Hospital Ins & Outs for Support Coordinators

Lisa explores Support Coordination best practice when a person enters and exits hospital.

By Lisa Duffy

Updated 15 Apr 20249 Mar 2021

Hospital admissions for NDIS Participants can mean a challenging game of ‘who is doing what’ when considering the Support Coordination role, the Participant, the State- or Territory-funded health supports, and inpatient clinical teams. 

One possible difficulty is Support Coordinators who believe that their role is to transition, refer, and link Participants that involve only NDIS-funded supports. This could also mean that when a Participant becomes a hospital inpatient, the Support Coordinator may think they can now have a ‘break’ from their role. 

Nope. Sorry, guys. This is the time for true collaboration.

The tell-tale sign of a contemporary Support Coordinator is one who understands the role within the full gamut of support options: Informalsupport, community support, Mainstream services, and NDIS-funded support. Having strong, current, and key contacts and networks with Community and Mainstream services is essential and can make the job of an often busy, overwhelmed, and priority-conflicted Support Coordinator that much easier. 

It also absolutely leads to better outcomes for Participants. 

This is even more telling and important when there is an Interface between Support Coordination, an NDIS Participant, and inpatient and acute hospital admissions.

What is the best way to navigate everyone’s roles? Does the hospital Social Workertake over? Should we assume that? Is there even a Social Worker on the ward? Does the Participant have a say about who leads things? Is there an NDIS-funded Occupational Therapist (OT) and now also an inpatient OT? Should they talk to each other? Should the Support Coordinator introduce them? 

Phew. So many humans. 

My favourite thing to happen at these times is… the Case Conference.


Case Conferences at the interface

Google provides a lovely, neat, and tidy definition of a Case Conference:

Case conferencing is a more formal, planned, and structured event separate from regular contacts. The goal of case conferencing is to provide holistic, coordinated, and integrated services across providers, and to reduce duplication. Case conferences are usually interdisciplinary, and include one or multiple internal and external providers and, if possible and appropriate, the client and family members/close supports.

(Source: New York State Department of Health)

In other words: get all the players in a room or on a Zoom or phone call and make a plan about how to work together in an effective, efficient way that keeps the best interests of the Participant at the core of all discussions.

Case Conferences should:

  • Have the consent of and involve the Participant
  • Have a clear agenda
  • Have a clear chairperson: this could be the Support Coordinator
  • Have clear outcomes
  • Be documented, including all the actions allocated to all involved
  • Have clear, agreed time frames for actions and review (this could also include an agreed date for the next Case Conference)

It is essential to put egos aside, remove all assumptions, and work as a team… being very careful not to step on anyone’s toes and not double up and waste time. 

The Support Coordinator may have felt like the central point of contact and keeper of all knowledge on ‘the outside’, but politics and roles may shift when we bring in the internal politics of a hospital. 

Support Coordinators need to be crystal clear about and comfortable with our role boundaries and understand that this line, and where it may be crossed, is different for every Participant and every hospital. 

Case Conferences can often have the following attendees (and you may be the person doing the inviting and organising):

  • The Participant
  • Informal support person
  • Social Worker
  • OT (inpatient and also possibly NDIS-funded community OT), 
  • Clinical inpatient medical team 
  • Nursing Unit Manager
  • A representative from the NDIA (such as an NDIS Planner)


Skills of Support Coordinators at the Health/NDIS interface

Support Coordinators at the Health Interface will need the following skills in their toolbox:

  • A detailed understanding of NDIS, COAG Applied Principles, and the NDIS Operational Guidelines on Planning: Appendix so we can be clear about ‘who funds what’ and ‘whose responsibility is it?’ when considering NDIS funding and Mainstream Health
  • Confidence in and understanding of the discharge planning conversation
  • Ability to liaise effectively with key stakeholders such as the inpatient and community health team, family members, service providers, and the NDIA; this also requires confidence and a clear understanding of your role boundaries
  •  Understanding of the impacts on the Participant and informal supports when there may have been a new injury, requirement for rehabilitation, or a major change in circumstances

Support Coordination during a hospital admission: top tips and things to think about

So, if you find yourself in a situation where you are supporting someone during a hospital admission and planning for a safe discharge, it’s time to focus on some of the more specific tasks of the Support Coordinator, when considering your relationship to the Participant, their circle of support, and logistics!

