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Policy No.:   eg. D0146 (inserted by CGES) 

 

 
 
 

 
 

Management of  
Patients with Complex Needs  

Requiring Discharge or 
Transition Placement 

 
Policy Directive 

 
Version No:  2 
Approval date:  20/07/2020 
   



 
Management of Patients with Complex Needs Requiring Discharge or Transition Placement Policy Directive 
INFORMAL COPY WHEN PRINTED  Page 2 of 19 

OFFICIAL 

Contents 
 
List of Appendices ......................................................................................................................... 3 
1. Policy Statement .................................................................................................................. 4 
2. Roles and Responsibilities .................................................................................................. 4 
3. Policy Requirements............................................................................................................ 5 

3.1 Key principles underpinning this Policy Directive:..................................................... 5 
3.2 Early Identification of Discharge Plan ....................................................................... 5 
3.3 Preparing for Discharge ............................................................................................ 6 
3.4 Developing a Patient Management Plan ................................................................... 8 
3.4.1 Patients Requiring Geriatric Services ....................................................................... 8 
3.5 Progressing Placement ............................................................................................. 9 
3.6 Identifying Barriers to Discharge ............................................................................. 11 
3.7 Addressing Barriers to Discharge ........................................................................... 12 
3.8 Escalating Continuing Delayed Discharge .............................................................. 13 
3.9 Options for Managing Delayed Discharge to Residential Care .............................. 14 
3.9.1 OPTION 1: Care Awaiting Placement Program (CAP) ........................................... 14 
3.9.2 OPTION 2: Respite ................................................................................................. 14 
3.9.3 OPTION 3: Transfer to a Peri-Urban Hospital ........................................................ 15 
3.9.4 OPTION 4: Transition Care Program (TCP) ........................................................... 15 
3.9.5 OPTION 5: Other Community Supports .................................................................. 16 
3.10 Declined Placement Offers and Refusal to Discharge ............................................ 16 

4. Implementation &amp; Monitoring ............................................................................................. 17 
4.1 LHN Implementation ............................................................................................... 17 
4.2 Data Collection and Monitoring ............................................................................... 17 

5. National Safety and Quality Health Service Standards ..................................................... 17 
6. Definitions .......................................................................................................................... 18 
7. Associated Policy Directives / Policy Guidelines and Resources ..................................... 18 
8. Document Ownership &amp; History ........................................................................................ 19 
  



Management of Patients with Complex Needs Requiring Discharge or Transition Placement Policy Directive 
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List of Appendices 
Appendix 1. Hospital Team Checklist ........................................................................................ 20 

Appendix 2. Early Identification Placement Pathway ................................................................. 26 

Appendix 3. Information for Clinicians - Approaching Patients about a Transfer (Adult) .......... 27 

Appendix 4. Patient Information Sheet   Residential Aged Care Placement ............................ 29 

Appendix 5. Patient Placement Pathway ................................................................................... 31 

Appendix 6. My Hospital Discharge to Community Plan (Adult) ................................................ 32 

Appendix 7. My Hospital Discharge to Community Plan (Paediatric) ........................................ 33 

Appendix 8. Delayed Discharge Patient Placement Pathway ................................................... 34 

Appendix 9. My Hospital Transfer Plan (Adult) .......................................................................... 35 

Appendix 10. My Hospital Transfer Plan (Paediatric) .................................................................. 36 

Appendix 11. Patients with Complex Needs Requiring Discharge Escalation Flowchart ............ 37 

Appendix 12. Letter for Discharge (Adult) .................................................................................... 38 

Appendix 13. Letter for Discharge (Paediatric) ............................................................................ 39 



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Management of Patients with Complex Needs 
Requiring Discharge or Transition Placement 

Policy Directive 
1. Policy Statement

SA Health is committed to providing the South Australian community with timely and equitable 
access to health services and ensuring the efficient use of available resources in public 
hospitals. 

The purpose of the Policy Directive Management of Patients with Complex Needs Requiring 
Discharge or Transition Placement is to provide the framework to guide early identification, 
intervention and management of barriers and delays to timely discharge for patients who have 
been admitted to a metropolitan public hospital and are considered unlikely to be able to leave 
hospital without additional support. 

This Policy Directive supports patients who have been admitted to hospital and: 

  Have been assessed, or are on the pathway to being assessed, by an Aged Care
Assessment Team (ACAT) as being eligible for permanent residential care or other
services such as residential respite care or transition care; or

  Have been assessed, or are on the pathway to being assessed, as eligible through the
National Disability Insurance Scheme (NDIS) Access Determination for community
based supports, Supported Independent Living (SIL) or Specialist Disability
Accommodation (SDA); or

  Through discussions with the hospital team have indicated that they are seeking to be
discharged to permanent residential care (Residential Aged Care Facility (RACF) or
NDIS), temporary supported accommodation (for children), or home with community
based supports in place; or

  Have not been successfully discharged or placed in a transition location and/or
continue to face a range of barriers and delays to discharge relating to
accommodation, applications, approvals, access and the patient/family/carer/guardian.

2. Roles and Responsibilities

Chief Executive (CE): 
Will take reasonably practical steps to develop and issue system-wide policies applying to Local 
Health Networks, the SA Ambulance Service, and the Department for Health and Well-being. 

Local Health Network (LHN) Governing Boards: 
Will take reasonably practical steps to ensure that effective clinical and corporate governance 
frameworks (where relevant) are in place to ensure the LHNs are compliant with this policy 
directive. 

LHN Chief Executive Officers (CEO): 
Will take responsibility to 

  Promote compliance with this Policy Directive;
  ensure provision of documented hospital discharge protocols and other protocols to

support the patient pathway;
  report LHN hospital discharge rates as per the Service Level Agreement; and
  refer any significant strategic issues to the Department for Health and Wellbeing.

LHN Chief Operating Officers (COO): 
Will take responsibility to 

  Operationalise the Policy Directive;
  ensure effective partnerships are established and maintained with agencies involved in

the discharge, transfer or placement of patients with complex needs;
  ensure all relevant staff are aware of this Policy Directive;
  ensure local level monitoring occurs in compliance with this Policy Directive; and



Management of Patients with Complex Needs Requiring Discharge or Transition Placement Policy Directive 
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  escalate significant delays, persistent declined offers and complex discharge to the
LHN CEO.

Authorised Admitting Medical Practitioners (Consultant, Medical Fellow or Visiting Medical 
Officer): 
 Will take responsibility to 

  Discuss with the patient/family/carer/guardian whether they are seeking discharge to
RACF, SIL, SDA or to the community with additional support;

  document in the patient s medical record that they have been referred to the relevant
hospital team to plan their discharge;

  refer the patient for the required assessments; and
  maintain clinical governance of the patient during their entire admission.

All hospital staff involved in discharge or transition placement planning: 
Will take responsibility to 

  Ensure effective partnerships are established and maintained with the patient and their
family/carer/guardian;

  develop and maintain effective working relationships with agencies involved in the
discharge, transfer or placement of patients with complex needs;

  escalate significant delays or complex discharge to the Divisional Director and LHN
COO; and

  comply with this Policy Directive.

Health care professionals within SA Health teams responsible for the management of patients 
requiring placement differ between hospital sites and therefore the exact roles and 
responsibilities of individuals is not included within this Policy Directive. 

Roles and responsibilities within SA health teams and how the Policy Directive is 
operationalised are to be determined by the LHN. 

3. Policy Requirements

3.1 Key principles underpinning this Policy Directive: 
  The patient s needs are the priority throughout the placement process.
  Patients are only discharged or transferred following medical clearance to do so.
  Older patients, patients who live with a disability, and patients with complex needs may

be at risk of functional decline the longer they stay in hospital following resolution of
their acute or sub-acute episode of care.

  Early information about residential care options and community based support services
assists with preparing for discharge or transition placement when the time comes.

  Regular contact and a collaborative approach between the hospital team,
patient/family/carer/guardian, the residential care facilities (RACF or NDIS) or
appropriate supported accommodation (paediatric specific), and any relevant agencies
and departments is ongoing throughout the placement process.

3.2 Early Identification of Discharge Plan 
Where possible, within 24 hours of a hospital admission, the following is to occur: 

  Patient indicates whether they are seeking permanent residential care, wish to explore 
their needs and housing options, or wish to return home with the assistance of 
community based support services.

  Planning for discharge care commences, even though this cannot occur until the acute 
or sub-acute care episode is complete.

  Patients who may need referral to geriatric services and have their current care 
delivered in partnership with a geriatric model of care are identified for a risk 
assessment. This is recommended for all patients over 65 years of age, or over 50 
years of age for patients of Aboriginal or Torres Strait Islander descent (see Patients 
Requiring Geriatric Services section 3.4.1 of this Policy Directive; page 8).

  Existing NDIS participants are identified and their current supports are documented 
including any concurrent supports/services that will continue while in hospital. 



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  A meeting is arranged between the patient/family/carer/guardian and the hospital team
to discuss and commence development of a patient management plan.

  For those patients moving to permanent residential care or temporary support
accommodation, the hospital team will advise that whilst every endeavour will be made
for the patient to be discharged to their preferred location, this cannot be guaranteed.
Where there are delays in achieving timely discharge, alternative suitable placement
options may need to be considered.

See Appendix 1, Item 1: Hospital Team Checklist, Early Identification of Patients (page 20) 
See Appendix 2: Early Identification Placement Pathway (page 26) 

3.3 Preparing for Discharge 
The hospital team is to undertake the following steps (where applicable) in preparation for 
discharge: 

Information Exchange 

  Contact the patient/family/carer/guardian to seek any relevant information. All
significant care, guardianship, lifestyle and financial matters that may impact on the
patient s care or placement are to be considered and addressed.

  Provide the patient/family/carer/guardian with contact details for the hospital team and
the ACAT or National Disability Insurance Agency (NDIA) representatives supporting
them through the process.

  Provide the patient/family/carer/guardian with verbal and written information about their
rights and responsibilities. If English is not the preferred language, or there are other
perceived language barriers, an interpreter service is to be offered.

  Gather all relevant clinical information and undertake a psychosocial assessment of
the patient.

  Discuss the roles of each party (hospital team, residential facility, community based
service, patient/family/carer/guardian) post-discharge to ensure a sustainable
placement.

Office of the Public Advocate 

  Determine the patient s care requirements, and if the patient is unable to participate in
decision making due to mental incapacity and does not have family members or a
carer to assist in this process, the Office of the Public Advocate (OPA) should be
engaged.

  The OPA cannot be engaged prior to a clinical assessment being undertaken.
  The OPA Information Service can be contacted via phone 08 8342 8200 or email

opa@agd.sa.gov.au.

Aged Care 

  For patients that are over 65 (and are not existing NDIS participants) seeking
permanent residential care in an aged care facility, the patient/family/carer/guardian is
to complete a Residential Aged Care Calculation of Your Cost of Care form if
Centrelink does not already have the patient s income information. Centrelink will have
this information if the patient receives a means tested income support payment, or a
Home Care Package.

  Direct the patient/family/carer/guardian to Centrelink if they require support to complete
the form.

  The patient must be medically stable and consent must be obtained from the
patient/family/carer/guardian for the ACAT assessment to progress.

  If the patient/family/carer/guardian has previously identified an appropriate RACF
which is available, but they are waiting for an ACAT assessment, the hospital team is
to advocate for the assessment to be prioritised to enable timely placement.

  Provide the patient/family/carer/guardian with access to information regarding the aged
care system via www.myagedcare.gov.au or phone 1800 200 422.

  Request that the patient/family/carer/guardian list a minimum of five preferred RACF
locations (with consideration given to rural and remote locations where appropriate).





