Arrival and Registration 

Welcome and Introductions 

In late 2025, negotiations between the Commonwealth and state and territory governments over Australia’s next five-year public hospital funding agreement reached a critical impasse. State and territory health ministers rejected the federal government’s revised funding proposal—valued at more than $20 billion and including targeted measures to address hospital bed block—arguing it fell short of prior commitments and was insufficient to meet escalating demand across the health system.

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At the centre of this funding deadlock is a deepening hospital discharge crisis.

Thousands of Australians, particularly older people and individuals with disability, remain in public hospital beds despite being medically ready for discharge. Inadequate access to residential aged care, supported accommodation, Specialist Disability Accommodation, and NDIS-funded supports has intensified pressure on acute services and exposed long-standing structural failures in how hospitals interface with aged care, disability, and community systems.

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This opening session will examine how the funding stalemate has crystallised systemic weaknesses in discharge planning and cross-sector integration.

Leaders from government, health administration, aged care, and the disability sector will explore the policy, economic, and operational implications of the impasse, and what it reveals about the urgent need for coordinated funding pathways and integrated discharge models.

Attendees will gain a clear national overview of the challenges facing Australia’s hospital system in 2026 and beyond, setting the foundation for the conference’s focus on practical, collaborative solutions to unblock hospital capacity and create safe, person-centred pathways from hospital to home.

Regional Western Australian hospitals are confronting a growing crisis in emergency departments and discharge management, with 2025 data showing over 7,000 hours of ambulance ramping in some months.

Discharge delays are particularly acute for patients who are medically fit but cannot access suitable aged care, NDIS supports, or community services.

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This session examines the key drivers of these challenges, including: limited regional infrastructure, GP access issues, workforce shortages, and higher costs of care. It will explore how these systemic barriers contribute to readmissions, prolonged hospital stays, and stress for patients, carers, and clinical teams.

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Attendees will gain insights into strategies and innovative approaches to address discharge barriers, including intermediate care options, integration with SDA and SIL supports, and cross-sector collaboration

 The session will highlight practical examples from regional WA and discuss policy, funding, and workforce solutions to improve Hospital-to-Home pathways for 2026.

​A 2024 national study exploring hospital discharge decision-making from the perspectives of patients, carers, and clinical staff identified fragmented communication, inconsistent workflows, and limited multidisciplinary coordination as major barriers to safe, effective discharge planning.

These challenges were echoed in earlier Western Australian research, highlighting systemic issues that contribute to patient stress, caregiver uncertainty, and increased risk of adverse outcomes.

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Building on these insights, the Australian Commission on Safety and Quality in Health Care launched the Medication Management at Transitions of Care Stewardship Framework in 2025, a nationally coordinated effort to reduce medication errors and improve continuity of care.

The framework introduces structured medication reconciliation, governance oversight, multidisciplinary collaboration, and interoperable digital tools to ensure safe, patient-centred handovers between hospitals, primary care, and community services. Together, these initiatives underscore the critical importance of coordinated, patient-focused Hospital-to-Home pathways, stronger communication, and integrated care planning.

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This presentation examines the 2025 framework and its practical application, showing how research findings and national initiatives inform patient-focused Hospital-to-Home pathways.

Attendees will gain insight into stronger communication, integrated care planning, and actionable strategies for healthcare providers, allied professionals, and SDA, SIL, NDIS, and impact housing stakeholders to enhance participant outcomes and system efficiency in 2026.

Q & A  and panel  

Morning tea 

Unplanned hospital readmissions continue to place immense pressure on Western Australia’s health, mental health, aged care, and disability systems.

WA’s vast geography, workforce shortages, housing constraints, and limited regional service capacity mean many patients are discharged long distances from their treating hospital, often into communities with minimal follow-up care.

These structural challenges significantly increase the risk of avoidable deterioration and repeat hospitalisation.
This session examines the key WA-specific drivers of repeat readmissions, including delayed discharge due to housing and NDIS constraints, limited community mental health coverage outside metropolitan Perth, and the impact of access block and ambulance ramping on safe discharge planning.

