Session 1
Hospital to Home – Disability, NDIS & Complex Care
8.30am - 12.00pm
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Session 2
NDIS/SIL Provider Session
Beyond the NDIS: Accident, Catastrophic Injury & Government-Funded Care Provider Pathways
12pm -1.30pm
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Session 3
Hospital to Home
Older Persons, Aged Care & In-Home Support
2.00pm - 4.00pm
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Overview
The NDISDA® Hospital to Home Queensland Forum brings together hospital and health professionals, the disability and NDIS sectors, allied health, aged care and community-based services to strengthen coordination across complex transition pathways.
Through facilitated education, professional discussion and cross-sector engagement, the program will examine the respective roles, responsibilities and operating environments of the organisations and professionals involved in supporting a person’s transition from hospital into the community.
The Forum will explore funding and support pathways, consent and information sharing, continuity of care, professional engagement, community readiness and the practical considerations that can influence timely, safe and sustainable transitions.
A central objective is to hear directly from the different parts of the pathway — identifying recurring challenges, strengthening shared understanding and exploring practical opportunities for improved coordination across organisational and sector boundaries.
Who should attend?
Hospital & Health Professionals • Discharge Planners
• Patient Flow • Disability & NDIS Liaison Officers/Managers
• Support Coordinators
• SIL & Complex Support Providers • SDA & Disability Accommodation
• Allied Health & Rehabilitation
• Assistive Technology
• Community & In-Home Support - Short Term Medium Term Accom
8.30am – 8.45am
Welcome & Setting the Scene: Hospital to Home (NDIS and Disability session)
Hospital to Home sits at the intersection of health, disability, funding, housing and community-based support systems, each operating within distinct responsibilities, requirements and governance frameworks.
This opening session will establish the context for a collaborative discussion focused on the factors that influence transition from hospital into the community, including NDIS Participant needs and preferences, funding and support arrangements, accommodation, consent and information sharing, functional requirements, equipment, workforce readiness and continuity of support.
The forum provides an opportunity to bring together perspectives from across the transition pathway and consider how effective coordination can support sustainable outcomes within the community.
8.45am – 9.30am
Roles, Responsibilities & Interfaces Across the Hospital to Home Pathway
Hospitals • NDIS • Support Coordination • Allied Health • SIL • SDA • Community Supports
A facilitated cross-sector discussion examining how the respective responsibilities of organisations and professionals align as a participant transition from hospital into community-based supports.
Key areas for discussion;
Respective roles across hospital, NDIA, Support Coordination, allied health and community-based services
• The interface between health and NDIS responsibilities
• NDIS Hospital Liaison Officers and relevant hospital pathways
• The role and timing of Support Coordination
• SIL, SDA and other home and living arrangements
• Distinctions between clinical care, disability supports, housing and community-based services
• Allied health, functional assessment, assistive technology and supporting information
• Participant choice, consent, privacy and information sharing
• Communication and escalation across multiple organisations
• Professional engagement between hospital teams and external organisations
• Continuity across points of transition
Central Discussion: Clarifying Roles, Responsibilities & Points of Transition
Exploring how responsibilities align across the Hospital to Home pathway, when different organisations and professionals become involved, and the information, coordination and support required to enable effective transition between hospital and community-based services.
9.30am – 10.10am
NDIS Funding, Support Coordination & Home and Living Pathways
A practical overview of the NDIS funding and support environment relevant to participants transitioning from hospital into the community.
Key Areas for Discussion
• NDIS funding fundamentals relevant to hospital-to-community transition
• Support Coordination and implementation of funded supports
• Supported Independent Living (SIL)
• Specialist Disability Accommodation (SDA)
• Individualised Living Options (ILO)
• Medium Term Accommodation (MTA)
• Allied health, assistive technology and home modifications
• Changes in circumstances and changing support requirements
• Roles of participants, nominees, Support Coordinators, providers and the NDIA
• Translating approved funding into practical community-based arrangements
• Communication and coordination between external organisations and hospital teams
Focus: Connecting Funding, Supports & Community Arrangements
Developing a shared understanding of the NDIS arrangements that may need to align around a participant and how funding, housing, support and coordination connect within the broader transition pathway.
10.10am – 10.25am
Morning Break
10.25am – 11.00am
From Clinical Readiness to Community Readiness
Information • Functional Needs • Medication • Equipment • Workforce • Consent • Continuity
This session is designed to be practical cross-sector discussion examining the information, supports and community arrangements that may need to align as a participant transition from the hospital environment.