  • First, get ready for health language. The NDIS Participant will now be referred to as a ‘patient’ or an ‘inpatient’, not a Participant; in fact, this word may confuse the inpatient clinical team. Suggestion: the person is known by their name?!
  • A Participant may have previously given consent to talk to you about their goals and support needs, but the hospital may not be willing to talk to you until they hear that from the person themselves and the person signs new forms that are specific to the hospital.
  • The Participant may ask you to be ‘the provider of information’ and give a handover to the inpatient team, as they may be sick of telling their story – the inpatient team will likely be deeply grateful for this, too!
  • You may be used to calling and emailing the Participant with ease and flexibility; however, you now need to fit into hospital routines, and contact may not be as easy.
  • Case noting is essential, especially when establishing role and task allocations and role boundaries; see the tips and tricks for case notes here
  • Hospital discharge timing has a huge impact on the follow-up tasks that you may need to complete. For example, you may have placed in-home and community support services on hold while the Participant is in hospital; do not assume that staffing on hospital discharge will be available as it was before admission. Plan, check, and confirm all of these items prior to discharge. You may need to raise alarms about discharge planning if the intended timing of the hospital does not match community support availability: speak up if the required in-home and community support availability is not in line with the discharge planning. Otherwise, the person may be discharged to home with inadequate support, which could have the negative unintended consequence of hospital readmission. 
  • The Participant may need additional support at home and in the community upon hospital discharge – this could require new referrals or edits to existing service requests and care plans.
  • If the hospital admission signals a Change of Circumstances in the Participant’s life, this may prompt the need for a Change of Circumstances application to the NDIA (S48 form) or a request for an unscheduled plan review (possibly urgently) – this is where the support of an inpatient clinical team could prove critical.
  • Inpatient reports and assessments: have any assessments or reports been done in hospital that could be useful and relevant information for the Participant’s scheduled plan review meeting or new Change of Circumstances application? If so, it is worth advising the Participant about the potential benefit of requesting these reports. For the same reasons, this inpatient stay may be an opportunity to request a specific assessment or report. For example, is there a multi-disciplinary inpatient team that could summarise and objectively document the functional support needs that the person requires for their personal care, mobility, and mealtimes? This could be critical information to highlight a new reasonable and necessary support request.
  • It may also be valuable to have a Hospital Discharge Summary as evidence of hospital admission for the purposes of NDIS assessment and formal funded support. For example, you may be working with someone who is attempting to include a diagnosis of Psychosocial Disabilityin their NDIS profile, and an admission to an acute mental health unit may provide evidence of functional impact and treatments trialled for their mental health diagnosis.
  • Be sure that you know what the word ‘collaboration’ means and be ready to walk the walk. Many people say words like ‘collaboration’, ‘teamwork’, and ‘multidisciplinary’ but lack communication with all stakeholders and cannot tell you what other members of the ‘team’ are actually doing for the best outcome of the Participant. As we have shouted out before, this is not the time for egos. The Support Coordinator can play a critical role within a complex and multi-disciplinary team – the crucial thing is knowing what that role is, striving for clarity, and avoiding duplication when supporting someone during a hospital admission. 
  •  You may act as an NDIS ‘translator’. That is, inpatient staff may ask you about the language to use in their reports and request guidance about how they may ‘fit in’ to a Change of Circumstances (S48) application.
  • Another way that you may need to act as an NDIS translator is to facilitate an understanding of the NDIS Operational Guidelines on Planning (that nugget of gold which is the translation and operationalisation of the NDIS legislation). In particular, you may be able to facilitate an understanding of ‘whose responsibility is it?’ when considering NDIS-funded and health-funded supports. For example, I recently used the Operational Guidelines on Planning Appendix 1 to help a parent understand whether it was the responsibility of the inpatient OT or the NDIS-funded Private Community OT to assess, document, and report an application for Supported Independent Living(SIL) for the Participant’s accommodation plans upon hospital discharge (hint: it was the responsibility of the NDIS-funded OT). 

So, there’s a lot to do and a lot to think about, but there is also a lot to gain and a lot of potential to make the hospital admission experience less overwhelming and more collaborative for the NDIS Participants we work with. 

Support Coordination can play a key role in collaborating with the Participant, their informal supports, and the inpatient clinical health team. Our combined aim should be facilitating the best outcomes and access to health care, safe hospital discharge planning, and prevention of hospital readmission.

Coming up, we will be exploring what support is available for everyone navigating this tricky Interface. Stay tuned for the next article.


Lisa Duffy

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