Improving the way hospitals and the NDIS work together to support people with disability to leave hospital and return to their community is key to keeping them out of aged care.
The Summer Foundation has been delivering projects, training and resources within mainstream health systems since 2016. We have produced a comprehensive range of resources, co-designed with health services, to streamline the interface between health and the NDIS. Highlights include:
Housing Needs and Preferences to Support Discharge Guide and Template
The Housing Needs and Preferences to Support Discharge Guide and Template are for health professionals to support a person with disability to describe the housing and support they want and need so that they can be discharged to suitable housing.
NDIS Capacity Building Framework Training Manual
In striving for best practice outcomes for NDIS participants, a health service may use this resource to provide a framework in the provision of information, training and mentoring to staff for practice change.
This manual includes links to resources and training videos.
If you would like more information or are interested in capacity building in your health service, please contact firstname.lastname@example.org
Collaborative Discharge Approach (CDA) Practice Guide
The CDA Practice Guide details the steps involved in effective discharge planning for younger people under 65 with disability or complex support needs in hospital.
Community of Practice
The Summer Foundation has set up a national Community of Practice for health practitioners, aiming to grow skills and share experiences of successful discharge planning outcomes.
This platform will enable innovation sharing and promote positive communication and professional insight, for the ultimate benefit of health professionals and the people with disability that they support.
Housing Brokerage Service
The Housing Brokerage Service is designed to support the discharge of people with disability from hospital to housing that aligns with their housing needs and preferences.
The service team uses a secondary consultancy approach to support and build the capacity of key professionals working alongside people with disability who are stuck in hospital and require suitable housing.
The Summer Foundation’s projects focus on:
- Increasing workforce capacity across sectors
- Helping navigate the NDIS and health interface through resource development
- Re-designing and streamlining the interface between sectors
- Building collaboration across sectors
Read about our past projects below:
Queensland hospital discharge and housing project
The NDIS represents a significant change in how patients with newly acquired disability and/or change in condition are funded for their ongoing disability supports.
The key outcomes this project works towards for people with complex disability support and housing needs in Queensland HHS facilities are:
- Reduced overstays in hospital beds
- Reduced entry to residential aged care
- Timely exit from hospital into high quality housing with appropriate support
This project will operate in 4 phases to achieve improved discharge and community living outcomes for Queensland HHS patients.
Phase 1: Getting systems working for discharge with NDIS supports
Phase 2: Articulating participant housing needs
Phase 3: Matching housing to solutions
Phase 4: Transitioning to interim and long-term housing
Leaving Hospital Well: Health collaboration discharge project – South Western Sydney Local Health District
The “Leaving Hospital Well – Collaborative Discharge Approach (CDA)” project aimed to demonstrate an approach for achieving positive outcomes for participants in hospital that can be replicated across Australia.
It was a partnership between South Western Sydney Local Health District, a local health district within New South Wales, and the Summer Foundation.
The project was implemented through a network of social work and occupational therapy ‘champions’, known as ‘NDIS Champions’, together with experienced support coordinators who had an interest in hospital discharge planning.
Training activities with 165 attendees built the knowledge, skill and competencies of the champions in navigating the NDIS with admitted patients. This was then disseminated by the champions to other staff in their site/service.
Progressive practice change was supported with regular coaching and reflective support (12 sessions in total), and the development of a practice guide and supporting resources.
The CDA project was successfully implemented with minimal specific resourcing within the local health district. Implementation through a champions network with executive level support made this possible.
The fundamental framework required for the success of the project was:
- Executive sponsorship
- An Local Health District project lead
- Subject matter expertise (provided by the Summer Foundation)
- Use of project implementation methodology
Leaving hospital well: Health collaboration Victoria
The Department of Health and Human Services funded the Summer Foundation Leaving Hospital Well Project: Health Collaboration Project. The aim of the project was to build capacity within Victoria’s health workforce to support people with disability to understand, access and navigate the NDIS to obtain a support plan that met their needs.
The project worked with mainstream systems and services to ensure young people, who required a seamless collaboration between health and disability supports, had their needs met in the new world of the NDIS.
The project aimed to do this by:
- Increasing workforce capacity across sectors
- Redesigning and streamlining interface issues between sectors
- Building collaboration and cross-sector linkages with key NDIS stakeholders
It targeted Victorian Local Health Networks (LHNs) likely to see the largest number of younger people with disability and complex support needs across metro and regional areas, LHNs that had been newly rolled out in the NDIS, as well as those that had been in the NDIS for some time.
Austin and Alfred Health were pilot sites for the Collaborative Discharge Approach (CDA).
The Leaving Hospital Well Project made a significant impact on building the capacity of Victoria’s health services to support people with disability to understand, access and navigate health and the NDIS. It built best practice collaborative discharge within the context of the NDIS.
Overall, the project saw a 71% increase in the capacity of how health services worked with the NDIS and younger people with disability and complex support needs.
Key capacity building improvements included the implementation of NDIS governance structures, policies, resources and data collection.
All of these are essential building blocks for developing staff skills and practical implementation of working with the NDIS, as well as providing a solid framework to embed streamlined NDIS practice in health services.
Redesigning the hospital – NDIS pathway
In this 3-year project the Summer Foundation partnered with 2 regional hospitals and the NDIS to test new approaches to discharge planning.
The project, funded by the William Buckland Foundation, aimed to improve the pathway from hospital back to the community for people who have acquired a significant disability. It also aimed to help people with complex health and disability gain supports to return home and reduce unnecessary stays in hospital.
Testing of the new approach started early in 2019 in regional hospitals in Geelong and Ballarat. Identified inpatients and their immediate family/social supports, allied health professionals and senior planners from the NDIA worked closely to improve the pathway through hospital and on to the community.
Streamlined outcomes included early access decisions, early planning and early support coordination with close collaboration between hospital staff and the local NDIS team.
NDIS Readiness for hospital project: A rapid response model
The Summer Foundation was funded by the Victorian Department of Health and Human Services’ Sector Development Fund to improve the experience between the NDIS and health systems.
This project developed a rapid response practice model where people with disability have access to the supports they need to remain in – or return to – the community after a significant change in their health circumstances.
The project developed resources and conducted a number of workshops with NDIS participants, primary care, allied health and hospital discharge professionals to better understand what happens when people’s needs suddenly change and how to create more responsive health and NDIS systems.
It produced this toolkit:
NDIS Readiness – A toolkit for Hospitals:
A more up-to-date version is the Capacity Building Framework training manual:
Hospital discharge readiness project
The Summer Foundation was funded by the Information Linkages and Capacity Building (ILC) stream of the National Disability Insurance Agency (NDIA) to work with the health sector across Australia to improve outcomes for NDIS participants.
This project aimed to improve the interface between the NDIS and mainstream services.
The project established local service connections and collaborations between health services and the NDIA to reduce the number of younger people entering aged care. It consulted with discharge planners in local health networks, with the NDIA, state government, health sector and housing sector representatives.
The project developed a toolkit that provides targeted information for hospital discharge staff and staff in acute and rehabilitation hospital settings relating to the discharge of people aged under 65 years who have acquired a disability.
You can see the toolkit – Discharge planning for younger people with complex support needs:
and the more up-to-date version, the Capacity Building Framework training manual here: