Podcast highlights: Supporting a person who needs to leave hospital

Communication
A person in hospital will often tell their support coordinator their
main goal is to get out of hospital as soon as possible! Support
coordinators can help the person understand what ‘getting out of
hospital’ can look like by asking questions. When a person says “I want
to go home”, Laura suggests asking follow-up questions such as: What
does that mean to you? What are you going home to? What are your main
concerns? This will help the person articulate their wishes and
priorities so you can start working together to plan a discharge from
hospital.
There can be a lot of information and actions to work through when a
person is in hospital, but it needs to be done at the person’s pace.
Make sure you don’t overload or overwhelm the person with information.
Support coordinators can ask the person how much information they
want, and how they would like to receive it. This might be through a
phone conversation, a written update or being included on email
correspondence. The support coordinator needs to strike a balance
between listening to the person, prompting and supporting them to unpack
what they want, and providing important information in a clear and
sensitive way.
Remember, what’s a priority for one person will not necessarily be a
priority for another person. Make sure you are listening to the person.
Working collaboratively
Building rapport, confidence and respect across teams is an important
part of collaboration. Alex and Laura recommend getting together as
soon as possible with the person and their hospital team so everyone can
understand each other’s roles. With collaboration you can establish
timeframes, allocate responsibilities to reduce duplication, assign
action items, and agree on how frequently you are going to meet and
communicate. Remember to ensure the person is included in these plans
and their voice and wishes don’t get lost.
Sally and her Mum encourage support coordinators to consider how to
best include the participant’s voice during meetings with the hospital
team. An example they shared is pre-recording a video to communicate the
person’s wishes, which the support coordinator can take to a meeting if
the person and their family are unable to attend.
Support coordinators should have a good understanding of NDIS
principles, operational guidelines and relevant legislation, as well as
showing the person and hospital team just what’s possible with the
NDIS.
Hospital teams are busy and Alex and Laura suggest being proactive in
learning about hospital processes and roles to help build collaborative
working relationships. Working with people in hospital and their
hospital team can also present great learning opportunities for support
coordinators – so be open to learning lots of new information and skills
along the way!
Sometimes it is not clear whether the NDIS or health is responsible
when it comes to disability related health supports. Laura suggests “a
good rule of thumb is if the support is directly related to the person’s
disability and the support is ongoing, it is likely to be able to be
funded by the NDIS”.
Laura and Alex have found getting funding for disability related
health supports can involve extra time and obstacles. It can be helpful
to work with the hospital team to come up with a solution, so this can
be presented to the NDIS in line with reasonable and necessary criteria
and COAG principles of responsibility.
Help a person understand their housing and support needs and preferences
Alex and Laura encourage support coordinators to help the person think holistically about what their future will look like when they do move out of hospital. This can help the person articulate what they want their housing to look like and what their priorities are.
Hospital teams do a lot of work to understand a person’s support needs, but in hospital a person does not get a lot of say about flexibility over their routine – for example, what time they can have a shower. Part of the support coordinator’s role is to let people know that once they leave hospital, they will have more choice and control about how, when and who supports them.
Laura and Alex suggest encouraging the person to think about their lifestyle outside of hospital, so a support model can be designed around this. Ask questions like: What’s important to you in your everyday life? Which aspects of this do you need support with? What do you want to be able to do? What role will family and informal supports play?
Understanding this, support coordinators can build a support model around the person.
Sometimes a person cannot return to living in their previous home – it might not be accessible or suitable for their support needs. Support coordinators can help explore new housing. Keep the person at the centre, find out what’s important to them: What do they enjoy about their surroundings? Do they want housemates, or would they prefer to live alone? What would they like to be close to? Alex and Laura use a template for this conversation and record the person’s preferences in how they want to live.
Interim plans
Keep in mind the person’s best long-term housing options may not be
available or ready to move into from hospital. Sometimes short-term or
interim housing may be necessary. In these scenarios, help the person
consider the benefits and risks of staying in hospital versus moving
into interim housing. If interim housing is required, consider using
Medium Term Accommodation (MTA).
Interim plans are usually for 3-6 months and are a collaborative
effort between health and the NDIS. Interim plans can be extremely
helpful when put in place early in a person’s hospital admission as they
allow the support coordinator to become involved early in the discharge
planning process. This means the person, their support coordinator and
their hospital team can work together to make sure everything is in
place to successfully support the person to transition out of hospital.
In Sally’s case, having an interim plan meant her support coordinator
could start working with her hospital team to plan what Sally needed
when she was discharged from hospital. It also allowed Sally’s support
workers to attend the hospital to complete ‘shadow shifts’ with nursing
staff, to learn how to meet Sally’s needs so everyone was confident
Sally could be well supported when she transitioned home. It also meant
Sally could start spending some time away from the hospital ward with
her support team to help her prepare for life after hospital. Both Sally
and Jenny agree this was an integral part of Sally’s successful
transition out of hospital.