NDIS Transition from
Hospital to Home
Coordinating a transition from hospital or rehab to home? MMT Care works alongside discharge planners to support NDIS participants transitioning from hospital, inpatient rehab, or acute care into SIL accommodation or home-based NDIS support — across NSW, QLD, and VIC.
Understanding the support
What is Hospital to Home
Transition Support?
Hospital to Home Transition support is the process of coordinating a participant's discharge from acute care into an appropriate home-based or SIL setting. It involves clinical liaison, support planning, and ensuring the environment and supports are ready before the participant arrives home.
Hospital discharge is one of the moments where things can go wrong for NDIS participants. Without careful coordination between the treating team, the NDIS, and the participant's support network, a person can find themselves in a situation that isn't safe, isn't appropriate, or doesn't reflect what the NDIS has funded for them.
MMT Care works directly with hospital discharge coordinators, social workers, allied health teams, and the participant's support coordinator to plan transitions that are thorough and well-paced — not rushed. The goal is a discharge that sticks, with the right support in place from day one in the new environment.
Clinical liaison
We communicate directly with the hospital team — not just through email chains — to understand the participant's clinical picture.
Home readiness
We confirm the destination home is appropriate, staffed, and equipped before the participant's arrival.
Support plan alignment
We review the participant's NDIS plan and identify whether existing funding covers the support needed at discharge.
Post-discharge monitoring
Support doesn't end on day one. We monitor the participant's settling-in period and raise any concerns with the clinical team.
"The discharge coordinator told us it would take months to find a suitable SIL home. MMT Care found a match, arranged the visit, and had everything ready before my son was discharged. It wasn't rushed — it was just done properly."
How it works
The discharge coordination process
Every hospital discharge is different. The pace depends on the participant's complexity, available placements, and the NDIS's response to any plan amendments needed. MMT Care is transparent about this from the first contact.
Referral & first contact
The hospital team, support coordinator, or family contacts MMT Care. We gather basic information about the participant's clinical picture and discharge goals.
Clinical liaison
Our team speaks directly with the hospital's discharge planner and treating team to understand the participant's needs, any clinical complexities, and the likely discharge date.
NDIS plan review
We review the participant's current plan to confirm funding is in place. If a plan amendment is needed, we advise the support coordinator and participant early — so there are no surprises.
Home identification
We identify available SIL homes or in-home options that are compatible with the participant's needs, location preferences, and housemate compatibility.
Transition planning
A detailed transition plan is developed with all stakeholders. We confirm staffing, equipment needs, medication management protocols, and any allied health handover documentation.
Post-discharge follow-up
We monitor the participant's first weeks in their new environment carefully, communicating with the clinical team and making adjustments to the support plan as needs settle.
Related service
Is the participant transitioning from
aged care?
Some participants receiving hospital discharge support were previously in aged care — either inappropriately placed or having moved from aged care funding to the NDIS. This is a distinct transition with its own complexity.
If the participant you're coordinating a discharge for has any aged care history — or if there's any question about whether they should be on the NDIS vs aged care — see our dedicated page on aged care to NDIS home discharge for specific guidance on how MMT Care supports these more complex transitions.
Aged Care to NDIS DischargeCommon questions
Questions about hospital discharge
Can MMT Care support a transition from rehab to home?
Yes. Transition from rehab to home — whether from an inpatient rehabilitation unit, a sub-acute ward, or a residential aged care setting — is one of the most common referrals we receive. The process is similar to a hospital discharge: we assess the participant's support needs, match them to a compatible SIL home or in-home support arrangement, and coordinate with the rehabilitation team to ensure nothing falls through the gap at the point of discharge. If the participant already has NDIS SIL funding, we can often move efficiently once a suitable home is identified.
How far in advance should we contact MMT Care about a discharge?
As early as possible. The more lead time we have, the more thoroughly we can plan — and the better the match we can find. Contacting us while the participant is still in hospital (not in the last few days) gives us the best chance of a thorough, well-coordinated discharge. We understand, however, that discharge planning in hospitals is often fast-moving, and we work with whatever time is available.
Does the participant need to be on the NDIS already?
Ideally yes — an active NDIS plan with SIL funding (or a plan that can be amended to include it) is required before placement can be confirmed. MMT Care can advise on what the plan needs to include, but accessing the NDIS for the first time is a separate process that the participant's support coordinator or LAC can assist with.
What if there's no suitable SIL home available?
We're honest about availability. If we don't currently have a compatible home, we'll say so — and we'll advise on whether a waitlist position, in-home SIL, or a different arrangement might bridge the gap. We won't place a participant in a home that isn't right just to fill a spot.
Who do support coordinators contact at MMT Care?
Use the contact form below or call 1300 066 822. Our team will direct your referral to the appropriate state-based coordinator for a response. Support coordinators are very welcome to refer directly — we work with coordinators regularly and understand the pressures of the discharge planning process.
Also from MMT Care
Related services
From discharge planners & families
Trusted to support the hardest
transitions in health care
"As a hospital discharge planner, I've tried many providers for complex patients. MMT Care are one of the few who actually coordinate with us, understand what 'hospital-ready' means, and follow through."
"My brother was in hospital for three months. MMT Care had a suitable home ready and made the transition feel calm and managed. The registered nurse on the team answered questions our GP couldn't."
"I was referred by my support coordinator. Moving from hospital into my MMT Care home was the smoothest part of the whole experience. They'd already set everything up before I arrived."
Make a referral
Coordinating a discharge?
Talk to our team
Whether you're a hospital discharge planner, a support coordinator, or a family member — use this form to start the conversation. Tell us as much as you can about the participant and the likely discharge situation.
Or call 1300 066 822