Discussions include;
• Relevant clinical and functional information for the receiving support environment
• Mobility, transfers, communication, swallowing, personal care and other functional support requirements
• Participant consent, privacy and appropriate information sharing
• Circumstances where NDIS plan or funding information may not be available to all parties
• Continuity of relevant information across the transition
• Community Support Readiness
• Medication information and continuity
• Access to allied health following discharge
• Assistive technology, equipment and home modifications
• Readiness of accommodation and community-based supports
• Workforce preparation for participants with complex support requirements
• Appropriate familiarisation and transition arrangements
• Communication between hospital teams, Support Coordinators and receiving services
• Supporting participants, families and carers to understand the roles of the organisations involved
Clinical Governance, Legal Considerations & Transition Risk
A professional discussion examining relevant governance and legal considerations associated with complex hospital-to-community transitions, including:
• Timely discharge and safe transition planning
• Clinical readiness and readiness of community-based arrangements
• Documentation and continuity of relevant information
• Participant choice, consent and decision-making
• Professional roles, scope and accountability
• Identified risks where supports, equipment or community arrangements remain in development
• Legal and professional considerations associated with transition timing and continuity of care
• Unplanned returns to hospital
Focus: Supporting Continuity across the transition
Examining how clinical, disability and community systems can maintain continuity while recognising the distinct expertise, responsibilities and governance requirements of each.
11.00am – 12.00pm
Hospital to Home Cross-Sector Roundtable
Supporting Sustainable Transitions & Reducing Avoidable Returns to Hospital
This session is designed to be a facilitated 1 hour discussion bringing together hospital and health professionals, NDIS representatives, Support Coordination, allied health, disability and community-based services.
The roundtable moves from the preceding education sessions into cross-sector discussion — providing an opportunity for participating organisations to identify the practical challenges they experience, hear the perspectives of other parts of the pathway and explore opportunities for stronger coordination.
Hospital & Health Perspectives
Hospital and health representatives will be invited to consider:
• Factors influencing complex or extended transitions
• External arrangements or decisions that can affect transition timing
• Challenges involving NDIS funding, consent, accommodation or support availability
• Communication and coordination with Support Coordinators and external organisations
• Appropriate and efficient engagement with external providers
• Duplication, repeated approaches and administrative pressures
• What hospital and health professionals would like the disability sector to better understand about the hospital environment and transition process
Disability & Community Perspectives
Disability and community representatives will be invited to consider:
• Challenges experienced when establishing community-based supports
• Information required by receiving services and frontline support teams
• Medication, allied health, equipment and workforce-readiness considerations
• Timing of Support Coordination and receiving-service involvement
• Participant and family understanding of the different roles across the pathway
• What disability and community-based organisations would like other parts of the pathway to better understand
From Discharge to a Sustainable Transition — Reducing the Revolving Door
The discussion will look beyond the point of discharge to consider:
• Why some transitions become unstable after a participant returns to the community
• Early indicators that additional support or coordination may be required
• Communication when circumstances or support requirements change
• What can be learned from successful transitions
• Factors contributing to unplanned or potentially avoidable returns to hospital
• Opportunities for earlier intervention and stronger community-based continuity
• Maintaining appropriate connections across the pathway without duplicating existing professional responsibilities
Session 2
NDIS/SIL Provider Session
Beyond the NDIS: Accident, Catastrophic Injury & Government-Funded Care Provider Pathways
12pm -1.30pm
This session is designed for NDIS and disability service providers seeking to understand opportunities and provider pathways beyond the NDIS, particularly organisations delivering or considering complex, long-term and community-based support.
Suitable for:
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SIL & Supported Accommodation Providers
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Complex Care & High-Intensity Support Providers
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Registered NDIS Providers
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Disability Support & Attendant Care Providers
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Support Coordination & Specialist Support Coordination Organisations
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Community & In-Home Support Providers
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Allied Health & Rehabilitation Organisations
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Disability Accommodation Providers
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Assistive Technology & Home Modification Providers
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Organisations supporting people with acquired brain injury, spinal cord injury and other catastrophic or complex injuries
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CEOs, Directors, Operations, Compliance, Quality, Clinical Governance and Business Development Leaders
Session Overview
The disability and complex-care environment extends beyond the NDIS.
People who sustain serious or catastrophic injuries may receive rehabilitation, attendant care, disability support and long-term assistance through state-based accident insurance, catastrophic injury, lifetime care and other government-funded schemes.
For NDIS and SIL providers, these systems can operate very differently from the NDIS, with separate provider registration or approval processes, funding arrangements, governance requirements, service authorisation, reporting expectations and workforce requirements.
This dedicated 1 hour 30 mins professional development session provides an introduction to the broader funded-care landscape, with a particular focus on Queensland's National Injury Insurance Scheme Queensland (NIISQ) and an overview of comparable state-based accident and lifetime-care schemes across Australia.
