A hospital-to-SIL referral should explain the person's preferred living arrangement, daily and overnight support needs, expected discharge timeframe and funding position. Coordinated Care Services (CCS) can discuss whether its supported independent living service is an appropriate option and assess the referral against available accommodation and support capacity. The hospital remains responsible for clinical discharge planning and determining medical readiness.
For a person leaving Canberra Hospital or Queanbeyan Hospital, the first useful step is a coordinated conversation about what life outside the ward will require. A room, a proposed discharge date and a support budget are each part of that conversation. None of them alone establishes that the arrangement is ready.
Submit a hospital-related SIL referral to CCS with consent or appropriate authority, or review CCS supported independent living before contacting the team. This guide is for participants, families, hospital social workers, occupational therapists and support coordinators preparing that discussion. It does not imply that CCS has a formal partnership with either hospital.
The goal is a referral that lets everyone identify what is suitable, what is still missing and who will address it. Clear information can reduce avoidable back-and-forth. An agreed support arrangement still depends on individual assessment, funding, staffing, property suitability and the hospital's discharge process.
Start with the person's preferred destination and daily life
Before discussing an available home, ask where the person wants to live and what matters about that location. They may want to return to familiar surroundings, remain close to family, or maintain a connection with work, culture or community. Those preferences should be visible in the first referral summary.
Discharge planning can become dominated by the immediate need to leave hospital. A provider needs enough information to consider the person's ordinary life as well. Include what a settled week would look like: preferred waking times, important relationships, meaningful activities and the ways the person communicates choices.
Describe the person's involvement in decision-making. Can they join a phone discussion, review photographs, attend a visit or use a communication aid? Do they prefer questions in advance? Who do they want alongside them? Ask the person how information should be shared rather than assuming that the referrer should receive every update.
An appropriate referral also distinguishes a chosen supporter from a person with formal decision-making authority. Record relevant consent and authority accurately. If there is uncertainty, clarify it before asking someone to make commitments on the participant's behalf.
This approach makes the referral more useful to CCS and more recognisable to the person it concerns. The handover should describe an individual with preferences and relationships, as well as the assistance needed for a workable transition.
Check whether SIL is the service you are seeking
SIL concerns support with daily living for someone who needs assistance or supervision across the day and overnight. It is separate from the housing itself. The NDIS guide to supported independent living explains the service and how it differs from specialist disability accommodation.
A person leaving hospital may need a different combination of services. Someone returning to their own home might require scheduled personal care visits and help attending appointments. Another person may need environmental modifications or an accommodation option with features that a particular shared home cannot provide.
State whether SIL has been identified in the person's plan, is being considered, or is one of several possibilities. Avoid presenting a proposed funding outcome as an approved arrangement. If the current plan no longer reflects the person's needs, the hospital and the person's NDIS contacts can identify the relevant planning process.
Where scheduled in-home support appears more appropriate, explore CCS assistance with daily life as part of the enquiry. This gives the intake conversation a useful alternative without assuming that a move into shared accommodation is necessary.
CCS's role in this enquiry is to assess its potential service contribution. Funding decisions, clinical recommendations and housing decisions have their own responsibilities. Making those roles clear early helps prevent a referral being delayed because different people are waiting for the same task to be completed by someone else.
Prepare a concise referral summary before sending reports
A practical initial referral should be short enough for the receiving team to understand the request quickly. Put the purpose, timeframe and key support requirements near the top. Reports can then provide the detail needed to explore suitability through an agreed sharing process.
| Referral detail | What makes it useful |
|---|---|
| Participant involvement | Preferred name, communication method, consent and chosen supporters |
| Current setting | Hospital, relevant team contact and the referrer's role |
| Requested service | SIL enquiry, preferred area and essential household considerations |
| Timeframe | Target discharge date, its current status and any known dependencies |
| Daily assistance | Tasks, frequency, level of help and times when needs overlap |
| Overnight assistance | What support is required and how often it may be needed |
| Environment | Access, equipment, bathroom and other essential property requirements |
| Funding | Current status, relevant plan information and management arrangement |
| Further information | Reports available, outstanding assessments and agreed sharing method |
Use functional descriptions. “Needs assistance to transfer using assessed equipment and the prescribed staffing arrangement” tells the provider more than “mobility issues.” Equally, do not include sensitive detail just because it appears in an existing report. Explain the information's relevance to the proposed support.
