Discharged but Not Alone: How Support Makes All the Difference After Hospital
Why Is the Hospital-to-Home Transition So Critical for NDIS Participants? For many people supported under the National Disability Insurance Scheme (NDIS),…
Hospital Discharge
Enabling safe, timely hospital-to-home transitions that protect wellbeing and restore independence.
Working closely with participants, hospitals, families and discharge teams, Claro helps people living with complex disability transition from hospital to home or suitable accommodation within the community where they can thrive.
Our Hospital Discharge Service 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. Claro specialises 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
Claro provides an efficient and clinically supported pathway for safe hospital-to-home transitions.
- 72-hour activation window, including early clinical assessment and risk screening.
- 7-day, standardized onboarding workflow for safe discharge and community reintegration.
- A dedicated, multidisciplinary Specialist Support Worker 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.
The Claro Approach
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 support workers 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 assessments
- Person-centred support planning
Why It Works
Hospital Relief
Relieves hospital bed pressures with a clinically sound, structured discharge process.
Participant Stability
Ensures participant stability and consistent care during transition.
Team Capacity Building
Builds capacity of local teams through upskilling, supervision, and clinical oversight.
Proven Outcomes
Proven outcomes in SIL and SDA utilisation growth without compromising quality.
What Clinicians & Coordinators Can Expect
Our proven discharge model reduces re-admission risk through comprehensive clinical governance and personalised care planning. We take responsibility for the complex coordination, freeing up your hospital staff to focus on patient care.
- A single point of contact for discharge planning and onboarding.
- Comprehensive support plan developed before discharge and reviewed within one week.
- Strong communication with treating teams to ensure continuity of care.
- Transparent updates and outcome reporting throughout the process.
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.
Benefits for Stakeholders
Hospitals
Faster, safer discharges; reduced readmissions; reduced length of stay; confidence in provider capability, pressure reduction system-wide (ramping, ED flow).
Allied Health
Collaborative handover and continuity in therapeutic goals; data-driven reporting on outcomes.
Support Coordinators
Reliable provider capacity; clear processes; consistent quality; and improved participant satisfaction.
NDIS Registered Provider
Partner with Claro
Deliver a rapid, clinically safe, and system-saving discharge pathway.
Reduce Health System Pressure
Improve Participant Outcomes
Clinically Safe Transitions
NDIS • TAC • NIISQ • iCare • LSA • ICWA
Why you can trust us
Three Decades of Expertise
With 30 years in complex support and national coverage across Australia, we have the experience and infrastructure to handle even the most challenging cases with confidence.
Proven Outcomes
Our specialized approach has helped thousands of clients achieve greater independence while maintaining the highest safety standards. We regularly exceed quality benchmarks and client satisfaction metrics.
NDIS Practice Standards Compliance
Full accreditation and compliance with NDIS Practice Standards, ensuring all services meet regulatory requirements while delivering exceptional care outcomes.
Award-Winning Care
Recently recognised as the Most Outstanding Disability Support Provider in Australia, demonstrating our commitment to excellence in specialized disability support services.
Start the conversation about your complex client needs
Our team is ready to discuss how we can support your clients' transition to community-based care. With immediate availability in most regions and flexible service arrangements, we make complex coordination straightforward and reliable.
Talk to Us Today
Frequently Asked Questions
With Claro’s specialist hospital discharge program in most cases we can initiate within 72 hours, and have you in a safe and supported home-like environment within 7 days.
When coordinating a person’s discharge from hospital many stakeholders need to be in sync to ensure a safe discharge. The hospital team need to liaise with an individuals own support network, allied health professionals, accommodation providers and support services. Claro’s Hospital Discharge Program has standardized this process, creating clear communication channels, straightforward processes and systems, and is executed by highly trained and experienced staff. Claro also work closely with the best accommodation providers in Australia, so can coordinate not only your accommodation but also the support you need once discharged.
The first step is to speak to the hospital care team about whether you or your loved one are ready to leave hospital safely. If yes, then reach out to Claro to discuss your suitability for our Hospital Discharge Program. We can connect you with our highly experienced team of professionals to find you the right accommodation and support services, often within 7 days. Our thorough program not only ensures a swift and efficient discharge, but our high standards of clinical oversight mean greatly reduced risk of readmission or health decline.
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