 
Management of Patients with Complex Needs Requiring Discharge or Transition Placement Policy Directive 
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  Advise the patient/family/carer/guardian to visit a range of RACFs to assist with their 
preference listing. 

  Direct the patient/family/carer/guardian to the Australian Aged Care Quality Agency if 
they would like to review the facilities they are considering 
https://www.agedcarequality.gov.au/reports. 

NDIS (including paediatric participants) 

  Provide the patient/family/carer/guardian with access to information regarding the 
NDIS system via www.ndis.gov.au or phone 1800 800 110 and Commonwealth Carer 
Gateway via www.carergateway.gov.au or phone 1800 422 737. 

  Health staff can also contact their local NDIS Health Liaison Officer (HLO) for further 
information on, and support with, NDIS via SA.Health.liaison@ndis.gov.au. 

  Request that the participant complete the NDIS Hospital Discharge consent form. 
  If the patient is a prospective NDIS participant, support the 

patient/family/carer/guardian to complete an Access Request Form. Refer the patient 
to the National Access Team (NAT) for an NDIS Access Decision. A priority pathway 
has been established for access decisions for hospital patients: email nat@ndis.gov.au 
and enter the following in the subject line: PRIORITY   Urgent decision required: 
&lt;insert person s first and last name&gt;. 

  Note that participants require approval from NDIA prior to exploring residential care 
options and/or completing an ACAT assessment. 

  If it is an existing participant (access has previously been met) with an increased 
support need, support the participant to complete a Change of Circumstances form 
and, where applicable, a Request for Review. It is important to involve the patient and 
their family/carer/guardian in the completion of these documents. 

  Support the participant to prepare for the planning meeting by discussing the patient s 
change in circumstances, support needs and goals. This may include a goal of 
returning home with additional support or home modifications, or exploring alternative 
housing options. 

  Direct the patient/family/carer/guardian to NDIS housing information if they are seeking 
an NDIS accommodation service https://www.ndis.gov.au/participants/housing-and-
ndis.  

  Where possible, it is important for health staff to conduct allied health assessments in 
preparation for the planning meeting to reflect and support the participant s level of 
need, assistive technology or home modifications, and facilitate the discharge process. 

  Support the participant to engage with their Support Coordinator/Local Area 
Coordinator early in the discharge process and begin identifying the participant s 
support needs and exploring suitable housing options and locations. 

  Once a suitable option has been identified, and supports are approved by NDIA, 
initiate a discharge planning meeting with the Support Coordinator. 

  Further details of the hospital discharge can be found in the NDIS Hospital Discharge 
Journey Map. 

Fees 

  Ensure the patient/family/carer/guardian is provided with information regarding 
potential fee implications arising from an extended stay in hospital. 

  Each LHN is required to establish its own management and communication processes 
regarding fees, however, the approach taken should not interfere with the relationship 
between the patient and those clinicians providing care. 

  The relevant fees include: 

o Long Stay Nursing Home Type (NHT) patient fee - incurred after 35 days of 
continuous hospitalisation as per the SA Health Fees and Charges Manual; 

o Long Stay NHT patient and the Long Stay NHT Basic Benefit fees - incurred if a 
patient has been admitted as a private patient, after 35 days of continuous 
hospitalisation; and 

o Overnight Stay Fee   incurred if a patient/family/carer/guardian requests and 
subsequently receives single room accommodation, as per the SA Health Fees 
and Charges Manual. 













Management of Patients with Complex Needs Requiring Discharge or Transition Placement Policy Directive 
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See Appendix 3: Information for Clinicians, Approaching Patients about a Transfer (page 27) 

3.4 Developing a Patient Management Plan 
As a minimum, the Patient Management Plan is to include: 

  The estimated date of discharge to a residential care facility, support provider or home
as agreed between the patient/family/carer/guardian, hospital team and service
providers.

  The patient s specific needs and care requirements post-discharge, as agreed between
the patient/family/carer/guardian, hospital team and service providers. This may
include, but not be limited to:

Primary Care Needs

o Links with General Practitioner, community nursing agencies, social worker,
peer support groups, educational or care supports etc.

Home Care Needs (for those discharging to the community) 

o Physical requirements and modifications (including how these will be funded
and timeframe for completion).

o Aid and equipment needs (including funding and timeframe).
o Personal and domestic needs (such as washing, cleaning, shopping, laundry

etc).
o Meal preparation support (e.g. meals on wheels).
o Transport needs and capacity (e.g. local council, SA Transport Subsidy

Scheme, Department of Human Services Mobility Allowance).
o Personal safety needs (including emergency contact information and

strategies).

Medication Needs 

o Education about medication.
o Dispensing and follow-up/review arrangements.

Follow Up 

o Plan for appointments post discharge, including outpatients.

Other information required in the Patient Management Plan: 

  A list of preferred (and suitable) residential care facilities as nominated by the
patient/family/carer/guardian (where possible a minimum of 5 for RACF and a minimum
of 2 for NDIS accommodation).

  Information about agreed roles post discharge (hospital, residential care facility,
community based services, patient/family/carer/guardian).

  The date/timeframe for ACAT or NDIS assessment (if known), noting that the ACAT
assessment is contingent on the medical clearance of the patient and Commonwealth
Policy.

  The outcome of the patient s assessment for ACAT or NDIS eligibility.

See Appendix 1, Item 2: Hospital Team Checklist, Preparing for Discharge (page 20) 
See Appendix 1, Item 3: Hospital Team Checklist, Developing a Patient Management 
Plan (page 21) 

3.4.1 Patients Requiring Geriatric Services 

  To assist in the identification of patients who may need referral to geriatric services and
have their current care delivered in partnership with a geriatric model of care, a risk
assessment is recommended for all patients over 65 years of age, or over 50 years of age
for patients of Aboriginal or Torres Strait Islander descent.

  Any risk assessments performed prior to the acute episode should be considered where
possible, such as pre-admission clinic.

  A risk assessment is a priority, undertaken within 24 hours of admission where possible



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and repeated at frequent intervals throughout the patient journey, using an assessment 
tool; each LHN is to implement their preferred tool at a local level. 

  The risk assessment consists of a series of questions to identify the functional state of the
patient and the outcome of the assessment may result in referral to a Geriatrician.

  It is recognised there are various assessment tools currently being utilised within SA Health
that may constitute a risk assessment, therefore additional documentation may not be
required to support this Policy Directive. The risk assessment is to include key measures of
patient functionality such as whether or not:

o The patient is currently living alone or living alone with additional supports in
place;

o the patient recently presented to hospital requiring treatment (and if yes, why);
o the patient has significant cognitive impairment/advanced dementia;
o the patient has significant behavioral concerns, and is potentially at risk of self-

harm or risk to others;
o the patient has the capacity to perform basic tasks of daily living;
o the patient is at high risk of falls; and/or
o there is progressive deterioration in the patient s physical, mental or

functioning status, or whether the level of care currently available to the patient
indicates that a return to their home is not a feasible option.

  Following the risk assessment, the patient may be referred to geriatric services for further
management of their ongoing geriatric care needs. This referral can occur in parallel with
other acute services e.g. person presents to the emergency department with a fractured
upper limb following a fall at home and requires assessment by the orthopaedic team.

  Geriatric services may determine the management of the patient will need to consider
ongoing care options following their acute episode which may include:

o Returning home with additional care support or Transition Care Program
(TCP);

o short term respite; or
o residential TCP or permanent placement in a RACF.

  Assessment is to consider potential for improvement and explore appropriateness of an
admission to a Geriatric Evaluation and Management (GEM) Unit and other rehabilitation
options prior to a definitive plan around discharge to a RACF.

  Placement information including permanent RACF options is to be discussed in parallel to
prepare the patient/family/carer/guardian for possible future transition into a RACF if
required.

  The Patient Information Sheet Residential Aged Care Placement is to be provided to the
patient/family/carer/guardian and outlines the processes of placement in a RACF following
hospital discharge, including accepting or declining a RACF placement.

  If the risk assessment determines the patient does not require permanent RACF placement
following their current episode of care, but may require permanent RACF placement in the
foreseeable future, the hospital team is to convene a meeting with the patient/family/carer/
guardian prior to discharge to provide information in preparation for when they do
potentially require a permanent RACF placement.

See Appendix 4: Patient Information Sheet, Residential Aged Care Placement (page 29) 

3.5 Progressing Placement  
Residential Care (over 65) - Preparing for Discharge 

The hospital team is to do the following: 

  Liaise with the patient/family/carer/guardian to enact the actions agreed to in the Patient
Management Plan.

  Remind the patient/family/carer/guardian that whilst every endeavour will be made to place
the patient in their preferred location this cannot be guaranteed, and alternative transition
options may need to be considered.

  If not already undertaken, encourage the patient/family/carer/guardian to visit RACFs to



 
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identify preferred locations. 
  Request that the patient/family/carer/guardian advises the hospital team as soon as 

possible of their decision. 
  If the patient chooses to discharge to a transitional location, ensure that the 

patient/family/carer/guardian liaises with their preferred RACFs to advise of their 
temporary location and contact details, and to confirm they are still seeking to move to 
their facility. 

  Once the facility has been selected by the patient/family/carer/guardian, liaise with the 
accommodation provider about the transfer and discharge arrangements. 

Supported Accommodation (Paediatric) - Preparing for Temporary Step Down 

The hospital team is to do the following: 

  Liaise with the patient/family/carer/guardian to enact the actions agreed to in the Patient 
Management Plan. 

  Remind the patient/family/carer/guardian that whilst every endeavour will be made to place 
the patient in their preferred location this cannot be guaranteed, and alternative options 
may need to be considered. 

  Once the facility has been selected by the patient/family/carer/guardian, liaise with the 
accommodation provider about the transfer and discharge arrangements. 

  Liaise with the patient/family/carer/guardian regarding discharge arrangements including 
transport requirements etc. 

Returning Home - Preparing for Discharge 

The hospital team is to do the following: 

  Liaise with the patient/family/carer/guardian to enact the actions agreed to in the Patient 
Management Plan. 

  Discuss the home care needs that have been identified by the patient/family/carer/guardian 
and hospital team, including but not limited to: 

o Physical requirements and modifications; 
o aid and equipment needs; 
o personal and domestic needs (such as washing, cleaning, shopping, laundry 

etc.); 
o meal preparation support (e.g. meals on wheels); 
o transport needs and capacity (e.g. local council, SA Transport Subsidy 

Scheme, DHS Mobility Allowance*); and 
o personal safety needs (including emergency contact information and 

strategies). 
  Liaise with the patient/family/carer/guardian regarding discharge arrangements, including 

transport requirements. 
  For NDIS participants, support the patient to engage with their Support Coordinator or 

Local Area Coordinator to implement services. 

*Note   DHS Mobility Allowance is not available for NDIS participants. Please refer to 
www.servicesaustralia.gov.au for eligibility requirements. 

Discharge Planning Meeting 

Once the patient is deemed medically fit for discharge, the hospital team is to prepare for a 
case conference with the patient/family/carer/guardian prior to discharge. This is to ensure all 
aspects that may impact on a successful placement have been addressed. 

The following should be prepared by the hospital team for the case conference: 

o Medical information that supports discharge from hospital. 
o Details about the day of discharge, including transport arrangements etc. 
o Handover, discharge and contact information for all individuals/agencies 

responsible for providing care or support post-discharge. 
o Information about the roles and responsibilities for agencies and services 

providing care post-discharge. 




