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75 Lennox St, Maryborough
Queensland, Australia
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Email us
info@communitycarefoundation.org.au
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Call us
(07) 4123 6288
Hospital Transitions
Working closely with participants, hospitals, families and discharge teams, CCF helps people living with complex disability transition from hospital to home or suitable accommodation within the community where they can thrive.
Our Professional team supports participants who are ready to leave hospital to return home or find medium and long term housing, and coordinate the support services they need.
Exiting hospital and establishing the right care and accommodation can be challenging. CCF specializes in supporting individuals requiring complex care, and take a personalised approach to those who trust us to support them. Your support is backed by our industry-leading clinical governance and delivered by our team of highly skilled support workers.
The Challenge
- NDIS participants experience lengthy hospital stays due to provider delays.
- Readmission to hospital is common due to insufficient clinical oversight and planning.
- Costs escalate and our health and support system experienced increased strain.
- Coordination between healthcare teams, NDIA and support providers is inconsistent due to no one taking the lead with a robust program.
- Participants may experience avoidable deterioration and loss of function while in hospital.
The Solution
CCF provides an efficient and clinically supported pathway for safe hospital-to-home transitions.
- Quick response window, including early service assessment and risk screening.
- 7-day, standardized onboarding workflow for safe discharge and community reintegration.
- A dedicated, multidisciplinary Specialist team deployed for initial support.
- Parallel processing of Supported Independent Living Service Agreements, Rosters of Care and staffing.
- Senior, skilled staff provide mentoring and continuity for 4-6 weeks post-discharge.
- End-to-end coordination with hospital teams, guardians and families.
Efficient discharge planning
Our experienced team arranges required assessments and documentation proactively
Workload relief
We handle documentation burden and coordinate with multiple providers
Reduced readmissions
Clinical oversight and thorough planning support long-term continuity of care
Improved outcomes
Our specialist-trained team deliver 24/7 care tailored to complex needs
Key Services Include
- Medium Term Accommodation coordination
- Supported Independent Living arrangements
- Allied health partner coordination
- Funding and equipment needs identification
- Person-centred support planning
Participant Benefits
- Manage the transition process in collaboration with participants and their networks.
- Coordinate with Allied Health partners to ensure readiness of the home or supported living environment.
- Connect participants with suitable Medium Term Accommodation (MTA) options to enable safe discharge.
- Partner with Supported Disability Accommodation (SDA) providers to find the ideal long-term home.
- Provide highly trained support workers for 24/7 Supported Independent Living (SIL) supports.
- Develop a person-centred support plan and Roster of Care tailored to individual needs and goals.
- Partner with nursing and allied health professionals to deliver coordinated supports.
- Advocate for funding changes as participant circumstances evolve.
- Partner with nursing and allied health professionals to deliver coordinated supports.
- Advocate for funding changes as participant circumstances evolve.
- Oversee clinical care to reduce risk of hospital re-admission.
