Hospital to Home
What is Hospital to Home?
Hospital to Home is a coordinated support pathway for people who are in hospital, with or without an NDIS plan, and need help planning a safe and supported return to the community.
It is for people at risk of a delayed, unsafe or unsupported discharge, and for people who need income, housing, assistive technology, home modifications or community supports coordinated as they leave hospital.
Who this pathway is for
- People in hospital, with or without an NDIS plan, where discharge planning or interim supports are required
- People at risk of delayed, unsafe, or unsupported discharge
- People transitioning from hospital back into the community who need income, housing, assistive technology, home modifications, or community supports
How we may help
- Coordinate discharge planning together with hospital and community teams
- Connect people to income supports such as the Disability Support Pension
- Support referrals, applications and coordination relating to housing, assistive technology and home modifications, working alongside the responsible services and decision-makers
- Focus on safety, continuity of care, and reducing avoidable re-hospitalisation
- NDIS plan
- You do not need an NDIS plan to reach out - this pathway supports people with and without one.
- Cost
- This pathway is delivered through Marra Bridge's existing supports - no-cost Case Management (subject to eligibility and capacity) or NDIS-funded Support Coordination - depending on individual circumstances.
- Who we work alongside
- We work alongside hospital discharge planners, treating teams, housing providers, and any existing support coordinator or case manager already involved.
- Service area
- We provide services across the ACT and NSW.
- Response time
- We aim to respond to referrals within 2 business days.
What this pathway does not control or guarantee
- Marra Bridge does not directly provide, fund, approve or guarantee housing, equipment, home modifications or NDIS supports - these decisions sit with the relevant housing authority, funding body or the NDIA
- This pathway does not replace the hospital's own discharge planning team or clinical decision-making
What happens next
You can refer someone, or get in touch to talk it through first. We aim to respond within 2 business days.
Frequently AskedQuestions
We aim to respond to referrals within 2 business days.
Yes. We accept referrals from hospitals, mental health teams, and community organisations.