2027
National Hospital-to-Home CarePathways
Older Persons, Aged Care & Complex Hospital Discharge Roundtable Forums

Across Australia, hospitals are facing increasing challenges in discharging older patients who no longer require acute hospital treatment but cannot safely transition into residential aged care, their own homes or other appropriate community care settings.

For many older Australians, discharge is complicated by dementia, cognitive impairment, complex medical conditions, behavioural support requirements, limited aged care accommodation, assessment delays and difficulties securing appropriate services.

These challenges contribute to prolonged hospital stays, commonly described as delayed discharge or hospital bed blocking, placing considerable pressure on hospital capacity, emergency departments, clinical teams, social workers and discharge planners.

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For older people, remaining in hospital longer than clinically necessary can also increase the risk of physical deterioration, functional decline, confusion, distress and loss of independence.

The challenge is particularly significant for patients living with dementia, complex behavioural needs, multiple chronic conditions or limited family and community support.

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In some circumstances, an older person may be medically ready for discharge but have nowhere suitable to go. In others, an appropriate placement may be identified but cannot proceed because of assessment requirements, funding arrangements, clinical complexity, workforce limitations or unresolved legal and decision-making issues.

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These are not challenges that hospitals can resolve independently.

They require a coordinated response involving health services, aged care providers, government agencies, allied health professionals, disability services and the wider community care sector.

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The 2027 National Hospital-to-Home CarePathways Forums will provide an opportunity to bring these sectors together to examine the issues contributing to delayed hospital discharge and explore practical approaches to improving transitions for older Australians.

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Why these National Roundtables are important

Hospital discharge delays involving older people are placing increasing pressure on Australia's health and aged care systems.

The challenges extend beyond the availability of hospital beds.

Hospitals must frequently coordinate complex arrangements involving residential aged care placement, clinical handover, dementia care, capacity and consent, guardianship, family involvement, rehabilitation, funding approvals and the availability of appropriate care services.

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The situation becomes particularly difficult where an older person has complex needs that cannot be readily accommodated within existing aged care settings.

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For example, a patient living with advanced dementia may be medically ready for discharge but unable to access a residential aged care facility equipped to manage their clinical and behavioural support requirements.

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Another patient may require a specialist aged care placement, ongoing nursing care or a combination of rehabilitation and community support before discharge can safely proceed.

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These situations can result in extended hospital stays, uncertainty for families and considerable pressure on hospital personnel.

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The central question for these national forums is: How can hospitals, aged care services and relevant professionals work more effectively together to reduce unnecessary discharge delays while maintaining safe, appropriate and person-centred care?

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Building on the National NDIS Hospital-to-Home Roundtables

During 2026, NDISDA® and National Hospital-to-Home CarePathways facilitated professional roundtables bringing together hospital personnel, disability-sector representatives and relevant specialists to examine the challenges associated with complex hospital discharge.

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These discussions identified recurring barriers involving funding arrangements, accommodation availability, communication between services, workforce readiness, legal responsibilities and the coordination of appropriate care.

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The forums also demonstrated the value of providing hospital personnel with an independent, structured environment in which to discuss the practical challenges they experience.

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Building on this work, Health2Ageducate® and NDISDA® are extending the national roundtable program to address the particular challenges affecting older Australians and the aged care sector. The approach remains consistent with the existing Hospital-to-Home program.

Rather than focusing solely on presentations, the forums will encourage professional discussion, shared experience and practical consideration of the barriers preventing timely and safe hospital discharge.

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Our intention is to hear directly from hospital personnel, aged care professionals and other relevant specialists, identify common challenges across participating states and contribute to discussions about achievable improvements.

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Key Issues for National Discussion

1. Hospital Bed Blocking and Delayed Discharge

Understanding why older Australians remain in hospital after they are medically ready for discharge.

Discussion will examine the principal causes of delayed discharge, including residential aged care shortages, assessment and funding delays, limited specialist accommodation and the availability of suitable care arrangements.

Consideration will also be given to the impact on hospital bed capacity, patient flow, emergency departments, hospital personnel and older patients.

2. Dementia, Cognitive Impairment and Complex Behavioural Needs

Addressing one of the most challenging areas of hospital-to-aged-care transitions.

Older people living with dementia, delirium, cognitive impairment or complex behavioural presentations can experience significant difficulties accessing appropriate residential aged care placements.

The forum will explore the challenges associated with specialist dementia care, behavioural support, clinical complexity, workforce capability and the availability of suitable facilities.

Discussion will also consider how hospitals and aged care organisations can improve coordination when an individual requires a higher level of support than is readily available.

3. Residential Aged Care Availability and Placement Challenges

Examining the barriers to securing suitable residential aged care placements.

The availability of aged care beds does not always mean that a facility can accommodate an individual with complex needs.

The discussion will consider placement availability, specialist care requirements, regional and metropolitan differences, provider capacity and the practical challenges associated with transitioning patients from hospital into residential aged care.

4. Legal and Safe Hospital Discharge

Understanding the legal, clinical and organisational responsibilities involved in discharging older patients.

