Support matched to needs, goals and risk
Participants preparing to leave hospital, experiencing discharge delays or needing coordinated nursing, disability support and community reintegration.
Specialist service
Hospital Discharge Support
Coordinated transition support from hospital back to home and community.
Person-centred and culturally respectful
Nogap’s model is person-centred, trauma-informed, recovery-oriented and culturally safe. Referrals are reviewed for support needs, consent, current services, location, urgency and any clinical or safety considerations before commencement.
Services included
What this pathway can include
The exact support mix depends on participant goals, funding, consent, documentation and workforce suitability.
Practical supports
- Discharge planning communication with hospitals, families and support coordinators
- Home readiness, nursing follow-up and practical support commencement planning
- Referral triage for urgency, risks, equipment, medication and support needs
- Coordination of community supports to reduce preventable readmission risk
- Service agreement and onboarding pathway after referral acceptance
What good support should improve
- Clearer next steps for hospitals, families and support coordinators
- Faster planning for safe commencement after discharge
- Improved continuity between hospital instructions and community care
Who can refer
Participants, families, hospitals, GPs, support coordinators, allied health teams, justice agencies, veteran organisations and government services can refer through the online referral pathway.
Referral process
Simple pathway from enquiry to commencement
Referral
Submit the online form, call the team or send supporting documents through the referral portal.
Triage
The team reviews eligibility, urgency, risk, support needs, documents and service location.
Planning
Nogap confirms next steps, consent, service agreement needs and staff matching.
Commencement
Supports begin after onboarding, documentation and agreed service arrangements are in place.
Frequently asked questions
Hospital Discharge Support FAQs
Can discharge planners refer directly?
Yes. Hospital discharge planners and allied health teams can use the referral pathway.
Can urgent discharge referrals be prioritised?
Urgency can be identified in the referral so the team can triage response needs.
What documents help with discharge referrals?
NDIS plan details, hospital discharge summaries, clinical notes, risk information and consent documents are useful.
Make a referral
Need hospital discharge support in Perth or regional WA?
Use the referral pathway to share participant details, consent, urgency, risk information and supporting documents. For urgent safety concerns, contact emergency or crisis services first.