Developing a safe discharge plan for people with disability in response to COVID19

PURPOSE

The purpose of this resource is to assist health clinicians who are supporting a person with disability who is being considered for discharge as a result of COVID-19. You can browse this resource online below or download this resource as a PDF located in the sidebar of this page.

ISSUE

As a result of the need for health services to respond to COVID-19 (Coronavirus), there is a significant risk to people with disability. We know that there are people with disability stuck in hospitals across Australia. Health services now have a heightened need to discharge inpatients in order to free up hospital beds to treat people with Coronavirus. Health services may be forced to either discharge people home early from hospital and/or to interim housing options that are not sustainable or appropriate long term.

ACTIONS RECOMMENDED

The following actions should be taken to ensure a safe and effective discharge plan for a person with disability leaving hospital under a COVID-19 crisis response. Click on each numbered section below to find out more about each action and to download other useful resources.

  • NDIS secondary consultation framework
    • Internal NDIS champions
    • Internal NDIS Project lead/specialists
    • Supervisors/senior clinicians/team leaders
    • NDIA Health Liaison Officer (HLO)
    • NDIA Community and Mainstream Engagement Team
    • NDIA Complex Support Needs Team
    • NDIA Exceptionally Complex Support Needs Program
    • Subject matter experts (e.g. Summer Foundation, champions/NDIS project leads from other health services)
    • Summer Foundation’s Health and NDIS Community of Practice
  • Post acute care
  • High risk of re-admission program
  • Community rehabilitation services
  • Medical and rehabilitation in the home programs
  • Community health
  • HACC program for younger people services
  • Disability advocacy agencies
  1. Escalate a planning/plan review meeting before discharge via the HLO and advocate for support coordination (SC) within the plan.
  2.  
  3. Clarify what critical information you require for the planning/plan review meeting. This includes:
    • Identified goals
    • Documented description of the person’s long-term housing needs and preferences
    • Support plan e.g. 24/7 care plan which describes the person’s support needs
    • Details of long-term and interim housing exploration process thus far
  4. Engage a SC early. Consider via pro bono hours until an interim plan is developed with SC hours included. If a patient has an existing plan, utilise NDIA COVID-19 response of inclusion of SC hours within core supports, to either engage an SC if the patient does not have one already, or to add additional hours to support discharge planning.
  5.  
  6. Consider what essential safeguards should be in place to avoid a failed discharge or getting ‘stuck’ in interim housing option:
    • An interim plan (this is an NDIS plan that is approved for a 3-6 month period)
    • SC hours (equivalent to a minimum of 4 hours a week to explore housing options)
    • Extensive hours for 'assistance with daily life' in Core Budget (so it can be used flexibly and to ensure support workers are effectively trained in infection control)
    • Funding for health related disability supports, including personal protective equipment and nursing hours, both as a preventative measure and if the person does contract COVID-19
    • Funding for interim housing e.g. Short Term Accommodation (STA) and Medium Term Accomodation (MTA)
    • Capacity building supports for ongoing exploration of housing options and maintaining functional capacity. This could include hours for allied health to support people, including through the use of telehealth, to achieve their functional goals within their home environment and assessing alternative housing environments as they become available
    • Provision for psychological support to assist the person through this unprecedented period
    • Funding for the hire of essential AT required to leave hospital until quotes etc can be sourced for purchase
  7. Ensure a health clinician attends the planning/plan review meeting with an NDIA planner to advocate for supports recommended:
    • Advocate for flexibility in NDIS funding, to account for changes in the person’s needs that require urgent attention i.e. potential increases in cleaning of the person’s home, urgent assessments required to address additional equipment needs (e.g. need for a hoist to minimise person-to-person transfers where possible)
    • If planning/plan review meeting needs to occur following discharge, provide patient/NOK with pre-planning document, including support recommendations, and explore community service follow-up for ongoing advocacy and assistance with the process
COVID-19 poses the following risks to people with a disability if the above actions are not considered:  
  • Premature discharge from hospital to home or interim housing without consideration of the long-term housing options that best meet the person’s housing needs and preferences
  • Heightened chance of transmission of COVID-19 (or another infection) if discharged to an environment where likelihood of exposure is greater e.g. Residential Aged Care Facility
  • High vulnerability to serious complications if infected by COVID-19
  • Re-admission to hospital due to discharge with inappropriate/insufficient supports/housing
  • Increased chance of exposure due to reliance on others, where social distancing is impossible to achieve
  • Breakdown in vital supports due to anticipated NDIS and health workforce shortage
  • May not be deemed a priority for resources and therefore subjected to possible rationing/triaging of medical services and equipment

ADDITIONAL RESOURCES

COVID-19 resources and policy for people with disability and providers
Collaborative Discharge Approach – An overview
Pre-planning template
Health Service FAQs

This information is accurate at the time of publication. For further updates and the latest information on the health and NDIS interface in this Covid-19 climate, please link to Summer Foundation’s Community of Practice.

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