This discussion will consider duty of care, discharge readiness, consent, decision-making capacity, guardianship arrangements, clinical risk, information sharing and the responsibilities of hospitals and receiving care organisations.

Particular attention will be given to situations where a patient is medically ready for discharge but appropriate accommodation or care arrangements are unavailable.

The objective is to improve professional understanding of safe discharge responsibilities and the practical considerations involved in complex transitions.

5. Aged Care Assessments, Funding and System Delays

Examining how assessment and funding processes affect discharge timeframes.

Older patients may experience delays while awaiting aged care assessments, eligibility decisions, funding allocation or the commencement of appropriate services.

Discussion will consider how these processes affect hospital discharge planning and where improved communication or coordination may reduce unnecessary delays.

6. Support at Home Reforms 2026–2027

Understanding the implications of Australia's changing aged care arrangements for hospital discharge.

The Support at Home program and subsequent reforms have introduced changes to aged care funding, assessment, service delivery and access to home-based supports.

This discussion will consider the practical implications for older people who may be able to return home with appropriate assistance.

Topics may include funding availability, restorative care, personal care, assistive technology, home modifications, provider capacity and the commencement of essential services.

Support at Home will be examined as one component of the broader hospital discharge pathway, alongside residential aged care, rehabilitation and other care options.

7. Complex Health Needs, Rehabilitation and Clinical Care

Supporting older patients who require ongoing clinical or multidisciplinary assistance.

Discussion will consider patients with multiple chronic conditions, significant mobility limitations, rehabilitation needs, complex medication requirements or ongoing nursing support.

The forum will examine the challenges involved in coordinating appropriate services and ensuring continuity of care following hospital discharge.

8. Communication, Families, Consent and Decision-Making

Improving communication between hospitals, aged care services, older patients and families.

Complex discharge arrangements may involve family disagreements, consent issues, decision-making capacity concerns, guardianship processes or difficulties sharing essential information.

Discussion will examine how clearer communication, appropriate escalation and improved coordination can support safer transitions.

9. Workforce Readiness and Receiving Care Capacity

Understanding whether aged care services have the workforce and capability to receive patients with complex needs.

The availability of suitable accommodation is only one part of discharge planning.

Residential aged care facilities and community care organisations must also have appropriately trained staff, clinical support arrangements and the capacity to meet the individual's needs.

The forum will consider workforce shortages, specialist skills, clinical handover and the responsibilities of receiving organisations.

10. Identifying Practical Solutions and Future Pathways

Moving beyond identifying problems to examining opportunities for improvement.

The roundtable will encourage discussion about better communication between hospitals and aged care providers, improved assessment and placement coordination, workforce capability, professional education and potential system improvements.

The intention is to identify common challenges and practical opportunities that may contribute to more timely, safe and sustainable discharge arrangements.

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Who should attend?

These national forums are designed for professionals and organisations involved in hospital discharge, residential aged care, dementia care, complex care coordination, disability support and the transition of older Australians into appropriate care settings.

• Hospital and Health Professionals

• Hospital executives and health service managers

• Hospital social workers and discharge planners

• Patient flow and bed management personnel

• Geriatric medicine specialists and geriatric assessment teams

• Nursing directors, clinical nurse consultants and nurse unit managers

• Hospital aged care liaison personnel

• Rehabilitation and allied health professionals

• Complex care coordinators and transition care teams

• Hospital disability liaison officers

• Mental health and older persons' specialist services

• Residential Aged Care and Aged Care Professionals

• Residential aged care providers and facility managers

• Aged care executives and clinical care managers

• Specialist dementia care providers

• Aged care assessment professionals

• Transition care and restorative care services

• Community nursing and aged care organisations

• Support at Home providers

• Aged care placement and care coordination professionals

• Organisations supporting older people with complex health and behavioural needs

• NDIS Providers Considering Entry into Aged Care

• NDIS providers interested in understanding or expanding into the aged care sector are welcome and encouraged to attend.

 

This includes:

• NDIS providers exploring aged care service delivery

• Disability support organisations considering diversification

• SIL and community-based support providers

• Nursing and complex care providers

• Allied health and rehabilitation businesses

• Providers experienced in supporting people with complex behavioural or functional needs

• Organisations seeking to understand aged care registration, governance and regulatory obligations

• Existing NDIS businesses interested in the differences between NDIS and Commonwealth-funded aged care arrangements

These forums offer an opportunity for NDIS providers to better understand the challenges facing hospitals and the aged care sector, including the service capabilities and regulatory responsibilities involved in supporting older Australians.

NDIS registration does not automatically authorise the delivery of government-funded aged care services. Separate aged care registration and regulatory requirements may apply.

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• Allied Health and Specialist Professionals

• Occupational therapists and physiotherapists

• Speech pathologists and rehabilitation specialists

• Dementia and behavioural support specialists

• Psychologists and mental health professionals

• Community nursing and complex clinical care providers

• Assistive technology and mobility equipment specialists

• Social workers and care coordination professionals

• Government, Policy and Professional Representatives

• Commonwealth and state government representatives

• Health and aged care policymakers

• Aged care and disability regulators

• Aged care assessment and funding representatives

• Professional associations and peak bodies

• Researchers and academics

• Legal, governance, quality and compliance professionals

• Health and aged care consultants

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Why attend?

The National Hospital-to-Home CarePathways Forums provide an opportunity to participate in professional discussions about the challenges affecting older Australians who remain in hospital while awaiting appropriate care.

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Attendees will have the opportunity to:

• Better understand the causes and consequences of delayed hospital discharge and prolonged hospital bed occupancy.

• Examine the challenges associated with dementia, cognitive impairment and complex behavioural care needs.

• Discuss residential aged care placement barriers and the availability of suitable care facilities.

• Improve understanding of legal and safe discharge responsibilities.

• Consider aged care assessments, funding arrangements and the implications of the Support at Home reforms.

• Examine workforce readiness, clinical handover and continuity of care.

• Share professional experience and contribute to discussions about practical improvements.

• Understand the aged care environment and service requirements, particularly for NDIS providers considering diversification.

• Contribute to broader national discussions leading into the 2027 National Integrated Care Summit in Melbourne.

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Forum Format

The forums will be conducted as facilitated professional roundtables incorporating expert contributions, moderated discussion and audience participation.

Each session will provide an opportunity to examine the principal challenges affecting hospital-to-aged-care transitions, hear relevant professional perspectives and discuss potential improvements.

The format is intended to encourage meaningful discussion rather than a series of lengthy presentations.

Hospital personnel will have an opportunity to share their experiences of discharge delays and the barriers they encounter when arranging appropriate care for older patients.

Aged care, disability, allied health and other relevant professionals will be invited to contribute their expertise and perspectives within a structured, respectful environment.

The discussions will focus on identifying common challenges, understanding the responsibilities of different sectors and exploring practical opportunities for improvement.

These are professional discussion forums, not provider referral or sales events.

Attendees will be expected to respect the professional code of conduct and non-solicitation principles that underpin National Hospital-to-Home CarePathways.

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What we aim to achieve

Through the national forums, NDISDA®, Health2Ageducate® and National Hospital-to-Home CarePathways aim to develop a clearer understanding of the challenges affecting older Australians who experience delayed hospital discharge.

Our objectives include:

• Identifying recurring causes of delayed discharge across participating states.

• Understanding the particular challenges associated with dementia and complex care needs.

• Examining barriers to residential aged care placement and appropriate accommodation.

• Improving awareness of legal and safe discharge responsibilities.

• Exploring assessment, funding and service coordination challenges.

• Identifying opportunities for better communication between hospitals and aged care organisations.

• Considering workforce capability and professional education needs.

• Gathering de-identified professional insights that may contribute to broader national discussions and future initiatives.

• The forums may also identify opportunities for tailored hospital-based workshops, specialist education sessions and further professional engagement.

• The focus is on identifying solutions, strengthening coordination and contributing to safer, more effective hospital discharge pathways for older Australians.

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Leading Into the 2027 National Integrated Care Summit — Melbourne

The National Hospital-to-Home CarePathways Forums form part of the engagement and evidence-gathering activities leading into the:

2027 National Integrated Care, Complex Needs & Hospital-to-Home Pathways Summit — Melbourne

2–3 June 2027 | 9.00 am – 5.00 pm

RACV City Club, 501 Bourke Street, Melbourne

The national conference will bring together professionals and organisations across:

Allied Health • Disability & NDIS • Aged Care • Mental Health • SDA & Community Housing • In-Home Support

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The 2-day summit will provide a broader national platform for examining complex care, hospital discharge, aged care reform, disability support, housing pathways and integrated service delivery.

Insights gathered through the Hospital-to-Home roundtables will help inform national discussions and identify opportunities for future professional education, collaboration and policy consideration.

The conference will include expert presentations, panel discussions and breakout workshops.

The national roundtables provide an opportunity to hear directly from those experiencing the challenges, while the Melbourne summit will provide a broader platform for examining potential solutions and future pathways.

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Join the National Discussion

The challenges associated with delayed hospital discharge, dementia care, residential aged care availability and complex transitions require a coordinated response across Australia's health and aged care systems.

Through NDISDA®, Health2Ageducate® and National Hospital-to-Home CarePathways, we are bringing together hospital personnel, aged care professionals, disability-sector representatives and relevant specialists to examine these issues and contribute to practical improvements.

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The forums provide an opportunity for meaningful professional engagement, informed discussion and the identification of opportunities to strengthen care pathways for older Australians.

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Our objective is to support timely, safe and appropriate hospital discharge while improving coordination between hospitals, aged care services and the wider community care sector.

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We invite hospital personnel, aged care professionals, NDIS providers exploring aged care opportunities and other relevant sector representatives to join these important national discussions.

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NDISDA, National Hospital to Home Carepathways and Health2ageducate Members will receive a 15% reduced rate ticket