Specialist pathway
Hospital Discharge & Transition Support
Helping NDIS participants leave hospital safely and build a life back in the community — with the right supports in place from day one.
Bridging hospital and home
Leaving hospital can be one of the most uncertain moments in a person's life — especially when disability, complex health needs or a lack of suitable housing are part of the picture. Together in Motion Services works alongside discharge planners, social workers, allied health professionals and support coordinators to make sure participants have a safe, supported pathway back into the community.
We do not make claims about funding eligibility or guaranteed outcomes. What we do is respond quickly, communicate clearly, and work as part of the participant's broader team to put practical supports in place.
Referrals welcome from
Who we work with
We welcome referrals and enquiries from anyone involved in a participant's discharge planning.
Hospital discharge planners
We respond to referrals within 2 business days and can attend discharge planning meetings where needed.
Social workers
We work collaboratively with hospital social work teams to understand the participant's situation and identify the most appropriate supports.
Families and carers
We keep families informed throughout the transition process and involve them in planning wherever the participant wishes.
Support coordinators and LACs
We partner with coordinators to implement supports quickly and communicate progress throughout the transition.
Allied health professionals
We work alongside OTs, physiotherapists, speech pathologists and other allied health professionals to ensure supports align with clinical recommendations.
NDIS participants and their families
Participants and their families can contact us directly to explore what supports may be available during and after a hospital stay.
Supports we can provide
Subject to NDIS plan funding and current capacity. Contact us to discuss what may be available for a specific participant.
Medium Term Accommodation (MTA)
For participants who do not have a suitable home to return to, MTA provides a safe, supported place to live while longer-term housing is arranged.
Assistance with Daily Living
Personal care, medication prompting, meal preparation and other daily living supports from the day of discharge.
Community participation
Support to re-engage with community life, social connections and activities that matter to the participant.
Transport
Accessible transport to medical appointments, therapy sessions and community activities.
Transition planning and goal-setting
Working with the participant to identify goals, build routines and plan for life after hospital.
Coordination and communication
Active liaison with the hospital team, support coordinator, family and other providers throughout the transition.
How the referral process works
Make a referral or enquiry
Contact us by phone, email or online referral form. For urgent situations, call us directly. We aim to respond within 2 business days.
Initial conversation
We speak with the referrer and, where possible, the participant and their family to understand the situation, supports needed and any time pressures.
Capacity and planning check
We confirm current capacity and work with the team to identify the most appropriate supports. We are transparent if we cannot assist and will try to suggest alternatives.
Supports in place
Once agreed, we put supports in place as quickly as possible — including accommodation where needed — and maintain communication with all parties.
A note on funding and eligibility
Together in Motion Services does not determine NDIS funding eligibility or guarantee specific discharge outcomes. All supports are subject to the participant having relevant NDIS plan funding and Together in Motion Services having current capacity in the relevant location. We encourage early contact so we can work through options together.
Common questions
Ready to make a referral or discuss a participant's needs?
Our team is here to help. Reach out by phone, email or online referral form.