The session will help providers understand:
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What alternative government-funded care pathways exist beyond the NDIS
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How NIISQ and state-based injury and lifetime-care schemes operate
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How provider requirements can differ from the NDIS
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Registration and approval pathways
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Attendant care, complex support and coordination opportunities
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Governance, compliance and workforce considerations
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What an organisation should consider before seeking to operate across multiple funded-care systems
This is a separate provider-only professional development session and does not form part of the Hospital to Home Cross-Sector Roundtable.
Session Focus
Queensland – NIISQ
An introduction to Queensland's catastrophic injury care environment and the National Injury Insurance Scheme Queensland, including:
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Accident and catastrophic injury care pathways
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NIISQ participant and support environment
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Provider registration requirements
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Attendant care and support services
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Coordination of supports
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Home modifications and assistive technology
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Complex and long-term support requirements
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Provider governance and service expectations
Understanding the Differences
The session will examine important considerations for providers accustomed to the NDIS environment, including:
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Differences between NDIS and statutory injury schemes
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Provider registration and approval
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Funding and service authorisation
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Documentation and reporting
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Quality, safeguarding and risk
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Clinical and practice governance where applicable
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Workforce capability
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Supporting people with complex and catastrophic injuries
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Working with participants, families, clinicians, rehabilitation professionals and funding bodies
Provider Readiness
For organisations considering diversification beyond the NDIS, the discussion will also consider:
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Is our existing workforce appropriately skilled?
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Do our governance and compliance systems meet the requirements of another funding environment?
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Do we have the capability to support people with catastrophic or complex injuries?
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What additional registration, approval or organisational requirements may apply?
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How do we determine whether another funded-care system is appropriate for our organisation?
Beyond the NDIS
The purpose of this session is not simply to explain how to register with another scheme. It is to give disability providers a clearer understanding of the broader accident, rehabilitation, catastrophic injury and government-funded care environment and the organisational considerations involved in operating within it.
Understand the pathways. Understand the requirements. Assess your organisational readiness.
Who should attend?
Hospital & Health Professionals • Discharge & Patient Flow Teams •
Aged Care & Support at Home Providers • Residential Aged Care • Transition & Restorative Care • Dementia & Complex Care Providers • Allied Health & Rehabilitation • Community & In-Home Support
• Care Coordinators
SIL providers or NDIS providers interested in In home Aged Care Support or are currently registered
2.00pm – 2.10pm
Setting the Scene: Supporting older people from Hospital to Home
The transition of an older person from hospital may involve the intersection of health, aged care assessment, rehabilitation, allied health, in-home support and family or informal care.
This opening session will establish the context for a focused discussion on access to appropriate post-hospital support and the practical considerations that can influence recovery, independence, continuity and a sustainable return to the community.
2.10pm – 2.45pm
From Hospital to Home: Navigating Aged Care, Transition Care & In-Home Support
Support at Home • Transition Care • Restorative Care • Allied Health • Rehabilitation • In-Home Support
A practical cross-sector examination of the principal aged care and community-based pathways relevant to older people following hospitalisation.
• Aged Care Assessment & Post-Hospital Pathways
• Aged care assessment and access pathways
• Support at Home and care management
• Transition Care following hospitalisation
• Restorative Care and short-term recovery pathways
• Allied health, nursing and rehabilitation
• In-home personal care and community-based supports
• Assistive technology and home modifications
• Responding to changed functional or care requirements following hospitalisation
• Family and carer involvement
NDIS to Aged Care — Understanding the Transition
A focused examination of the interface between the disability and aged care systems, including:
• NDIS participants approaching and passing age 65
• Circumstances in which existing participants may remain within the NDIS
• Entry into aged care pathways where applicable
• Support at Home and residential aged care considerations
• Planning where disability and ageing-related needs intersect
• Changes in funding and service arrangements
• Supporting individuals and families to understand the respective systems and available pathways
• Maintaining continuity as funding and service arrangements change
Focus: The Right Pathway at the right time
Developing a shared understanding of the assessment, funding, post-hospital recovery and community-support pathways available to older people following hospitalisation, particularly where their functional or care requirements have changed.
2.45pm – 3.30pm
Hospital to Home Aged Care Cross-Sector Roundtable
From Hospital to Sustainable Support at Home
A facilitated discussion bringing together hospital and health professionals, aged care, allied health, rehabilitation, in-home support and community-based services.
Rather than presuming where the principal challenges lie, the roundtable provides an opportunity to hear directly from participating organisations about the practical issues experienced between hospital and the commencement or continuation of appropriate support within the community.