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o Information related to the residential care facility, SIL facility, SDA or
community based service providers.

o Information and education about medication post-discharge.
o Review and follow up appointments, including frequency.
o Information for the patient/family/carer/guardian at time of discharge (e.g. My

Hospital Discharge to Community Plan).
o Information about the circumstances in which the patient should visit the

emergency department post-discharge.
o Information to prevent avoidable readmission to hospital, including services

and strategies to support successful transition (e.g. Rapid Access Service and
Dementia Australia Severe Behaviour Response Teams (SBRT) or
appropriate complex support plan for paediatrics).

o Strategies if the patient presents to hospital for re-admission shortly after
discharge.

Following the case conference, the hospital team is to complete the My Hospital Discharge to 
Community Plan detailing what was agreed to at the case conference regarding their 
discharge arrangements and post-discharge care. 

See Appendix 1, Item 4: Hospital Team Checklist, Progressing Placement (page 22) 
See Appendix 5: Patient Placement Pathway Diagram (page 31) 
See Appendix 6: My Hospital Discharge to Community Plan (Adult) (page 32) 
See Appendix 7: My Hospital Discharge to Community Plan (Paediatric) (page 33) 

3.6 Identifying Barriers to Discharge 
There may be a range of barriers or delays affecting timely discharge or transition placement, 
some of which are able to be addressed through early identification and early discharge 
planning. However, other delays are more challenging and are listed below: 

Accommodation 

  Lack of suitable housing and/or support options due to high complex needs.
  Difficulty accessing equipment or arranging home modifications or community services

in a timely manner.
  Limited housing availability for those with no fixed address who are waiting for SA

Housing or Community Housing (ineligible for NDIA or RACF, or complex paediatric
patients).

  Inability to access a preferred RACF.

Other Supports and Requirements 

Delays in coordinating community support services or acquiring the necessary physical 
requirements including:  

  Home modifications.
  Access to appropriate in-home care supports (including paediatric nursing).
  Aids and equipment.
  Support to assist with personal and domestic needs (including washing, cleaning,

shopping, laundry etc).
  Support for meal preparation (e.g. meals on wheels).
  Transport needs and capacity (e.g. local council, SA Transport Subsidy Scheme, DHS

Mobility Allowance*).
  Personal safety needs including emergency contact information and strategies.

*Note   DHS Mobility Allowance is not available for NDIS participants. Please refer to
www.servicesaustralia.gov.au for eligibility requirements.

Applications, Approvals and Access 

Aged Care 

  Delays in receiving a Home Care Package (HCP) allocation following ACAT approval.




Page 12 of 19 
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  Limitations accessing sufficient support under the Commonwealth Home Support
Programme (CHSP), often whilst waiting for a HCP.

  Delay greater than 14 working days of receiving information from the Department of
Human Services regarding cost of care.

  Delay greater than 14 working days of returning means test statement from the
Department of Social Services.

  Respite option not identified on ACAT assessment.

NDIS (including paediatric participants) 

  Delays to the NDIS access and eligibility process, including requests for further
information.

  Delays to the NDIS plan approval, including reviews required due to inadequate
existing/active plans.

  Difficulty obtaining assessments required for NDIA approvals for SIL quotes, SDA
eligibility, assistive technology and/or home modifications whilst an inpatient in an
acute setting.

Guardianship/Citizenship 

  Citizenship/residency issues.
  Delays related to guardianship services.

Patient/Family/Carer/Guardian, Hospital Team or Other 

  Inability to get in contact with the family/carer/guardian.
  Family/carer/guardian not attending scheduled meetings or unresponsive to

correspondence.
  Family/carer/guardian unwilling to support/facilitate discharge.
  Parent/family/carer/guardian unwilling to take child home.
  Lack of flexibility regarding the placement location.
  History of frequent admissions with the same or similar Diagnosis Related Group

(DRG), and services offered and refused.
  Complex internal home environment.
  Complex financial issues (e.g. hardship).
  Frequent changes to the patient s discharge plan, either by the patient/family/carer/

guardian or the hospital team.
  Requirement for a culturally sensitive discharge plan or placement.
  No agreed discharge plan with the estimated discharge date approaching.

3.7 Addressing Barriers to Discharge 
Barriers Relating to Accommodation, Other Supports and Requirements, Applications, 
Approval and Access 

If the barriers and delays to discharge relate to the above, the hospital team is to work with the 
relevant agencies and departments using their established relationships and escalation 
procedures, to expedite processes where possible and support the 
patient/family/carer/guardian towards a timely discharge. 

Delays Accessing Residential Care 

For all delays associated with accessing residential care, the hospital team is to consider options 
such as the Care Awaiting Placement (CAP) Program, respite, transfer to a peri-urban hospital, 
TCP, appropriate supported accommodation, or other community supports. 

Please refer to section 3.9 Options for Managing Delayed Discharge to Residential Care of 
this Policy Directive (page 14) for more information. 

Barriers Relating to the Patient/Family/Carer/Guardian, Hospital Team or Other 

If the barriers and delays relate to the patient/family/carer/guardian, the hospital is to work with 
the patient/family/carer/guardian towards resolving those barriers. This may require a case 
conference, and the hospital team is to ensure that the patient/family/carer/guardian: 

Management of Patients with Complex Needs Requiring Discharge or Transition Placement Policy Directive 
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  Is given the opportunity to discuss the barriers to placement from their perspective.
  Is aware that their discharge and placement is appropriate for their care needs.
  Is advised that they no longer require hospitalisation and that public hospitals treat

people who are acutely unwell and need specialist care, so they will not be able to stay
in hospital.

  Is aware of the benefit in visiting placement offers as soon as possible (preferably
within 24 hours) of being notified of the vacancy, and to accept the placement as soon
as possible once they have confirmed its suitability.

  Is advised that whilst waiting for a suitable placement, and depending on their specific
care needs, they may be:

o Discharged home with support;
o discharged to a temporary placement;
o transferred to another (less acute) hospital.

  Is advised that further delays will be escalated to the Divisional Director (or similar) or the
COO of the LHN.

The hospital team will work with the patient/family/carer/guardian to develop an action plan 
inclusive of timeframes to address the barriers, as well as an agreed target discharge date. 
Outcomes of the case conference should be summarised in the patient s notes, including process 
to date and escalation details. 

See Appendix 8: Delayed Discharge Patient Placement Pathway (page 34) 

3.8 Escalating Continuing Delayed Discharge 
If there is: 

  No progress regarding accommodation, other supports and requirements, applications,
approvals etc. within a reasonable timeframe following the planned actions; or

  the hospital team has been unable to achieve any progress in escalating matters with the
relevant agency or department; or

  there has been no follow up by the patient/family/carer/guardian within 24 hours of any
agreed actions; or

  a dispute or disagreement remains between the hospital team and the
patient/family/carer/guardian;

The following should occur: 

  The hospital team is to advise the Divisional Director (or similar);
  where appropriate, the Divisional Director (or similar) is to advise the COO who may

discuss concerns with the OPA where relevant; and
  The Divisional Director (or similar) is to consider whether it is appropriate to charge a

fee for length of stay exceeding 35 days when the patient is post-acute, and apply the
local process and procedure.

NDIS (including paediatric patients) 

In addition to the above, if there is: 

  No progress regarding NDIS eligibility, plan progress and NDIS approvals (including
accommodation, other services/supports, home modifications or assistive technology)
within a reasonable timeframe; and

  the hospital team has been unable to achieve any progress in escalating matters at a
local level including contacting Local Area Coordinator, Support Coordinator and NDIS
HLO;

The following should occur: 

  The hospital team refer to the LHN NDIS Site Representative;

  if the LHN NDIS Site Representative is unable to resolve the issues locally, escalate to
the NDIS HLO;

  if the LHN NDIS Site Representative and NDIS HLO are unable to resolve the issues
locally, escalate to the LHN NDIS Site Working Group Representative and State Health



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NDIS Representative; 

  the State Health NDIS representative will escalate the issue to the NDIS Service
Delivery team and provide feedback to the LHN site representatives;

  if there is no response or progress within 1 month of the action escalation to the NDIS
Service Delivery Team, the State Health NDIS representative will escalate to the
Critical Incident Service Response Team.

If the patient is waiting for NDIS SIL and/or SDA options and declines more than one suitable 
offer, the hospital team is to refer to section 3.10 Declined Placement Offers and Refusal to 
Discharge of this Policy Directive (page 16). 

Aged Care 

If the patient is waiting for residential care in a RACF, declines more than one suitable offer, and 
all options in section 3.9 Options for Managing Delayed Discharge to Residential Care of this 
Policy Directive (page 14) have been considered, then the hospital team is to refer to section 
3.10 Declined Placement Offers and Refusal to Discharge of this Policy Directive (page 16). 

See Appendix 8: Delayed Discharge Patient Placement Pathway (page 34) 

3.9 Options for Managing Delayed Discharge to Residential Care 
There are a range of options available to manage delayed discharge for patients who: 

  Are awaiting placement in a RACF;
  have accepted an offer of placement, however the placement location is not ready for

the patient to be transferred;
  have declined suitable offers for placement; or
  have completed their acute or sub-acute episode of care and are medically fit for

discharge.

Options 1-5, including eligibility, are outlined below. 

3.9.1 OPTION 1: Care Awaiting Placement Program (CAP) 

  The patient must be assessed by hospital staff as requiring RACF placement or be
waitlisted for a RACF prior to admission.

  If a patient has been waitlisted for a RACF and there is a delay in transfer (that has
been determined will be overcome within 21 days) they are eligible for the CAP
program.

  Whilst eligibility for the CAP program is not subject to ACAT approval, to avoid delays
in RACF placement post CAP, ACAT approval for a permanent RACF is to be sourced
prior to CAP program admission.

  If a patient has been approved for the CAP program, hospital staff are to refer to the
CAP Pathway and Escalation Process Flowchart within the Care Awaiting Placement
Program Policy Directive.

  Transfer of patient should be in alignment with the LHN processes and the Transfer of
Individuals between Public Health Services and Residential Aged Care Services Policy
Guideline.

  If a suitable permanent placement within a RACF has not been secured within 35 days
of the hospital admission date, the patient may be charged the Long Stay Nursing
Home Type Patient fee.

  If delays in securing an aged care placement are predicted to continue past the
allocated 21 day CAP program length of stay, where appropriate options two through to
five should be explored instead.

3.9.2 OPTION 2: Respite 

  Short term care limited to a maximum of 63 days per financial year, providing
additional support to the patient or their carer.

  Support can be provided formally or informally, in a residential or community setting.
  Residential Respite is subject to ACAT approval, however an Income and Assets

Assessment is not required.








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  To access Commonwealth Home Support Programme (CHSP) Respite services
applications must be referred via the Commonwealth My Aged Care system.

  If the patient has been identified as requiring permanent RACF but there is a delay in
transfer, they can be provided with a respite service in the interim period.

  If respite is to occur within a residential setting, transfer of patient should be in
alignment with LHN processes and the Transfer of Individuals between Public Health
Services and Residential Aged Care Services Policy Guideline.

  If there is a delay in ACAT assessment, option three and/or some services under
option five should be explored.

  If a patient has already exhausted their allocated 63 respite days per financial year,
where appropriate, options one, three, four and five should be explored.

3.9.3 OPTION 3: Transfer to a Peri-Urban Hospital 

  Transfer to a peri-urban hospital provides ongoing patient care whilst awaiting 
Residential Care placement. Care is provided in a hospital setting equipped with 
providing specialist care in a less busy and more home-like environment than an acute 
metropolitan hospital.

  Patients must be assessed by hospital staff as requiring Residential Care placement.
  If the patient has been identified as requiring permanent RACF they can be transferred 

to a peri-urban hospital to ease the pressure on metropolitan hospitals acute bed 
availability.

