Supports at the Hospital Interface

As we explored in my last article, Support Coordination at the Interface between the NDIS and health can be a complex game of defining and maintaining role boundaries and potentially a particularly challenging part of our role.  However, when done well, Support Coordination at the Interface can play a critical role in facilitating the best access to health care for Participants, safe hospital discharge planning, and prevention of hospital readmission. 

But this is all a lot for a single Support Coordinator to juggle. So what help is out there? Today, we’ll be looking at some of the people who support the Support Coordinators. 

Support at the interface

Fantastically, some parts of Australia have developed programs specifically to support the Interface between the NDIS and Health, particularly when an NDIS Participant is a hospital inpatient. The likelihood of the inpatient team being appreciative of your input and support around what happens ‘on the outside’, in terms of community supports, is probably as high as how appreciative you will be of the inpatient team helping you make sense of the ins and outs of hospitals and discharge planning. 

Let’s agree to check our egos at the door and work together – don’t be afraid to ask questions and reach out for support when working in complex contexts like these, where we work at the Interface of community formal NDIS-funded supports and Health. 

In NSW, some Local Health Districts (LHDs) are lucky enough to have a Disability Strategy Unit (DSU). Key responsibilities of the DSU include supporting the district response to the NSW Health Disability Inclusion Action Plan (DIAP) and implementation of the NDIS.

I was lucky enough to speak to Nicole Marchisone, the manager of one of the DUs in Sydney, to learn more.

The South East Sydney Local Health District (SESLHD) DU was developed from the ground up, once everyone realised that there was a gross underestimation of the role of Health services in the implementation, translation, and operationalisation of the NDIS. 

Unsurprisingly, each LHD implements its NDIS Strategy in a different way. This is often due to staffing and funding availability and the pressures on those roles. For example, the SESLHD has thousands of staff, manyof whom may cross paths with an NDIS Participant at any stage. That’s a lot of people for an NDIS Transition Lead or DU with minimal staff members to support and train. 

So, the SESLHD took the NDIS lead and, in the spirit of capacity building, has worked out a process to inform and educate as many staff as possible by working in a consulting capacity through a group of dedicated NDIS Education Champions across three major hospitals. 

The Champions come from both inpatient and community roles, mostly from Allied Health; each agrees to dedicate somehours per month to NDIS education, so that they can then inform their colleagues and be the first point of contact for questions in their team.  

Training and education can include:

• Supporting inpatient and community clinicians, medical teams, and Allied Health staff to understand the NDIS Interface
• Facilitate using NDIS language in report writing and assessments
• Translating an NDIS Plan

If required, the NDIS Education Champions can then refer to the DSU:

•  To contribute to complex discharge planning and then ideally contribute to a lower likelihood of hospital readmission and a greater likelihood of equal access to health care

• For NDIA escalations, there is a top-secret email address that the DSU has direct access to, to highlight all Mainstream Health-related NDIS escalation priorities, such as requesting an urgent Plan Review or highlighting a significant Change of Circumstances application to facilitate safe discharge from hospital

The DSU can become involved with a referral from the inpatient team (often the Social Worker), with the consent of the Participant. 

It is critical that the Support Coordinator not bypass the inpatient clinical team: even if you know that a DUor equivalent service exists, you should facilitate contact via the clinical team. If you are not sure whether there is an NDIS Transition Lead or DU, ask, ‘Do you have an NDIS team or person that manages escalations to the NDIA?’. The DUwill not always have a direct relationship with Participants or their families: it may be more important for them to build the capacity of the treating team to do that. See? No egos 😊.

In another part of the country, the Government of Western Australia Department of Health has a Disability Health Network that aims to ‘improve health outcomes for people with disability by enabling consumers, families and carers, health professionals, hospitals, health services and the WA Department of Health to engage and collaborate effectively to facilitate health policy and increased coordination of care across the State’. 

We also cannot forget the potentially wonderful support that can be sought from the NDIA-funded Exceptionally Complex Support Needs (ECSN) Program. Each state and territory has had this program rolled out slightly differently (with NT and SA still finalising the tender selection process), but all successful tenders will eventually provide:

1. Assistance to NDIS Participants (aged 18 and over) with complex needs who are experiencing crisis or at risk of entering a crisis situation. The focus is on strengthening Support Coordination and Mainstream responses (which, of course, can include Health).
2. The service provider tendered to deliver the ECSN program in NSW, Marathon Health, explains: the ECSN team can assist professionals who are supporting NDIS Participants with complex support needs including Support Coordinators, disability support workers, Allied Health staff and people providing Mainstream supports.
3. After Hours Crisis Referral Line: The ECSN program includes an After Hours Crisis Referral line for emergencies. This service is for approved referrers only: emergency service organisations (police, ambulance, public and private hospitals), acute state mental health services, and federal police and state justice officers. One of the roles of the Support Coordinator can be to inform hospital staff that this service exists to support them.

So, in summary, what am I trying to say here? 

An NDIS and Mainstream Interface often means complexity for the Participant you are working with. This is not the time for a Support Coordinator to rest; rather, you should be clear about your role and your boundaries, keep communication clear and open with the NDIS Participant, and use careful organisational and documentation skills.

But you can’t do everything by yourself! Look around and see what other supports are available, who else is looking out for the Participant’s best interests, and what resources you can draw upon. You know how they say teamwork makes dreamwork? Well, corny sayings aside, this is an opportunity to get both systems (Health and NDIS) to work at their best to achieve the best outcomes for the Participant.