Specialists in hospital discharge and transitions from custody
We help NDIS participants move safely out of hospital and out of prison or other custodial settings into stable homes and support, across Victoria and South Australia. We reply to every referral within one business day.
- NDIS Registered Provider
- Provider No. 4050152781
- No cost to refer
Why transitions matter
Leaving hospital or custody is one of the most high-risk moments in a person's life. If supports aren't ready on day one, small gaps quickly become big problems: a return to hospital, a night without housing, or a missed appointment that leads back into custody.
We plan early so housing, providers and clinical follow-up are confirmed before the move, not scrambled together afterwards. We treat every participant with dignity and respect, whatever their history.
Transitions are a core specialty of Splendid Coordination, across Victoria and South Australia.
Two settings, one careful approach.
Whether someone is leaving a ward or a correctional facility, the goal is a safe move into a stable home.
Hospital discharge
We work with the hospital team to get participants home, or to a suitable new home, safely and without unnecessary delay.
- Working with discharge planners, social workers and NDIA Health Liaison Officers
- Supporting long-stay patients who are medically ready to leave but can't until supports are in place
- Arranging accommodation options (such as Medium Term Accommodation, or SIL and SDA where funded), assistive technology, home modifications and allied health
- Preventing readmission through follow-up and crisis planning
Transitions from custody
We plan with justice and corrections teams so people leaving prison or custody have somewhere to go and someone in their corner.
- Pre-release planning with corrections staff, case managers and NDIA Justice Liaison Officers
- Coordinating housing, mental health, alcohol and other drug (AOD) and disability supports so they're ready on release day
- Working alongside community corrections, legal and parole requirements
- Reducing the risk of reoffending and homelessness through stable, coordinated support
Common barriers we solve
The same obstacles come up again and again.
No accommodation on discharge
We look at every option, from going home with modifications to Medium Term Accommodation where funded, and push for decisions quickly.
A lapsed or unsuitable NDIS plan
If a plan has expired or no longer fits, we work with the NDIA to get it updated before the move.
No providers ready
We line up providers with real availability and confirm start dates.
AOD and mental health needs
We connect people with alcohol and other drug services and mental health care, with first appointments booked.
Parole and legal conditions
We build supports around parole, bail or community corrections requirements, so the plan helps the person meet them.
No ID or bank account
We help sort out identification, a bank account, Medicare and Centrelink, which are often missing after a long stay.
Five steps to a safe, stable move.
The earlier we're involved, the smoother the transition.
Early referral
Contact us as soon as a date is on the horizon.
Joint planning meeting
We meet with the participant and the hospital or corrections team to agree goals, risks and what has to be ready.
Supports secured
We line up housing, providers, clinical follow-up and any equipment, and confirm start dates.
Transition day support
We're there on the day, making sure the participant gets where they need to be.
First 90 days
We follow up closely, solve problems early and adjust supports until things are stable.
How it looks in practice
Two examples of the kind of transitions we plan.
Rosa leaves hospital after four months
Rosa is 58 and had a stroke. She'd been on a hospital ward for four months and was medically ready to leave, but her two-storey home was no longer safe and nothing else was in place.
Within a week of the social worker's referral, we held a planning meeting with Rosa, her daughter, the discharge planner and the NDIA's Health Liaison Officer. We arranged a short stay in Medium Term Accommodation while home modifications were assessed, and lined up occupational therapy, equipment and a GP follow-up.
Rosa left hospital three weeks later with everything ready on day one, and moved back home once the modifications were finished.
Jayden's release from custody
Jayden is 27 and lives with an intellectual disability and ADHD. He was due for release with parole conditions and nowhere stable to live. Previous releases hadn't lasted.
His case manager referred him four months early. Together with the NDIA's Justice Liaison Officer, we updated his plan, found a place to live, organised his ID and a bank account, and booked mental health and AOD appointments.
On release day, his coordinator met him and took him home and to his first parole appointment. After 90 days of close support, he's settled and stepping down to less intensive coordination.
What we need from referrers
We welcome referrals from hospital social workers and discharge planners, corrections and justice staff, LACs and the NDIA, families and participants themselves. To help us move quickly, please include:
- Expected discharge or release date, and where the person is now
- NDIS number and a copy of the plan, if available
- Current supports, treating team and key contacts
- Known risks, including AOD, housing and any parole conditions
- Consent from the participant or their nominee
Transition FAQs
Can you start working with someone while they're still in hospital or custody?
Yes, and we encourage it. The earlier we're involved, the more time there is to line up housing, providers and clinical follow-up. We can meet on the ward, in custody where allowed, or by video.
Does the participant need Level 3?
Not always, but many transitions are complex enough that Level 3 Specialist Support Coordination is the best fit. We'll advise on what the participant needs to leave safely.
What if the person isn't an NDIS participant yet?
We can't deliver NDIS-funded coordination until a plan is in place, but we're happy to talk with the referrer about the access process and the evidence needed. NDIA Health and Justice Liaison Officers can also help.
What if the discharge or release date changes?
Dates often move. We keep in close contact with the hospital or corrections team and adjust the plan, so providers and housing are ready whenever the day comes.
How long do you stay involved after the move?
We stay closely involved through the first 90 days, which is when most problems show up. After that, we keep coordinating for as long as the plan funds it, stepping support down as things settle.
Planning a discharge or release?
Contact us early. We reply to every referral within one business day. There's no cost to refer.