  Transfer to peri-urban hospital is not subject to ACAT approval or Income and Assets 
Assessment.

  Inter-hospital transfers of patients should follow LHN transfer and clinical handover 
procedures.

  Various documents should be utilised to explain the reasons for transfer to the patient/
family/carer/guardian along with relevant handouts including:
o Patient Information Sheet   Once you start to get better.
o Patient Frequently Asked Question s - Transfer to another hospital; and
o Patient Information Sheet - Residential Aged Care Placement.

  Each LHN should prepare its own procedures in line with relevant policies and 
guidelines to enact this pathway.

  Appendix 9 or 10: My Hospital Transfer Plan, should be completed and provided to the 
patient as soon as the pathway has been enacted. 

3.9.4 OPTION 4: Transition Care Program (TCP) 

  The TCP offers short term care (maximum 12 weeks, although extensions can be
granted for an additional 6 weeks) and seeks to optimise the functioning and
independence of older people following a hospital stay.

  TCP can occur in a residential or community setting.
  Patients must have ACAT approval for TCP.
  If the patient has been identified as requiring permanent RACF placement and is

experiencing delays in finding a suitable placement, the TCP can facilitate supported
discharge until a placement can be secured.

  An Income and Assets Assessment is not required.
  TCP is designed for two different functions: it seeks to enable older people to return

home after a hospital stay rather than enter RACF prematurely, as well as actively
maintain the individuals functioning whilst assisting them, their family and carers to
make appropriate long-term care arrangements.

  There is a daily care fee that patients are asked to contribute: 17.5% of the basic daily
rate of the single Aged Pension ($9.93 per day) when TCP takes place in the home or
85% basic daily rate of the single Aged Pension ($48.25 per day) when TCP takes
place in a RACF, however fee waivers and reductions are available. If the patient is
unable to pay any fees they will not be excluded from the program.

  As an ACAT approval is required for this service, if there is a delay in ACAT
assessment option three and some services under option five should be explored.





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3.9.5 OPTION 5: Other Community Supports 

  Community supports include both Commonwealth and State funded services that
facilitate both supported discharge and hospital avoidance focused on rehabilitation,
short and long term care.

  Some supports require ACAT assessment to be undertaken in the community.
  Some supports require Income and Asset Assessments.
  Some Commonwealth funded supports require Regional Assessment Service

assessments undertaken in the community.
  Hospital staff to use the My Aged Care Hospital Referral Request form to refer patients

to My Aged Care Gateway for Commonwealth funded service.
  If the patient has been identified as requiring permanent RACF placement or

placement in the community with support and is experiencing delays in finding a
suitable placement, accessing both Commonwealth and State funded community
programs can facilitate supported discharge until a placement can be secured.

  A variety of community supports are available including:
o CHSP services
o HCP and Veteran s Home Care Packages (VHCP)
o Hospital and Health Care at Home (HHC@H)
o Country Home Link (CHL)
o Community Nursing Services
o Hospital in the Home (HITH)

  Additional information about the State funded services available can be found at the
Health Services section of the SA Health website https://www.sahealth.sa.gov.au and
information on Commonwealth funded services can be found at the My Aged Care
website https://www.myagedcare.gov.au/.

  The hospital team is to provide information to assist the patient/family/carer/guardian in
navigating the NDIS via https://www.ndis.gov.au or phone 1800 800 110.

3.10 Declined Placement Offers and Refusal to Discharge 

In the event that the patient/family/carer/guardian declines more than one suitable placement 
offer that meets most of their needs, and the patient/family/carer/guardian is unable to provide 
a reasonable explanation why the placement is not suitable, the hospital team will advise that 
the patient will need to consider discharge to a short-term, transition placement whilst waiting 
for their preferred location. 

The hospital team is to arrange a case conference and prepare correspondence to the 
patient/family/carer/guardian which as a minimum: 

  References the most recent case conference;
  reinforces that the patient s needs are the priority for the placement;
  confirms that the patient is medically fit to be discharged;
  acknowledges if the patient is being placed in a location that is not the

patient/family/carer/guardian s preferred location for placement, and provides a
commitment to work towards moving the patient to their preferred location;

  provides the location of the interim placement and type of accommodation (RACF/
NDIS accommodation or private residential address);

  provides information about the specific support strategies, modifications, equipment
and/or community based agencies required and provided to address their specific
needs post discharge;

  provides the date of discharge and advises that there will be a fee for length of stay
charged after the discharge date;

  provides the name and contact details of the care coordinator assisting post-discharge,
including the frequency of meetings following discharge to monitor their health needs,
care requirements and supports in place to ensure their health and wellbeing;

  provides information about discharge arrangements including transport etc.; and
  references the My Hospital Discharge to Community Plan.







Management of Patients with Complex Needs Requiring Discharge or Transition Placement Policy Directive 
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See Appendix 6 and 7: My Hospital Discharge to Community Plan (Adult and Paediatric) 
(pages 32 and 33)
See Appendix 12 and 13: Letter for Discharge(Adult and Paediatric) (pages 38 and 39)

If the patient/family/carer/guardian continues to decline the offer, and refuses to agree to 
arrangements to progress the placement, the hospital team is to prepare a brief for the LHN 
COO, with a CC to the Deputy Chief Executive Commissioning and Performance, 
Department for Health and Wellbeing to seek approval to proceed. 

The briefing is to include the following as a minimum: 
  Patient history including complexities and barriers to discharge.
  Location of placement offer/s.
  Reason for declined placement (if provided).
  ACAT or NDIS eligibility.
  Discharge preparations including details regarding primary care, home care,

medication, follow up, communication etc. post-discharge.
  Agencies providing care post-discharge.
  Staff involved.
  Relevant dates regarding discharge/placement.
  Draft correspondence to the patient regarding discharge details.
  An outline of the escalation strategies already implemented.
  Legal advice if already sought.
  Proposed strategy if the patient refuses to leave/discharge on the planned date such

as engaging security, the South Australian Police or Child Protection Services.

4. Implementation &amp; Monitoring

4.1 LHN Implementation 
  LHNs are required to operationalise this Policy Directive within their organisational

structure to achieve maximum benefit for their populations in their geographical area.
  LHNs are to identify an Executive Lead and local clinical leads inclusive of nursing,

medical and allied health to implement and embed strategies to manage complex
patients requiring discharge or transfer placement into practice.

  A local implementation team is to be established (with terms of reference and regular
meeting times) to:

o Identify and manage local implementation and outcome measures;
o collect baseline data;
o develop and maintain relationships with key service partners providing care to

complex patients;
o identify actual or potential barriers and solutions to discharging or transferring

complex patients to a RACF, an NDIS accommodation service, or community
based placement; and

o define and measure local outcome measures, timing of measuring outcomes
and how the outcomes will be tracked and reported.

  LHNs are to develop a communication strategy for implementation and to report
achievements.

  LHNs are to develop an education package to support this Policy Directive.

4.2 Data Collection and Monitoring 
  LHNs are to monitor and report on the implementation of this Policy Directive. Minimum

data indicators are to include:

o Patient experience and satisfaction.
o LHN hospital discharge rates and length of stay for long-stay patients.

5. National Safety and Quality Health Service Standards



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6. Definitions

In the context of this document: 

  Appropriate placement means placement in a RACF, NDIS accommodation service
or community location that best meets the patient s individual needs and
circumstances, inclusive of but not limited to their assets and physical and emotional
needs.

  Complex patient means a patient whose condition may involve co-morbidities and
psychosocial factors. This could include older people who are becoming frailer, carer
stress or reduced ability to function independently. This may also mean a satiation with
multi-faceted factors preventing or contributing to a decision being made by the
patient/family/carer/guardian.

  Guardianship Order means an order made by the South Australian Civil and
Administrative Tribunal that appoints a guardian to make accommodation, health care
and/or lifestyle decisions on behalf of a person with a mental incapacity.

  Medically fit means the patient is considered by hospital staff to have completed their
acute episode of care and that their health condition has stabilised and may be
improving. A person deemed as medically fit is clinically ready to be discharged from
hospital.

7. Associated Policy Directives / Policy Guidelines and Resources
Policy Directives 

  Care Awaiting Placement Program   Policy Directive
  Hospital Discharge and Criteria Led Discharge - Policy Directive

Policy Guidelines 
  Transfer of Individuals between Public Health Services and Residential Aged Care

Services - Policy Guideline

Patient Information Sheets 

  Frequently Asked Questions   Transfer to Another Hospital
  Residential Aged Care Placement
  Care Awaiting Placement Program
  Receiving your care in SA Health Hospitals
  Once you start to get better

Information for Clinicians 

  Approaching Patients about a Transfer or Discharge

Related Resources 

  SA Health, Health Service Framework for Older People
  Charter of Residents Rights and Responsibilities (Aged Care Act 1997)

National 
Standard 1 

Clinical 
Governance 

National 
Standard 2 

Partnering 
with 

Consumers 

National Standard 
3 

Preventing &amp; 
Controlling 
Healthcare- 
Associated 
Infection 

National 
Standard 4 

Medication 
Safety 

National 
Standard 5 

Comprehensive 
Care 

National 
Standard 6 

Communicating 
for Safety 

National 
Standard 7 

Blood 
Management 

National 
Standard 8 

Recognising &amp; 
Responding to 

Acute 
Deterioration 

? ? ? ? ? ? ? ?


















































 
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8. Document Ownership &amp; History 

Approval 
Date Version 

Who approved New /  
Revised Version Reason for Change 

20/07/2020 V2.0 
Lynne Cowan, Deputy Chief 
Executive Commissioning and 
Performance. 

Language changed to be more 
patient/person centred, additional 
information included relevant to paediatrics, 
improved navigation of document. 

dd/mm/yy  V1.0 &lt;approving authority&gt; Original &lt;approving authority&gt; approved version. 
 

Document developed by:  Health Services Programs &amp; Funding 
File / Objective No.: 2020-04587 (A2007595) 
Next review due:  01/08/2025 
Policy history: Is this a new Policy Directive (V1)? N 
 Does this Policy Directive amend or update an existing Policy 

Directive version? N 
 If so, which version? N/A 
 Does this Policy Directive replace another Policy Directive with a 

different title? Y (2014-10362 (eA890425)) 
 If so, which Policy Directive? Management of Complex Patients 

Requiring Residential Aged Care Placement 
ISBN No.: 978-1-76083-301-5 



 
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Appendix 1 
Hospital Team Checklist 
Management of Patients with Complex Needs Requiring Discharge or Transition Placement Policy Directive 

1 - Early Identification of Discharge Plan (within 24 hours of admission [where possible]) 
 Step/Task ? Related Resource/Action  
1 Identify patients who are seeking permanent residential care, wish to explore their needs and housing options, or 

wish to return home with the assistance of community based support services. 
Note NDIS participants (including paediatric participants) require exploration of alternative housing options and 
approval from NDIA prior to exploring residential care options. 

 See Appendix 2: Early Identification 
Placement Pathway 
See Appendix 4: Patient Information 
Sheet - Residential Aged Care 
Placement 

2 Commence planning for discharge care.   
3 Identify patients who may need referral to geriatric services and have their current care delivered in partnership 

with a geriatric model. 
Note recommended for all patients over 65 years of age, or over 50 years of age for patients of Aboriginal or 
Torres Strait Islander descent 

 See 4.4.1 of the Policy Directive (page 
8) 

4 Identify existing NDIS participants and document their current supports, including if any concurrent 
supports/services will be required while they are in hospital. 

  

5 Arrange a meeting between the patient/family/carer/guardian to commence development of the patient s 
management plan. 

  

6 For those patients moving to permanent residential care or temporary support accommodation advise that whilst 
every endeavour will be made for the patient to be discharged to their preferred location, this cannot be 
guaranteed and alternative suitable placement options may need to be considered. 

