Arrival and Registration 

Welcome and Introductions 

Hospital discharge is a pivotal transition point in the care journey, where outcomes are shaped not only by clinical readiness but by the strength of collaboration across health, aged care, disability, and housing systems.

This session explores the central role of hospital social workers in coordinating this complex interface and strengthening pathways that enable safe, timely, and person-centred discharge.

Hospital social workers sit at the intersection of multiple systems, working across organisational and sector boundaries to align services and support continuity of care.
They play a critical role in care coordination, risk assessment, advocacy, and discharge planning, translating complex system requirements into practical, individualised outcomes for patients, families, and carers.

The discussion will also explore the realities hospital social workers face in managing complex discharges, including the systemic barriers that arise when health services, aged care, disability supports, and housing systems are not effectively aligned.

It will highlight how effective cross-sector collaboration can reduce fragmentation, strengthen continuity of care, and improve discharge outcomes for individuals and families.

Delayed discharge is rarely the result of a single issue; rather, it reflects the complexity of coordinating care across health, disability, and housing systems.

This session provides a practical, system-level perspective on discharge planning within acute care, focusing on patients with complex needs, including those requiring advanced wound care, diabetes management, behavioural supports, and specialised equipment.

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It will explore the key barriers that impact on safe and timely transitions from hospital to home, including:
•    Challenges arising in NDIS planning when a participant is in hospital 
•    Accessing to appropriate housing and support services including income support
•    Translating hospital-level clinical support into community delivery
•    Medication continuity, including Schedule 8 requirements

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By examining these challenges, the session highlights where system misalignment occurs and the implications for patient outcomes, hospital capacity, and cross-sector coordination.

Attendees will gain a clearer understanding of the realities shaping discharge decision-making and the importance of integrated approaches to enable safe, sustainable transitions from hospital to home.

Q & A  and panel  

Morning Tea 

Across Australia, delays, changes, or interruptions in Specialist Disability Accommodation  and related NDIS housing and support funding are contributing to a growing cycle of hospital readmissions and prolonged hospital stays.

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When Participants are medically ready for discharge but cannot access appropriate SDA or supported living arrangements in a timely way - due to delayed decision-making, funding adjustments, or changes in accommodation plans- they often remain in hospital beds longer than necessary or are readmitted shortly after discharge.

These repeated transitions place further strain on hospital capacity, contribute to bed block, disrupt continuity of care, and increase costs in an already stretched health system.

This session will explore how SDA funding pathways, plan reviews, and transitional support arrangements intersect with hospital discharge planning and post-discharge stability.

Delegates will gain insight into the systemic impact of delayed SDA approvals, the challenges of accommodating people with complex support needs in community settings, and the downstream effect on emergency departments, inpatient units, and discharge coordinators when housing and supports are unstable or withdrawn.
 

The discussion will also examine strategies to reduce readmissions and improve continuity of care through stronger collaboration between hospitals, NDIS providers, and housing stakeholders.

Topics will include early identification of Participants requiring SDA or supported living, streamlined transition frameworks, housing predelivery planning, and integrated care pathways that support sustained discharge outcomes rather than short-term exits.

By understanding and addressing the “revolving door” phenomenon, delegates will be better equipped to enhance hospital flow, reduce unnecessary bed occupancy, and support participants to live safely and sustainably in the community.

​​People with psychosocial disability in WA often face significant barriers after leaving hospital, particularly when NDIS access is delayed or limited. Thin provider markets, low acceptance rates for psychosocial disability, and limited transitional supports mean many individuals are discharged without timely, recovery-oriented care.

This gap frequently drives repeated hospital presentations and crisis-driven care.

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In WA, mental health accommodation often intervenes as a temporary safety net — providing short-term, transitional housing to prevent immediate harm. While these services stabilize patients, they are time-limited and not designed for long-term recovery. Despite these challenges, early successes in integrated hospital-to-community pathways and recovery-focused NDIS planning demonstrate that the revolving door can be slowed — and, in some cases, broken.

This session focuses on the community and NDIS perspective, exploring practical WA-specific solutions, including:

• Bridge funding and rapid access mechanisms to cover the period between hospital discharge and NDIS plan activation

• Integrated hospital-to-accommodation-to-community pathways combining clinical support, housing, and psychosocial services

• Proactive engagement of NDIS and community providers prior to hospital discharge

• Culturally safe, locally relevant approaches for Aboriginal, regional, and remote populations

• Recovery-oriented supports that prioritize autonomy, skill-building, and social inclusion

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Delegates will gain practical strategies to improve post-hospital outcomes, reduce readmissions, and build sustainable community supports — showing that even in WA’s challenging landscape, effective and hopeful solutions exist.

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This session is essential for NDIS providers, hospitals, mental health services, NGOs, policymakers, and service coordinators seeking actionable strategies to support people with psychosocial disability.

Hospital discharge is a critical juncture in patient care, particularly for vulnerable populations such as people with disabilities, mental health conditions, and the elderly

Inadequate assessment, planning, or follow-up can result in serious harm or death, raising complex legal questions around duty of care, clinical negligence, and hospital accountability.

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This session will explore the legal implications of discharge decisions, examine Australian case law and coroner findings, and highlight best-practice strategies to safeguard patients while mitigating legal risk.

Attendees will gain insights into how hospitals, clinicians, and policymakers can ensure safe, evidence-based discharge processes that protect patients and reduce liability.

Q & A  

Networking and lunch  

Depart