food, electricity or internet, and it isn't emergency housing. Daily supports in MTA come from other parts of the plan.

Short-term accommodation (STA), sometimes called short term respite, is different. Its main purpose is to give participants and their informal supports a break.

If SDA is the long-term goal, our guide on how to access SDA funding in NSW explains the process.

What to prepare before discharge

Evidence

Ask the treating team for reports on function, support needs and equipment. NSW Health and the NDIA developed a Hospital Discharge Assessment template that NSW hospital staff use to describe a participant's support needs for discharge.

For home and living supports, an OT's functional capacity assessment is often key evidence.

Home and equipment assessments

Ask whether an OT will assess the home, what equipment is needed from day one and who will provide it. Ask, too, whether any home modifications are recommended, and what will happen in the meantime.

A support roster

Draft a simple roster for the first few weeks: who will help, when and with what. Include family, paid supports and appointments. Any gaps show what needs arranging before the discharge date.

How Lofty Care Services can help

Lofty Care Services is a registered NDIS provider. Based in Georges Hall, our mobile team supports participants across Sydney. Depending on the plan, we can help with:

• Daily living: personal care, meals and household tasks

• Complex needs: high intensity care from support workers trained for complex daily personal activities

• Support at home: Supported Independent Living (SIL), around the clock, for people with higher support needs

• Nursing: community nursing for high care needs related to disability

• Transport: getting to follow-up appointments and community activities.

We can't ask the NDIA to reassess a participant's plan, but we can share information about our supports to help with planning. Ask us about current SIL and SDA options, or read about our NDIS services in Bankstown and Canterbury-Bankstown.

Family checklist for leaving hospital

1. Tell the hospital team the person is an NDIS participant, and consent to them contacting the NDIA.

2. Ask for the estimated date of discharge and who is coordinating the discharge.

3. Ask the team to involve the NDIA's health liaison officer.

4. Share the NDIS plan, current supports and any Support Coordinator's details.

5. Collect reports and assessments that describe changed support needs.

6. Confirm equipment, home set-up and transport home.

7. Ask whether a plan variation, plan reassessment or MTA is needed, and who will request it.

8. Contact providers early and agree start dates for supports.

9. Check the discharge summary, medicines information and follow-up appointments before leaving.

Frequently asked questions

Who organises hospital discharge for an NDIS participant?

In NSW public hospitals, the hospital team leads discharge planning. The NDIA's hospital discharge team, including health liaison officers, works with them on NDIS supports. A Support Coordinator can also be involved if the participant has one.

Can NDIS funding pay a support worker in hospital?

Generally, no. Hospital staff provide personal care during a hospital stay. The NDIS can still fund some supports for complex communication needs or behaviours of concern while a participant is in hospital.

Can someone apply for the NDIS while in hospital?

Yes. With the person's consent, hospital staff can contact the NDIA and help them apply. The NDIA's health liaison officers can also help with the access request.

What is medium-term accommodation (MTA)?

MTA is NDIS funding for somewhere to live, usually for up to 90 days, while a participant waits for their long-term home or supports. Participants leaving hospital may get MTA if they're eligible for SDA, SIL, ILO or home modifications.

When should we contact a provider like Lofty Care Services?

As early as possible, once the participant agrees. Early contact gives time to plan supports, match workers and agree start dates before the discharge date.

Talk to Lofty Care Services: call 0431 714 119 or enquire online.

Hospital teams, Support Coordinators and allied health professionals can also make a referral.

This article is general information, not medical advice or advice about an individual NDIS plan. Checked against NDIS and NSW Health sources in November 2026.