 See Appendix 3: Information for 
Clinicians - Approaching patients 
about a transfer 

2   Preparing for Discharge 
 Step/Task  ? Related Resource/Action  
  INFORMATION EXCHANGE 
 If English is not the preferred language, or there are other perceived language barriers, an interpreter service 

is to be offered. 

  

1  Contact the patient/family/carer/guardian to seek relevant information (i.e. significant care, guardianship, 
lifestyle and financial matters that may impact on the patient s care or placement). 

  

2  Provide the patient/family/carer/guardian with contact details for the hospital team and the ACAT or NDIA 
representatives supporting them. 

  

3  Provide the patient/family/carer/guardian with verbal and written information about their rights and 
responsibilities. 

 Rights and Responsibilities English 

4 Gather all relevant clinical information and undertake a psychosocial assessment.   
5 Discuss the role of each party post discharge to ensure a sustainable placement (i.e. hospital team, residential 

facility, community based service, patient/family/carer/guardian). 
  

  OFFICE OF THE PUBLIC ADVOCATE (OPA)   
1 Determine whether the patient is unable to participate in decision making due to mental incapacity and does 

not have family members or a carer to assist in this process. 
  

2 
 

If the above is true, undertake a clinical assessment of the patient and engage the OPA (the OPA cannot be 
engaged prior to assessment). 

 OPA Information Service  
08 8432 8200 or opa@agd.sa.gov.au  

  AGED CARE    
1 
 

For patients seeking permanent residential care in an aged care facility and where Centrelink does not have the 
patient s income information the patient/family/carer/guardian is to complete a Residential Aged Care 
Calculation of Your Cost of Care form. Direct the patient to Centrelink if required. 
Note Centrelink will have the patient s income information if the patient receives a means tested income support 
payment or a Home Care Package. Direct the patient to Centrelink if required. 

 Centrelink phone number for Older 
Australians: 132 300 
(Mon   Fri, 8 am   5 pm)   

2 Ensure patient is medically stable and consent has been obtained from the patient/family/carer/guardian to 
progress an ACAT assessment. 
Note if the patient/family/carer/guardian has previously identified an appropriate residential aged care facility 
(RACF) which is available, advocate for ACAT to be prioritised. 

  

4 Provide the patient/family/carer/guardian with access to information about the aged care system.  www.myagedcare.gov.au  
1800 200 422 

5 Request the patient/family/carer/guardian list a minimum of five preferred RACF locations and advise they 
visit a range of RACFs to assist with their preference listing. 

  

6 Direct the patient/family/carer/guardian to the Australian Aged Care Quality Agency if they would like to 
review the facilities they are considering. 

 https://www.agedcarequality.gov.au/re
ports. 

  NDIS (including paediatric patients/participants)  NDIS Hospital Discharge Journey Map 
1 Provide the patient/family/carer/guardian with access to information regarding the NDIS system. 

Note Health staff can also contact their local NDIS Health Liaison Officer (HLO) for further information on, and 
support with, NDIS via SA.Health.liaison@ndis.gov.au. 
Note participants require approval from NDIA prior to exploring residential care options and/or completing an 
ACAT assessment. 

 www.ndis.gov.au 
1800 800 110 
Commonwealth Carer Gateway 
www.carergateway.gov.au 
1800 422 737 

2 Request that the patient/family/carer/guardian complete the NDIS Hospital Discharge consent form.  NDIS Hospital Discharge consent form 
3 If the patient is a prospective NDIS participant, support the patient/family/carer/guardian to complete an 

Access Request Form. 
 Email: nat@ndis.gov.au and enter the 

following in the subject line:  












 
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Appendix 1 
Hospital Team Checklist 
Management of Patients with Complex Needs Requiring Discharge or Transition Placement Policy Directive 

Refer the patient to the National Access Team (NAT) for an Access Decision. A priority pathway has been 
established for access decisions for hospital patients. 

PRIORITY   Urgent decision 
required:&lt;Insert Patient First Name 
and Last Name&gt; 

4 If the patient is an existing participant (access has previously been met) with an increased support need, 
support the patient/family/carer/guardian to complete a Change of Circumstances form, and where 
applicable, a Request for Review. 

  

5 Support the patient/family/carer/guardian to prepare for the planning meeting by discussing the patient s 
change in circumstances, support needs and goals. 

  

6 Direct the patient/family/carer/guardian to NDIS housing information if they are seeking an NDIS 
Accommodation Service. 

 www.ndis.gov.au/participants/housing-
and-ndis 

7 Conduct allied health assessments in preparation for the planning meeting to reflect the patient s level of 
need. Support the patient/family/carer/guardian to engage with their Support Coordinator/Local Area 
Coordinator early in the discharge process. 

  

8 Once a suitable option has been identified, and supports are approved by NDIA, initiate a discharge planning 
meeting with the Support Coordinator. 

 Further details of the hospital 
discharge can be found in the NDIS 
Hospital Discharge Journey Map. 

  FEES   
1 

 
Ensure the patient/family/carer/guardian is provided with information regarding potential fee implications arising 
from an extended stay in hospital. 
The relevant fees include: 

  Long Stay Nursing Home Type (NHT) patient fee - incurred after 35 days of continuous 
hospitalisation. 

  Long Stay NHT patient and the Long Stay NHT Basic Benefit fees - incurred if a patient has been 
admitted as a private patient, after 35 days of continuous hospitalisation. 

  Overnight Stay Fee   incurred if a patient/family/carer/guardian requests and subsequently 
receives single room accommodation. 

 SA Health Fees and Charges Manual 

2 Note each LHN is required to establish its own management and communication processes regarding fees, 
however the approach taken should not interfere with the relationship between the patient and those providing 
care. 

 See Appendix 3: Information for 
Clinicians - Approaching patients 
about a transfer 

3 - Developing a Patient Management Plan  
 Step/Task  ? Related Resource/Action  
  If the patient was earlier identified as requiring referral to geriatric services (to have their current care 

delivered in partnership with a geriatric model), ensure a risk assessment takes place. 
 See 4.4.1 of the Policy Directive (page 

8) 
  It is recognised there are various assessment tools currently being utilised within SA Health that may 

constitute a risk assessment, however the risk assessment is to include key measures of patient functionality, 
such as whether or not: 

  The patient is currently living alone or living alone with additional supports in place; 
  the patient recently presented to hospital requiring treatment (and if yes, why); 
  the patient has significant cognitive impairment/advanced dementia; 
  the patient has significant behavioral concerns, and is potentially at risk of self-harm or risk to 

others; 
  the patient has the capacity to perform basic tasks of daily living; 
  the patient is at high risk of falls; and/or 
  there is progressive deterioration in the patient s physical, mental or functioning status, or whether 

the level of care currently available to the patient indicates that a return to their home is not a 
feasible option. 

  

1  Include estimated discharge date.   
2  Outline the patient s specific needs and care requirements post-discharge, as agreed with the 

patient/family/carer/guardian, which may include: 
  Primary Care needs 
? Links with General Practitioner, community nursing agencies, social worker, peer support groups, 

educational or care supports etc. 
  Home care needs 
? Physical requirements and modifications (including how these will be funded and timeframe for 

completion). 
? Aid and equipment needs (including funding and timeframe). 
? Personal and domestic needs (such as washing, cleaning, shopping, laundry etc). 
? Meal preparation support (e.g. meals on wheels). 
? Transport needs and capacity (e.g. local council, SA Transport Subsidy Scheme, Department of 

Human Services Mobility Allowance). 
? Personal safety needs (including emergency contact information and strategies). 

  Medication needs 
? Education about medication. 

  







 
 OFFICIAL   Page 22 of 25 
 

Appendix 1 
Hospital Team Checklist 
Management of Patients with Complex Needs Requiring Discharge or Transition Placement Policy Directive 

? Dispensing and follow-up/review arrangements. 
  Follow up 
? Plan for appointments post discharge, including outpatients. 

3  Include a list of preferred (and suitable) residential care facilities as nominated by the 
patient/family/carer/guardian. 

 Note where possible 5 RACFs and a minimum of 2 NDIS accommodation sites. 

 See Appendix 4: Patient Information 
Sheet, Residential Aged Care 
Placement 

4 Provide information about the agreed roles post discharge (i.e. hospital, residential care facility, community based 
services, patient/family/carer/guardian). 

  

5 Provide the date/timeframe for ACAT or NDIS assessment (if known) noting that the ACAT assessment is 
contingent on the medical clearance of the patient and Commonwealth Policy. 

  

6 Provide the outcome of the patient s assessment for ACAT or NDIS eligibility.   

4 - Progressing Placement  
 Step/Task ? Related Resource/Action  
  RESIDENTIAL CARE (Over 65 or ATSI over 50 )   
1 Liaise with the patient/family/carer/guardian to enact the actions agreed to in the patient management plan.   
2 Remind the patient/family/carer/guardian that whilst every endeavour will be made to place the patient in their 

preferred location this cannot be guaranteed and alternative transition options may need to be considered. 
  

3 If not already undertaken, encourage the patient/family/carer/guardian to visit RACFs to identify preferred 
locations. 

  

4 Request the patient/family/carer/guardian advises the hospital team of their decision as soon as possible.   
5 If the patient chooses to discharge to a transitional location, ensure they liaise with their preferred RACFs to 

advise of their temporary location and contact details, and to confirm they are still seeking to move to their 
facility. 

  

6 Once the facility has been selected by the patient/family/carer/guardian, liaise with the accommodation provider 
about transfer and discharge arrangements. 

  

  SUPPORTED ACCOMMODATION (PAEDIATRIC) - PREPARING FOR TEMPORARY STEP DOWN   
 Liaise with the patient/family/carer/guardian to enact the actions agreed to in the patient management plan.   
 Remind the patient/family/carer/guardian that whilst every endeavour will be made to place the patient in their 

preferred location this cannot be guaranteed, and that alternative options may need to be considered. 
  

 Once the facility has been selected by the patient/family/carer/guardian, liaise with the accommodation provider 
about the transfer and discharge arrangements. 

  

 Liaise with the patient/family/carer/guardian regarding discharge arrangements including transport requirements 
etc. 

  

  RETURNING HOME   
1 Liaise with the patient/family/carer/guardian to enact the actions agreed to in the patient management plan.   
2 Discuss the home care needs that have been identified in conjunction with the patient/family/carer/guardian, 

including but not limited to: 
  Physical requirements and modifications; 
  aid and equipment needs; 
  personal and domestic needs (such as washing, cleaning, shopping, laundry etc.); 
  meal preparation support (e.g. meals on wheels); 
  transport needs and capacity (e.g. local council, SA Transport Subsidy Scheme, DHS Mobility 

Allowance*); and 
  Personal safety needs (including emergency contact information and strategies). 

Note *DHS Mobility Allowance is not available for NDIS participants. Please refer to www.servicesaustralia.gov.au 
for eligibility requirements. 

  

3 Liaise with the patient/family/carer/guardian regarding discharge arrangements, including transport 
requirements. 

  

4 For NDIS participants, support the patient to engage with their Support Coordinator or Local Area Coordinator to 
implement services. 

  

  DISCHARGE PLANNING MEETING   
1 Once the patient is deemed medically fit for discharge, prepare for a case conference with the 

patient/family/carer/guardian prior to discharge. This is to ensure all aspects that may impact on a successful 
placement have been addressed. 
The following should be prepared in advance: 

  Medical information that supports discharge from hospital. 
  Details about the day of discharge, including transport arrangements etc. 
  Handover, discharge and contact information for all individuals/agencies responsible for providing 

care or support post-discharge. 
  Information about the roles and responsibilities for agencies and services providing care post-

discharge. 
  Information related to the residential care facility, SIL facility, SDA or community based service 

providers. 

