From hospital to home, with the right support in place.

Leaving hospital after a significant illness, injury or change in circumstances can be a major transition. Finding suitable accommodation, coordinating complex supports and ensuring the right care is in place can be challenging for participants, families and hospital discharge teams alike.

At Community Care Foundation, we work alongside participants, families, hospitals and healthcare professionals to make that transition as safe, coordinated and seamless as possible. We support people living with complex disability to leave hospital and move into their own home or suitable accommodation within the community, with the supports they need to feel safe, build independence and move forward with confidence.

We look beyond the discharge date to what comes next.

A coordinated approach to complex transitions

We understand that every participant’s circumstances are different. Some people need short-term accommodation while their long-term living arrangements are finalised. Others require a new home, specialised equipment, complex clinical supports or a carefully coordinated Supported Independent Living (SIL) arrangement.

Our experienced team works proactively with participants and their support networks to identify what’s needed, address potential risks and coordinate the practical arrangements required for a successful transition. This includes working with hospital discharge teams, allied health professionals, nursing teams and the NDIA to help bring the right people and resources together.

Where suitable, we can coordinate Medium Term Accommodation (MTA), explore longer-term housing options, including Specialist Disability Accommodation (SDA), and establish tailored SIL supports. We also assist with identifying funding requirements, equipment needs, service agreements, staffing arrangements and individual support planning.

The right support, from day one

A successful hospital transition takes more than a roster of support workers. It requires thoughtful planning, clear communication and a team that understands the participant’s needs.

Community Care Foundation brings together experienced support workers, clinical oversight and coordinated service planning to establish supports that are responsive to each person’s circumstances. Our approach includes early assessment and risk screening, proactive preparation for discharge, and collaboration with the professionals involved in the participant’s care.

Following discharge, we focus on consistency, continuity and building a strong understanding of the participant and their goals. Where required, senior and experienced team members provide additional guidance and mentoring to support staff and help address challenges as they arise.

Our clinical governance framework underpins the way we plan, deliver and review supports, helping us identify risks early and maintain a focus on safety, quality and the participant’s wellbeing.

Better transitions. Stronger outcomes.

When hospital discharge planning and disability supports work together, participants have a better opportunity to settle into their new environment, maintain their skills and work towards their goals.

For hospital teams, families and support networks, having a coordinated provider can help reduce the administrative burden, improve communication and bring greater clarity to what needs to happen next. For participants, it means having a team focused not only on meeting their support needs, but on helping them establish a home and a life in the community.

We recognise that circumstances can change. As a participant’s needs, goals or clinical requirements evolve, we work with their support network and relevant professionals to review arrangements and identify the adjustments needed to maintain safe, appropriate and sustainable supports.

Working together for a successful transition

Whether a participant needs an interim accommodation solution, a new SIL arrangement or complex ongoing support following a hospital stay, CCF works collaboratively to help make the next step possible.

We welcome conversations with hospital discharge teams, participants, families, guardians and allied health professionals to explore individual circumstances, identify support requirements and work towards a practical pathway home.

Let’s work together to make the transition from hospital to home a positive step forward.