Through WA data, policy context, and real-world examples, delegates will explore how integrated hospital-to-home models, strengthened regional pathways, and preventative community-based care can reduce reliance on acute services.

Delegates will gain practical insights into designing discharge and transition models that reflect WA’s geographic and system realities while improving patient outcomes.

This session is essential for WA health executives, hospital managers, policymakers, community providers, and system planners.

​WA hospitals are facing mounting workforce pressures, with staff shortages and high patient acuity driving increased demand on existing teams.

Despite recruitment campaigns, vacancies in nursing, allied health, and support roles remain persistent, particularly in regional and remote locations. These shortages are compounded by an increasingly complex patient mix, including older adults with multiple chronic conditions, mental health comorbidities, and NDIS participants requiring high-support discharge planning.

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This session examines the interplay between workforce constraints, rising care complexity, and staff burnout, and how these factors affect hospital flow and hospital-to-home transitions. Reports from late 2025 to early 2026 indicate growing demoralisation among staff, reduced capacity for timely discharge planning, and challenges in maintaining quality patient care across both metropolitan and regional facilities.

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Delegates will explore:

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• The operational and patient safety impact of workforce shortages on hospital throughput and discharge efficiency.

• How increasing patient acuity and complex care needs amplify demand on overstretched staff.

• The consequences of staff burnout and demoralisation for timely hospital-to-home transitions.

• Evidence-based strategies to strengthen workforce sustainability, enhance staff wellbeing, and improve collaboration with NDIS and community care providers.

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Attendees will leave with practical insights to support workforce resilience, optimise hospital-to-home pathways, and ensure safe, patient-centred care—helping hospitals maintain capacity for those who require acute care, across both metropolitan and regional WA.

This session will examine hospital discharge as a critical point in healthcare delivery, influencing patient outcomes, continuity of care, and hospital resource utilisation.

Drawing on qualitative research conducted in an Australian medical ward-including interviews with patients, caregivers, and healthcare staff, and structured observations - the study identified three key themes: communication, system pressure, and continuing care.

Challenges included inconsistent information sharing, gaps between hospital teams, and patient confusion regarding follow-up care. System pressures to expedite discharges, particularly during weekends or out-of-hours periods, contributed to perceptions of premature discharge and unplanned readmissions.

The findings highlight the tension between patient-centred care and service efficiency, underscoring the need for improved communication, stronger community-based support, and structured systems for tracking referrals and post-discharge care.

Delegates will gain practical insights into strategies for optimising discharge processes, enhancing patient experience, and improving safety and continuity of care.

Lunch 

​​Prolonged hospital stays and repeat admissions remain a pressing challenge in Western Australia, particularly for people with disability who are medically ready for discharge but awaiting long-term supports.

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The WA “From Hospital to Home” pilot addresses this gap by providing a supported accommodation pathway for patients leaving hospital. These intermediate settings offer a home-like environment — with privacy, outdoor space, and social supports — designed to help individuals stabilise, build daily routines, and engage with community services while longer-term supports such as NDIS plans, aged care, or mental health services are arranged.

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This session provides an in-depth exploration of the pilot, highlighting its dual purpose:

• Reducing hospital congestion by freeing beds for acute care

• Supporting patient recovery by providing safe, transitional accommodation that bridges hospital and community life

• Delegates will examine 2026 insights from the pilot, including how intermediate housing can reduce prolonged hospital stays, lower readmission risk, and enhance continuity of care. Practical strategies for integrating hospital discharge planning with community-based housing, support services, and interagency coordination will be discussed.

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Delegates will gain actionable knowledge on how WA’s pilot model can be adapted and scaled, improving hospital-to-home outcomes, reducing reliance on acute care, and fostering recovery-oriented pathways for vulnerable populations.