  




 
 OFFICIAL   Page 23 of 25 
 

Appendix 1 
Hospital Team Checklist 
Management of Patients with Complex Needs Requiring Discharge or Transition Placement Policy Directive 

  Information and education about medication post-discharge. 
  Review and follow up appointments, including frequency. 
  Information for the patient/family/carer/guardian at time of discharge (e.g. My Hospital Discharge to 

Community Plan). 
  Information about the circumstances in which the patient should visit the emergency department 

post-discharge. 
  Information to prevent avoidable readmission to hospital, including services and strategies to support 

successful transition (e.g. Rapid Access Service and Dementia Australia Severe Behaviour Response 
Teams (SBRT) or appropriate complex support plan for paediatrics). 

  Strategies if the patient presents to hospital for re-admission shortly after discharge. 
2 Following the case conference, complete the My Hospital Discharge to Community Plan.  See Appendix 6 and 7: My Hospital 

Discharge to Community Plan (Adult 
and Paediatric) 

5   Addressing Barriers to Discharge 
 Step/Task ? Related Resource/Action  
1 Identify the barriers or delays affecting timely discharge or transition placement.   
2 If the barriers or delays relate to accommodation, other supports and requirements, applications, or approvals 

and access, work with the relevant agencies and departments, using established relationships and escalation 
procedures, to expedite processes where possible and support the patient towards timely discharge. 

  

3 If the barriers or delays are associated with accessing residential care, consider options such as the Care Awaiting 
Placement (CAP) Program, respite, transfer to a peri-urban hospital, TCP, appropriate supported 
accommodation, or other community supports. 

 See 4.9 of the Policy Directive (page 
13) 

4 If the barriers or delays relate to the patient/family/carer/guardian, work with them towards a resolution. This 
may require a case conference. Ensure the patient/family/carer/guardian: 

  Is given the opportunity to discuss the barriers to placement from their perspective. 
  Is aware that their discharge and placement is appropriate for their care needs. 
  Is advised that they no longer require hospitalisation and that public hospitals treat people who are 

acutely unwell and need specialist care, so they will not be able to stay in hospital. 
  Is aware of the benefit in visiting placement offers as soon as possible (preferably within 24 hours) of 

being notified of the vacancy, and to accept the placement as soon as possible once they have 
confirmed its suitability. 

  Is advised that whilst waiting for a suitable placement, and depending on their specific care needs, 
they may be: 
- Discharged home with support; 
- discharged to a temporary placement; 
- transferred to another (less acute) hospital. 

  Is advised that further delays will be escalated to the Divisional Director (or similar) or the COO of the 
LHN. 

Work with the patient/family/carer/guardian to develop an action plan which includes timeframes to address 
barriers and an agreed target discharge date. Summarise the outcomes of the case conference in the patient s 
notes, including process to date and escalation details. 

 See Appendix 8: Delayed Discharge 
Patient Placement Pathway 

6   Escalating Continuing Delayed Discharge  
 Step/Task ? Related Resource/Action  
1 If there is: 

  No progress regarding accommodation, other supports and requirements, applications, approvals etc. 
within a reasonable timeframe following the planned actions; or 

  the hospital team has been unable to achieve any progress in escalating matters with the relevant 
agency or department; or 

  there has been no follow up by the patient/family/carer/guardian within 24 hours of any agreed 
actions; or 

  a dispute or disagreement remains between the hospital team and the patient/family/carer/guardian; 
Then the following should occur: 

  The hospital team is to advise the Divisional Director (or similar); 
  where appropriate, the Divisional Director (or similar) is to advise the COO who may discuss concerns 

with the OPA where relevant; and 
  The Divisional Director (or similar) is to consider whether it is appropriate to charge a fee for length of 

stay exceeding 35 days when the patient is post-acute, and apply the local process and procedure. 

 See Appendix 8: Delayed Discharge 
Patient Placement Pathway 

2 For NDIS (including paediatric patients) 
In addition to the above, if there is: 

  No progress regarding NDIS eligibility, plan progress and NDIS approvals (including accommodation, 
other services/supports, home modifications or assistive technology) within a reasonable timeframe; 
and 

 See 4.10 of the Policy Directive (page 
16) 



 
 OFFICIAL   Page 24 of 25 
 

Appendix 1 
Hospital Team Checklist 
Management of Patients with Complex Needs Requiring Discharge or Transition Placement Policy Directive 

  the hospital team has been unable to achieve any progress in escalating matters at a local level 
including contacting Local Area Coordinator, Support Coordinator and NDIS HLO; 

The following should occur: 
  the hospital team refer to the LHN NDIS Site Representative; 
  if the LHN NDIS Site Representative is unable to resolve the issues locally, escalate to the NDIS HLO; 
  if the LHN NDIS Site Representative and NDIS HLO are unable to resolve the issues locally, escalate to 

the LHN NDIS Site Working Group Representative and State Health NDIS Representative; 
  the State Health NDIS representative will escalate the issue to the NDIS Service Delivery team and 

provide feedback to the LHN site representatives; 
  if there is no response or progress within 1 month of the action escalation to the NDIS Service Delivery 

Team, the State Health NDIS representative will escalate to the Critical Incident Service Response 
Team. 

3 Aged Care 
If the patient is waiting for residential care in a RACF, declines more than one suitable offer, and all options in 
section 4.9 of this Policy Directive (page 14) have been considered, then the hospital team is to refer to section 
4.10 of this Policy Directive (page 16). 

  

7   Options for Managing Delayed Discharge to Residential Care 
 Step/Task ? Related Resource/Action  
 There are a range of options available to manage delayed discharge for patients who: 

  Are awaiting placement in a RACF; 
  have accepted an offer of placement, however the placement location is not ready for the patient to 

be transferred; 
  have declined suitable offers for placement; or 
  have completed their acute or sub-acute episode of care and are medically fit for discharge. 

Options 1-5, including eligibility, are outlined on pages 14-16 of the Policy Directive 

 See 4.9 of the Policy Directive 

8   Declined Placement Offers and Refusal to Discharge 
 Step/Task ? Related Resource/Action  
 In the event that the patient/family/carer/guardian declines more than one suitable placement offer that meets 

most of their needs, and the patient/family/carer/guardian is unable to provide a reasonable explanation why the 
placement is not suitable, advise the patient that they will need to consider discharge to a short-term, transition 
placement whilst waiting for their preferred location. 

  

 Arrange a case conference and prepare correspondence to the patient/family/carer/guardian which as a 
minimum: 

  References the most recent case conference; 
  reinforces that the patient s needs are the priority for the placement; 
  confirms that the patient is medically fit to be discharged; 
  acknowledges if the patient is being placed in a location that is not the patient/family/carer/guardian s 

preferred location for placement, and provides a commitment to work towards moving the patient to 
their preferred location; 

  provides the location of the interim placement and type of accommodation (RACF/ NDIS 
accommodation or private residential address); 

  provides information about the specific support strategies, modifications, equipment and/or 
community based agencies required and provided to address their specific needs post discharge; 

  provides the date of discharge and advises that there will be a fee for length of stay charged after the 
discharge date; 

  provides the name and contact details of the care coordinator assisting post-discharge, including the 
frequency of meetings following discharge to monitor their health needs, care requirements and 
supports in place to ensure their health and wellbeing; 

  provides information about discharge arrangements including transport etc.; and 
  references the My Hospital Discharge to Community Plan. 

 See Appendix 6 and 7: My Hospital 
Discharge to Community Plan (Adult 
and Paediatric) 
 
See Appendix 12 and 13: Letter for 
Discharge(Adult and Paediatric) 

 If the patient/family/carer/guardian continues to decline the offer, and refuses to agree to arrangements to 
progress the placement, prepare a brief for the LHN COO, with a CC to the Deputy Chief Executive 
Commissioning and Performance, Department for Health and Wellbeing to seek approval to proceed. 
The briefing is to include the following as a minimum: 

  Patient history including complexities and barriers to discharge. 
  Location of placement offer/s. 
  Reason for declined placement (if provided). 
  ACAT or NDIS eligibility. 
  Discharge preparations including details regarding primary care, home care, medication, follow up, 

communication etc. post-discharge. 
  Agencies providing care post-discharge. 

  



 
 OFFICIAL   Page 25 of 25 
 

Appendix 1 
Hospital Team Checklist 
Management of Patients with Complex Needs Requiring Discharge or Transition Placement Policy Directive 

  Staff involved. 
  Relevant dates regarding discharge/placement. 
  Draft correspondence to the patient regarding discharge details. 
  An outline of the escalation strategies already implemented. 
  Legal advice if already sought. 
  Proposed strategy if the patient refuses to leave/discharge on the planned date such as engaging 

security, the South Australian Police or Child Protection Services. 
 



Patient Profile
Over 65 years / Over 50 years ATSI / Disability / NDIS (including paediatric participants) / Complex health needs

Admitted to Hospital

Undertake Risk Assessment within 24 hours

Is the patient likely to require Aged Care, Guardianship Services, additional in-home support, or care respite to be able to be discharged 
from hospital?

Hospital team to:
  Engage Geriatric Team as required
  Conduct psychosocial assessment
  Gather clinical information
  Engage Office of Public Advocate
  Develop Patient Management Plan

Hospital team to:
  Hold planning meeting with patient /

family / carer / guardian to provide
information about potential future
placement options

Is the patient medically fit for discharge?Will the patient be discharged to the 
community with support OR to a RACF?

Hospital team to:
  Provide patient information sheets
  Arrange family conference
  Enact Patient Management Plan
  Refer for ACAT or NDIS

Discharge patient with home and family 
support / care.

Commence ACAT assessment in the 
community if required.

Continue providing 
required care

Are there delays in the assessment?

Refer to
Sections 4.6 and 4.7 of 

the Policy Directive 
(pages 11 to 13)

See Appendix 5 
Patient 

Placement 
Pathway

YES NO

NONO

YES YES

YES NO

OFFICIAL  Page 26 of 26



Appendix 3 Information for Clinicians 

    OFFICIAL   Page 27 of 28 

Approaching patients about 
a transfer (adult) 
The purpose of this document is to assist you in talking to a patient about a transfer to 
another service, to ensure that all patients are being provided services from the most 
appropriate location.   

When talking to patients about transfers it is important to explain: 

  SA Health delivers services to patients from hospitals across the public health
system and the hospital the patient is currently in is just one part of the whole
system.

  It is common practice for patients to be moved between services in the health
system according to their care needs. This is to ensure they are located in the
best place for their care to be provided. This message becomes even more
important during periods of high demand for services.

  In managing the large number of patients seeking hospital care, SA Health
transfers patients to community hospitals to continue their care and recovery
whilst awaiting a place in another service facility. Transfers also occur for patients
that still require care before they are ready to go home, but who no longer need
the services provided by an acute hospital.

In approaching a patient about a planned transfer, it is important that they receive a full 
explanation of the purpose of the transfer, an assurance that their care and safety will 
be maintained, and the benefits of the transfer for the patient and the whole health 
system, to alleviate any concerns. 

The following key messages have been developed to assist you with these 
conversations. 

Key Messages 
Moving people through the health care system is necessary to ensure that all patients 
who require care from a busy acute hospital can access that care when they need it.  