Hospital & Health Perspectives
Hospital and health representatives are invited to consider:
• Factors affecting transition where an older person no longer requires acute hospital care
• Assessment, service availability and commencement of community-based support
• Challenges where functional or care requirements have changed following hospitalisation
• Availability of rehabilitation, equipment, home modifications or in-home support
• Communication and coordination with aged care and community-based organisations
• What hospital and health professionals would like aged care and community services to better understand
Aged care and community-based representatives are invited to consider:
• Information required to establish or adjust appropriate support following hospitalisation
• Changed functional, mobility, medication and care requirements
• Access to allied health, rehabilitation, equipment and home modifications
• Challenges where community-based services cannot commence immediately
• Family and carer understanding of available pathways
• What aged care and community-based services would like hospital and health professionals to better understand
• Supporting Recovery & Reducing Avoidable Returns to Hospital
The discussion will then consider what happens following the transition home:
• Early identification of changing functional or care requirements
• Continuity of medication, allied health and rehabilitation
• Access to appropriate in-home support
• Communication when circumstances change
• Family and carer sustainability
• Factors contributing to unplanned or potentially avoidable hospital presentations
• The role of Transition Care, restorative care and community-based support in recovery and maintaining independence
• Lessons from successful transitions
Closing Discussion: Strengthening continuity beyond hospital
How can hospital, aged care, rehabilitation and community-based services work across their respective responsibilities to support recovery, independence and sustainable support within the community?
Program Concludes – 3.30pm
NDISDA & Health2Ageducate Information and Disclaimer
NDISDA and Health2Ageducate Hospital to Home Queensland
Important Information & Disclaimer
NDISDA® & Health2Ageducate
The Hospital to Home program brings together two specialist professional networks to support education, cross-sector dialogue and stronger understanding across hospital-to-community transition pathways.
NDISDA® SDA Housing & Disability supports the disability and NDIS component of Hospital to Home, including engagement across disability supports, SIL, SDA, Support Coordination, allied health, housing and other relevant community-based pathways.
Health2Ageducate supports the health and aged care component, including engagement across aged care, Support at Home, Transition Care, restorative care, rehabilitation, allied health, in-home support and other relevant services for older people transitioning from hospital into the community.
Neither NDISDA® nor Health2Ageducate provides participant or client care, clinical care, Support Coordination, SIL, SDA, aged care or direct care services.
Education, Connection & Cross-Sector Engagement
Through Hospital to Home, NDISDA® and Health2Ageducate bring together hospital and health representatives, disability and NDIS-sector professionals, aged care and community-based services, allied health and rehabilitation professionals, researchers, industry experts and other relevant stakeholders.
The purpose is to support education, professional dialogue, greater cross-sector understanding and stronger coordination across hospital-to-community transition pathways.
Where assistance is requested, NDISDA® or Health2Ageducate may assist in identifying relevant services, organisations or potential pathways through their respective professional networks and, where appropriate, facilitate introductions to approved participating organisations.
Any assistance or facilitated introduction is subject at all times to the individual’s choice and control, informed consent, preferences and right to select, decline or change a provider or service. The individual, or their authorised representative where applicable, retains responsibility for deciding which provider or service they wish to engage.
All engagement must also respect applicable privacy and confidentiality requirements and the professional, clinical, procurement, governance and internal processes of participating hospitals, health services, aged-care services, government agencies and other organisations.
Fees & Funding
NDISDA® and Health2Ageducate do not take, deduct or receive fees from an individual’s NDIS participant plan, aged-care funding allocation, government-funded care package or other individual government-funded support plan.
Professional Engagement Requirements
Participating members and organisations are expected to maintain appropriate standards of professional conduct when engaging through Hospital to Home.
This includes no unsolicited solicitation of, or pressure on, hospital, health-service, aged-care, government or other participating representatives for referrals, placements, service opportunities or commercial engagement.
Professional conversations, relationship-building and the mutual exchange of contact details are welcome where the engagement is genuine, appropriate and welcomed by the parties involved.
At all times, Hospital to Home engagement must respect individual choice and control, informed consent, privacy and confidentiality, dignity, independence and the right to make decisions about care, support and service providers, together with the professional responsibilities and organisational processes of all parties involved.
Post-Transition Consultancy & Follow-Up
Where a member has been engaged through an NDISDA® or Health2Ageducate-facilitated pathway, the relevant network may undertake structured consultancy follow-up at approximately 3-month intervals to review the member’s ongoing engagement and identify service, communication, coordination or transition concerns that may require attention.
This is not participant or client monitoring, care coordination, case management or service delivery. Neither network assumes the responsibilities of treating practitioners, Support Coordinators, aged-care providers, care managers, service providers, hospitals or other responsible parties.
The follow-up provides an additional level of accountability within a facilitated pathway, supports appropriate professional standards among participating members and provides an opportunity to identify recurring service, communication or system-interface issues.
Where broader or recurring issues are identified, these may inform future Hospital to Home education, professional forums, research and cross-sector engagement, supporting continuous improvement across disability, aged care, health and community-based transition pathways.