This session is essential for hospital managers, discharge planners, allied health professionals, community housing and disability providers, mental health services, and policymakers seeking evidence-based solutions to streamline hospital-to-home transitions in WA.

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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.

Readmission to acute psychiatric units remains persistently high across Western Australia, particularly for people living outside metropolitan areas.

Limited after-hours community services, housing insecurity, and workforce shortages mean emergency departments continue to function as the primary crisis response for mental health presentations across WA.

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This session focuses on the hospital and clinical perspective, exploring why mental health patients repeatedly return to EDs and inpatient units.

Delegates will examine WA-specific drivers, including:

• Regional and remote service gaps

• Workforce shortages in mental health and allied health services

• Fragmented continuity of care between hospital services and community-based supports.

• Delegates will explore practical strategies to strengthen discharge planning, improve continuity between inpatient and community services, and reduce ED reliance for mental health crises.

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Delegates will gain actionable insights into building safer, culturally appropriate, recovery-oriented hospital-to-home pathways that prevent unplanned psychiatric readmissions.

This session is essential for hospital leaders, mental health clinicians, discharge planners, community providers, Aboriginal health services, and policymakers focused on clinical system reform.

Afternoon Tea 

​​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.

As hospitals continue to face delayed discharges and long-stay patients, the 2026 Support at Home reforms represent a transformative opportunity to improve hospital-to-home pathways for older Australians.

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This session will explore how government-set price caps, eight tailored funding classifications, and strengthened consumer protections will directly influence discharge planning, care coordination, and safe transitions from hospital to home.

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Delegates will gain insight into practical strategies for aligning hospital discharge processes with the new Support at Home framework, optimising home-based support, and reducing hospital bed block.

The session will also highlight how NDIS providers, disability services, allied health, and community support organisations can actively participate in this ecosystem, offering coordinated services that complement aged care supports and enable older Australians—and younger people with disability—to live safely and independently at home.

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By attending, delegates will leave with actionable insights to streamline hospital-to-home transitions, engage multi-sector partners, and implement the 2026 Support at Home reforms effectively, ensuring a sustainable and person-centred pathway from hospital care to home or community support.

Older Western Australians experience high rates of hospital readmission, particularly where frailty, cognitive impairment, and limited post-discharge supports intersect.

In regional WA, limited residential aged care availability and long waits for Home Care Packages often result in delayed discharge or discharge to unsafe environments, increasing the risk of falls, medication mismanagement, and rapid readmission.

This session examines WA-specific contributors to aged care readmissions, including workforce shortages, placement delays, and limited integration between hospitals, aged care providers, and primary health services.
Delegates will explore practical strategies to improve hospital-to-home and hospital-to-care transitions within WA’s aged care landscape.

Participants will gain insights into improving safety, independence, and recovery for older people across metro and regional WA.
This session is essential for aged care providers, hospital managers, allied health professionals, GPs, and policymakers.

This session will explore Western Australia’s Time to Think program, a nation-leading initiative designed to support older Western Australians who are medically ready for discharge but need additional time to make informed decisions about their long-term care and living arrangements.

The program provides dedicated short-term aged care beds across multiple providers, enabling patients to transition out of hospital with dignity while freeing up much-needed hospital capacity. Since its launch, Time to Think has already supported its first 100 patients and freed more than 1,100 hospital bed days, demonstrating measurable impact on both patient outcomes and hospital flow.

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Attendees will gain a clear understanding of how the program delivers a person-centred, compassionate approach to aged care transitions, the operational model and governance partnerships that underpin its success, and how it integrates with broader WA initiatives, including hospital-to-home pathways, community-integrated care hubs, and residential respite pilots.

The session will highlight practical lessons learned, enablers for scaling the model, and the role of targeted investment and cross-sector collaboration in reducing hospital congestion while supporting older Australians to make informed care choices.

By the end, delegates will appreciate how WA’s approach balances patient-centred care with system efficiency and provides a blueprint for sustainable, high-quality hospital-to-aged care transitions.

Last Q & A and Panel 

Networking and depart