The following points should be emphasised to patients, their families and/or 
representatives where relevant: 

&gt; Ascertain where the family of the patient currently travels to and from when visiting
the patient, and if the family has access to transport (private car). If the proposed
community hospital is not more than 20 kilometres or 20 minutes further for them to
visit compared to their current travel time, the minimal increase in travel time should
be highlighted.
For example: at the moment it takes your wife 20 minutes to get to the hospital, it
will only take her another 5-10 minutes to get to [enter community hospital name].

&gt; Car parking is free and much more accessible at [enter community hospital name]
and is close to the hospital main entrance.

&gt; There are a number of community hospitals in our health system. Wherever
possible every endeavour to find the best match to your specific location needs will



    OFFICIAL   Page 28 of 28 

be made, however while preferences will be considered, it is your care needs and 
the available hospital options at any given time which will determine the decision.  

&gt; Generally community hospitals are not as busy as metropolitan hospitals, so you
will quickly get to know all of the nurses and also your doctor, who will be able to
provide personalised care and support for the remainder of your treatment and
recovery.

&gt; Community hospitals are equipped to provide a range of therapies and wellness
services that are not ordinarily available in busy metropolitan hospitals. The care
you will receive at a community hospital is provided in a supported environment.

&gt; We will organise your transportation to your new hospital and ensure that someone
is there to receive you and get you settled upon your arrival.

&gt; Your family will be able to visit your new hospital anytime during visiting hours.

&gt; If you or your family have any questions or would like more information please let
us know.

Additional Information 
Ensure patients, their family and/or representatives have been provided with any other 
documents relevant to the patient s circumstances. Including but not limited to: 

&gt; Patient Information Sheet - Receiving your care in SA Health hospitals

&gt; Frequently Asked Questions- Transfer to another hospital

&gt; Patient Plan - My Hospital Transfer Plan



Appendix 4  Patient Information Sheet 

OFFICIAL   Page 29 of 30 

Residential Aged Care 
Placement 
South Australian public hospitals treat people who are acutely unwell and need 
specialist care. As soon as patients are medically fit, it is important that they are 
discharged to community services if ongoing support is required. For some, this place 
in the community will be a residential aged care facility. Hospital staff are committed to 
ensuring that both you and your family receive the best possible assistance in finding 
and securing a suitable residential aged care facility placement. 

General Information 

Early in your hospital admission staff will discuss, with you and your family, planning 
for your discharge to a community service; such as a residential aged care facility. If 
your hospital discharge is likely to require you moving to a residential aged care 
facility, there is a lot of information that you and your family will need to consider. 

Finding a suitable residential aged care facility placement 

Hospital staff will meet with you and provide you with information about finding a 
suitable residential aged care facility placement. This will include providing you with a 
list of residential aged care facilities. Assistance will be available for you to find and 
apply for facilities that can provide the care and support that you need. 

Once you identify several preferred facilities, you and your family will need to 
commence discussions with the facility staff to arrange a time to meet and discuss 
your requirements as soon as possible. This planning will ensure that when you are 
medically fit for discharge, your transfer to a residential aged care facility will not be 
delayed. 

What happens if my preferred residential aged care facility is not 
available? 
Please know that when you are medically fit for discharge every endeavour will be 
made to assist you to arrange a placement in your first preferred residential aged care 
facility. 

However, you are asked to identify several preferred facilities because sometimes 
rooms are not immediately available in your most preferred; this may include the 
facility where your partner resides. 

In times when first preferred facilities on your list do not have a room available in the 
foreseeable future, then other options will need to be considered, for example, other 
facilities on your list that currently have a room available. If this situation occurs it is 
considered to be fair that you accept the first appropriate placement offered to you, 
keeping in mind that you have the ability to move to your first preferred facility at a 
later date. 



OFFICIAL   Page 30 of 30 

If a placement cannot be confirmed in any facility on your list, we will seek to find an 
alternative facility for you to be transferred to until one of your preferences is achieved. 

Where appropriate you may be relocated from an acute metropolitan hospital to a 
community hospital. Community hospitals are equipped to provide specialised aged 
care services including aged care, therapies and wellness activities that are not 
always readily available in acute hospitals.  

The transfer to a community hospital equipped with aged care services will ensure you 
receive specialist care and support in a more home-like environment whilst awaiting 
placement. We will organise every step of your transfer to a community hospital as 
well as your transfer to your residential aged care facility placement when available. 

Every endeavour will be made to transfer you to a location closer to your home or your 
family, however at times this may not be possible. 

Another option that you and your family can consider is to discharge home to the care 
of your family with additional support services whilst awaiting a suitable facility 
placement. 

If a suitable placement has not been secured within 35 days of your admission to 
hospital, the hospital is required to charge you a fee to remain in hospital. This fee is 
comparable to the daily fee at a residential aged care facility. 

Where can I find out more about residential aged care placement? 

There is a lot of information available to you and your family about Aged Care 
Services. Please ask hospital staff for this assistance. 

Additionally, the Commonwealth Government has developed the My Aged Care 
website www.myagedcare.gov.au which has resources to assist in your decision 
making. A helpline is also available to you and can be contacted on 1800 200 422. 




Patient Profile
Over 65 years / Over 50 years ATSI / Disability / NDIS (including paediatric participants) / Complex health needs who is to be discharged to a community placement with additional 

support or to a RACF
OR

ACAT or NDIS assessment complete and patient eligible for NDIS funding to support independent living, placement in a RACF or appropriate supported accommodation

Hospital team to:
  Clarify that it is expected the patient will accept the first suitable placement offered;
  Advise that the patient s needs are the priority for the placement.

Has the patient / family / carer / guardian identified several preferred RACFs or community locations for placement?

Is there a placement available in the preferred location / RACF?

Are there any potential barriers to discharge?

Hospital team to 
discuss alternative 

placement options 
with patient / family / 

carer / guardian

Is another 
suitable 

placement option 
available?

If required, put 
additional 

supports in place 
for patient

Has the patient accepted the placement?

Is the placement location ready?

Refer to
Sections 4.6 and 4.7 of the 

Policy Directive
(pages 11 to 13)

Arrange discharge 
using Transfer to RAC 

Policy Guideline

Refer to Management of Patients with 
Complex Needs Requiring Discharge or 

Transition Placement Policy Directive

YES NO

YES NO

YES

NO

YES

NOYES

YES NO

OFFICIAL  Page 31 of 31



OFFICIAL: Sensitive//Personal privacy Page 32 of 32 
Patient Plan   My Hospital Discharge to Community Plan (adult) 
  Department for Health and Wellbeing, Government of South Australia. 
All rights reserved.  FIS: 16092.1  Developed July 2017 www.ausgoal.gov.au/creative-commons 

You are now medically fit for discharge.  
It is common for patients to be discharged to the community with appropriate community services in place according to 
their individual care needs. 
This plan is a record of how this will happen for you. 

Details of your community location after 
discharge: 

Contact details following discharge: 

enter name, address, phone 

Name and contact details of community support 
service: 

enter service name, address, phone 

Details of community support to be provided: 

enter support to be provided including hours per week 

Planned discharge date: 

enter discharge date 

Name and contact details of other community 
support service: 

enter name, address, phone 

Details of support to be provided: 

enter support to be provided including hours per week 

Other strategies (e.g. home modifications, 
transport, meals): 
enter details of other strategies 

Planned discharge time: 

enter scheduled discharge time 

Planned transport for discharge: 

enter discharge mode 

Where applicable 
Patient representative aware of discharge plan (e.g. Legal Guardian) 

enter name / status of patient representative, contact details 

Doctor / GP details: 
Doctor / GP accepting handover at discharge: enter name, contact details 

Admitting Doctor / GP: enter name, contact details 

You are being discharged from: 
Your hospital contact for any questions about your discharge: 

enter hospital name

enter contact details of the designated person from the discharge planning / support team 

enter address, phone 

Appendix 6
My Hospital Discharge to Community Plan (Adult) 
Management of Patients with Complex Needs Requiring Discharge or Transition Placement Policy Directive 



OFFICIAL: Sensitive//Personal privacy Page 33 of 33 
Patient Plan   My Hospital Discharge to Community Plan (Paediatric) 
  Department for Health and Wellbeing, Government of South Australia. 
All rights reserved.  FIS: 16092.1  Developed July 2017 www.ausgoal.gov.au/creative-commons 

Your child is now medically fit for discharge.  
It is common for patients to be discharged to the community with appropriate community services in place according to 
their individual care needs. 
This plan is a record of how this will happen for your child. 

Details of your child s location after discharge: 

Contact details following discharge: 

enter name, address, phone 

Name and contact details of community support 
service: 

enter service name, address, phone 

Details of community support to be provided: 

enter support to be provided including hours per week 

Planned discharge date: 

enter discharge date 

Name and contact details of other community 
support service: 

enter name, address, phone 

Details of support to be provided: 

enter support to be provided including hours per week 

Other strategies (e.g. home modifications, 
transport, meals): 
enter details of other strategies 

Planned discharge time: 

enter scheduled discharge time 

Planned transport for discharge: 

enter discharge mode 

Where applicable 
Patient representative aware of discharge plan (e.g. Parent / Legal Guardian) 

enter name / status of patient representative, contact details 

Doctor / GP details: 
Doctor / GP accepting handover at discharge: enter name, contact details 

Admitting Doctor / GP: enter name, contact details 

Your child is being discharged from: 
Your hospital contact for any questions about your child s discharge: 

enter hospital name

enter contact details of the designated person from the discharge planning / support team 

enter address, phone 

Appendix 7
My Hospital Discharge to Community Plan (Paediatric) 
Management of Patients with Complex Needs Requiring Discharge or Transition Placement Policy Directive 



Patient Profile
Over 65 years / Over 50 years ATSI / Disability / NDIS (including paediatric participants) / Complex health needs who is to be discharged to a community placement with additional 

support or to a RACF
OR

ACAT or NDIS assessment complete and patient eligible for NDIS funding to support care accommodation (paediatrics) or independent living or placement in a RACF
Hospital Team to identify potential barriers to discharge which may include:

  Hospital team unable to make contact with family / carer / guardian OR
  non-attendance at case conference meetings / no response to correspondence OR
  no preferred placement options available OR
  a suitable placement has been offered but not accepted (not the patient s preferred location)
  frequent changes to plan / lack of suitable options / lack of flexibility regarding placement OR
  difficulty accessing equipment / arranging home modifications / arranging services OR

Escalate to Divisional Director OR notify the COO for complex discharge requirements.

Convene a case conference with the patient / family / carer / guardian and ensure that the patient / family / carer / guardian:
  Is given the opportunity to explain their perceived barriers to placement;
  understands their discharge and placement is appropriate to their needs and they no longer require hospitalisation;
  is advised that public hospitals treat people who are acutely unwell and understands the requirement to visit available placements within 24 hours where possible;
  understands they will be discharged home with support to wait for suitable permanent placement, or be transferred to another hospital;
  Is aware of the potential fees associated with staying in hospital.

Is the patient likely to refuse to leave hospital on the 
planned discharge date?

Has the patient refused one or more offers for 
placement?Has any follow up with patient occurred since the case conference?

Communicate to patient as 
required

Divisional Director to advise 
whether it is appropriate to 

charge a fee for length of 
stay exceeding 35 days 

when patient is post-acute

Is there ongoing dispute or 
disagreement between the patient /

family /carer / guardian and hospital 
regarding placement?

Has the patient 
accepted a 

placement?

Arrange 
discharge using 

Transfer to RAC 
Policy Guideline

Refer to
sections 4.9 and 4.10 of the Policy 

Directive
(pages 14 to 17)

Hospital team to continue to progress towards discharge in collaboration with patient / family / carer / guardian

Hospital team to:
  Consider strategy if patient refuses to

discharge;
  liaise with DHW Legal Unit, if needed,

when consideration is given to engaging
Security, SAPOL services or Child
Protection Services;

  Brief LHN COO, DCE SA Health and
Minister/s as appropriate.

YES NO

NO

YES NOYES

YES YESNO

OFFICIAL  Page 34 of 34



Note for Clinicians: Document outcome of discussion in the patient s health record

is equipped to provide the healthcare you 
need to continue your health recovery.

It is common for patients to be transferred to other hospitals or services according to their individual care needs and where this 
care can best be provided. This plan is a record of how this will happen for you.

You are being transferred from  
Your hospital contact for any questions about your transfer:

Doctor / GP details:

Doctor / GP accepting handover:

Admitting Doctor / GP:

Details of the hospital you will be transferred to: Name and contact details of care facility you will be 
transferred to:

Planned ward: Key contact at care facility:

Planned transfer date: Planned transfer date:

Planned transfer time: Planned transfer time:

Planned transport: Planned transport:

Where applicable: Patient representative aware of transfer plan ? e.g. Legal Guardian; Substitute Decision Maker

Adult Patient Plan

My Hospital Transfer Plan

OFFICIAL: Sensitive//Personal privacy

Patient Plan   My Hospital Transfer Plan (Adult and Elderly)
  Department for Health and Ageing, Government of South Australia. All rights reserved.   FIS: 17122.1   Printed September 2017.

www.ausgoal.gov.au/creative-commons

 Page 35 of 35



Note for Clinicians: Document outcome of discussion in the patient s health record

is equipped to provide the healthcare and 
support that your child needs to continue their health recovery

It is common for patients to be transferred to other hospitals or services according to their individual care needs and where this 
care can best be provided. This plan is a record of how this will happen for your child.

Your child is being transferred from:  
Your hospital contact for any questions about the transfer:

Doctor / GP details:

Doctor / GP accepting handover:

Admitting Doctor / GP:

Details of the hospital your child will be transferred to: Planned Admission Ward:

Planned transfer date: Planned transfer time:

Planned transport mode:

Family and/or staff members accompanying child during transfer

Where applicable: Patient representative aware of transfer plan ? e.g. Legal Guardian; Substitute Decision Maker

Paediatric Patient Plan

My Hospital Transfer Plan

OFFICIAL: Sensitive//Personal privacy

Patient Plan   My Hospital Transfer Plan (Paediatric)
  Department for Health and Ageing, Government of South Australia. All rights reserved.   FIS: 17122.2   Printed September 2017.

www.ausgoal.gov.au/creative-commons

 Page 36 of 36



OFFICIAL

General Escalation

The hospital team is to 
advise the Divisional 

Director (or similar)

Aged Care Escalation

Escalation Triggers

LHN: Local Health Network
COO: Chief Operating Officer

DCE: Deputy Chief Executive Officer
NDIS: National Disability Insurance Scheme

HLO: Health Liaison Officer
SIL: Supported Independent Living 

SDA: Specialist Disability Accommodation
RACF: Residential Aged Care Facility

Early identification, intervention and 
management of barriers and delays to timely 

discharge is required for patients who have 
been admitted to a metropolitan public 

hospital and are considered unlikely to be 
able to leave hospital without additional 

support.

These are patients who: 
  have been assessed as eligible for

permanent residential care or other 
services

  have been assessed as eligible for 
community based supports

  are seeking to be discharged to
permanent residential aged care or home
with community based supports.

Where delays occur, activation of the 
escalation process will enable a more effective 

and timely response to the situation.

Key

Patients with Complex Needs Requiring 
Discharge

In addition to the Escalation Triggers in Box 1, if the patient has:
  Accepted an offer of placement in a RACF however the placement location is not ready for the patient to be transferred; or

  declined suitable offers for placement.

If there is: 
  No progress regarding accommodation,

other supports and requirements, 
applications, approvals etc. within a 
reasonable timeframe following the 
planned actions; or

  the hospital team has been unable to
achieve any progress in escalating 
matters with the relevant agency or 
department; or

  no follow up by the patient/family/carer/
guardian within 24 hours of any agreed
actions; or

  a dispute or disagreement remains
between the hospital team and the
patient/family/carer/guardian

The hospital 
team refer to the 

LHN NDIS Site 
Representative

If the patient is waiting for NDIS SIL and/or 
SDA and declines more than one suitable 

offer, the hospital team is to arrange a case 
conference and prepare correspondence to 

the patient/family/carer/guardian

In addition to the Escalation Triggers in Box 1, 
if there is: 

  No progress regarding NDIS eligibility, 
plan progress and NDIS approvals 
(including accommodation, other services/
supports, home modifications or assistive 
technology) within a reasonable 
timeframe; and

  the hospital team has been unable to 
achieve any progress in escalating 
matters at a local level including 
contacting Local Area Coordinator, 
Support Coordinator and NDIS Health
Liaison Officer.

If the patient is waiting for residential care in an aged care 
facility and declines more than one suitable offer, the 

hospital team is to arrange a case conference and prepare 
correspondence to the patient/family/carer/guardian

If the patient/family/carer/guardian continues to decline the 
offer, and refuses to agree to arrangements to progress the 

placement, the hospital team is to prepare a brief for the LHN 
COO, with a CC to the DCE to seek approval to proceed.

OPTION 1: Care Awaiting Placement 
Program (CAP): 

  For patient s waitlisted for a RACF 
with a delay in transfer determined
to be overcome within 21 days.

  If a patient has been approved for 
the CAP program, hospital staff are
to refer to the CAP Pathway and 
Escalation Process Flowchart 
within the Care Awaiting Placement
Program Policy Directive.

OPTION 4: Transition Care Program 
(TCP): 

  Short term care (maximum 12
weeks, with possible extension 
for additional 6 weeks) which 
seeks to optimise the 
functioning and independence of
older people following a hospital 
stay.

  TCP can occur in a residential
or community setting.

OPTION 5: Other Community 
Supports: 

  Community supports 
include both 
Commonwealth and State
funded services that 
facilitate both supported 
discharge and hospital 
avoidance focused on 
rehabilitation, short and
long term care

Where appropriate, the Divisional 
Director (or similar) is to advise the COO 

who may discuss concerns with the 
Office of the Public Advocate (OPA) 

where relevant.

The Divisional Director (or similar) is to 
consider whether it is appropriate to 

charge a fee for length of stay 
exceeding 35 days when the patient is 

post-acute, and apply the local process 
and procedures.

NDIS (including paediatric participants) Escalation

if the LHN NDIS 
Site Representative 

is unable to resolve 
the issues locally, 

escalate to the 
NDIS HLO

If the LHN NDIS Site 
Representative and HLO 

are unable to resolve the 
issues locally, escalate to 

the LHN NDIS Site Working 
Group Representative and 

State Health NDIS 
Representative.

The State Health NDIS 
Representative will 

escalate the issue to 
the NDIS Service 

Delivery Team and 
provide feedback to 

the LHN Site 
Representatives.

If there is no response or 
progress within 1 month of the 

action escalation to the NDIS 
Service Delivery Team, the 

State Health NDIS 
Representative will escalate to 

the Critical Incident Service 
Response Team.

If the patient/family/carer/guardian continues to decline 
the offer, and refuses to agree to arrangements to 

progress the placement, the hospital team is to prepare a 
brief for the LHN COO, with a CC to the DCE to seek 

approval to proceed.

OPTION 2: Respite: 
  Short term care limited 

to a maximum of 63
days per financial year, 
providing additional 
support to the patient or
their carer. 

  Support can be provided
formally or informally, in 
a residential or 
community setting.

OPTION 3: Transfer to a Peri-
Urban Hospital: 

  Ongoing patient care while 
awaiting Residential Care 
placement.

  Care provided in a hospital 
setting equipped with 
providing specialist care in 
a less busy and more
home-like environment than
an acute metro hospital.

Page 37 of 37



OFFICIAL: Sensitive//Medical in confidence 

Page 38 of 38 

Dear XXXXXX 

As discussed at your Case Conference held on [INSERT DATE] you are now medically fit 
for discharge from [INSERT HOSPITAL NAME]. 

We acknowledge that your preference is to [INSERT PREFERRED LOCATION] for the 
purpose of [INSERT REASONS].  We respect this choice and are working towards this 
outcome for you.    

Whilst we are working towards moving you to your preferred location, you will be 
discharged to [INSERT ADDRESS/TYPE OF ACCOMMODATION], and you will receive 
community based support for your specific needs.  This support includes [INSERT 
STRATEGIES / MODIFICATIONS / AGENCIES PROVIDING COMMUNITY BASED 
SUPPORT].     

The enclosed Hospital Discharge to Community Plan details the information related to your 
discharge on [INSERT DATE] including contact and transportation details and information 
about the community support you will receive at home.   

Our Care Coordinator will meet with you [INSERT FREQUENCY] after your discharge to 
monitor your health needs, care requirements and the supports in place to ensure your health 
and wellbeing.    

Please contact [INSERT] if you have any questions about your discharge arrangements. 

Yours sincerely,   

Appendix 12
Letter for Discharge (Adult) 
Management of Patients with Complex Needs Requiring Discharge or Transition Placement Policy Directive 



OFFICIAL: Sensitive//Medical in confidence 

Page 39 of 39 

Dear [INSERT NAME OF PARENT/GUARDIAN] 

As discussed at your child s Case Conference held on [INSERT DATE], [INSERT CHILD S 
NAME] is now medically fit for discharge from [INSERT HOSPITAL NAME]. 

Your child will be discharged to [INSERT ADDRESS/TYPE OF ACCOMMODATION], 
and will receive community based support for their specific needs.  This support includes 
[INSERT STRATEGIES / MODIFICATIONS / AGENCIES PROVIDING COMMUNITY 
BASED SUPPORT].  

The enclosed Hospital Discharge to Community Plan details the information related to your 
child s discharge on [INSERT DATE], including contact and transportation details and 
information about the community support they will receive at home. 

Our Care Coordinator will meet with you and [INSERT CHILD S NAME] [INSERT 
FREQUENCY] after discharge to monitor [INSERT CHILD S NAME] s health needs, care 
requirements and the supports in place to ensure [HIS/HER] health and wellbeing. 

Please contact [INSERT] if you have any questions about your child s discharge 
arrangements.  

Yours sincerely, 

Appendix 13
Letter for Discharge (Paediatric) 
Management of Patients with Complex Needs Requiring Discharge or Transition Placement Policy Directive 


	1.0 V3 Policy Directive-Management of Complex Patients 20191004
	1.1 Amalgamated Appendices
	1.01 Appendix 1 - Hospital Team Checklist
	1.02 Appendix 2 - Early Identification Placement Pathway
	1.03 Appendix 3 - Information for Clinicians_Approaching Patients RE Transfer
	Key Messages
	Additional Information

	1.04 Appendix 4 - Patient Information Sheet_Residential Aged Care Placement
	1.05 Appendix 5 - Patient Placement Pathway
	1.06 Appendix 6 - Draft_My Hospital Discharge Plan - Patient Plan_Adult
	1.07 Appendix 7 - Draft_My Hospital Discharge to Community - Patient Plan_Paediatric
	1.08 Appendix 8 - Delayed Discharge Patient Placement Pathway
	1.09 Appendix - My Hospital Transfer Plan_Adult
	1.10 Appendix - My Hospital Transfer Plan_Paediatric
	1.11 Appendix 11 - Escalation Flowchart
	1.12 Appendix 2 - EXAMPLE Letter for Discharge_Adult
	1.13 Appendix 3 - EXAMPLE Letter for Discharge_Child

	See Appendix 6 and 7: My Hospital Discharge to Community Plan (Adult and Paediatric)



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