If a key fact is unknown, label it as outstanding and name the person who can clarify it. A referral can be useful while work is still underway, provided uncertainty is visible. It becomes difficult to assess when assumptions are presented as settled facts.
Turn clinical recommendations into practical support questions
Hospital reports may describe needs in terms that require further discussion before they can become a support roster. The provider needs to understand what staff would actually do, when they would do it and what competence, equipment or oversight the task requires.
For personal care, explain the assistance required and any assessed approach to transfers or positioning. For communication, describe how the person expresses pain, disagreement, fatigue and a wish to stop. For eating and drinking, identify whether relevant assessment and instructions are available, without asking a support worker to independently interpret a clinical issue.
Medication arrangements should be clear about responsibilities, current instructions and the support being requested. A general statement that someone “needs medication help” can cover very different tasks. The receiving provider must establish whether the requested work is within its service scope and whether workers have the necessary training and information.
If behaviour support strategies are relevant, identify the current plan, professional contacts and authorised arrangements where applicable. Explain helpful preventative approaches and communication supports. Do not assume a diagnosis alone tells staff what a person needs.
Ask CCS to identify any part of the proposed support that requires additional assessment or a different service. An honest answer about scope helps the discharge team plan effectively. A referral should create a clear division of responsibilities between disability support, clinical care and other services involved in the transition.
Confirm that the proposed home can support the discharge plan
A suitable home must be assessed against the person's requirements, rather than against a general description such as accessible or spacious. Equipment size, circulation space, bathroom layout and the route between the bedroom and shared areas may all matter.
Where an occupational therapist is involved, arrange a clear process for reviewing relevant environmental requirements. Explain which features are essential, which changes have been recommended, and whether any assessment remains outstanding. The person should also have an opportunity to consider privacy, comfort and the atmosphere of the home.
Household compatibility belongs in this conversation. Consider sleep patterns, sensitivity to noise, expectations about visitors and the support needs of people sharing the environment. A physical space can meet an access requirement while the household arrangement remains unsuitable.
Ask what a visit or introduction could involve and how the participant's preferences will be accommodated. If a visit is not currently possible, discuss the alternatives and what still needs to be confirmed before a decision. Photographs and video can help someone prepare, but they do not resolve every question about access or household life.
For an additional set of questions, use the CCS SIL vacancy comparison guide. Treat it as a discussion aid. Availability and the suitability of any particular property need direct confirmation during the referral process.
Set out who owns each part of the transition
The NDIS guide to a hospital stay describes how hospital staff, NDIS contacts and a support coordinator, where involved, contribute to planning for discharge. The practical handover should make each person's responsibility visible rather than rely on a broad statement that the team will organise everything.
Choose a main contact for coordinating updates and agree who needs to be included. That contact should be able to explain the current plan, identify decisions that remain outstanding and confirm changes to the expected date. Record how the participant will receive information in an accessible form.
Separate the tasks that must be completed before arrival from those that can be reviewed after support starts. Delivery of essential equipment, confirmed staffing and necessary instructions may be prerequisites. Refining a preferred weekly activity schedule may be something the person wants to explore after settling in.
Ask for a short written action list with a named owner for each item. An entry such as “OT to confirm bathroom suitability” is more actionable than “access to be checked.” Add the date of the latest update so the team can distinguish current information from an earlier proposal.
When there are several organisations involved, confirm who will communicate a change. A revised discharge date needs to reach the provider arranging staff, the person organising transport and the participant's chosen supporters. The objective is a shared understanding that can survive a staff handover or a change in availability.
Understand funding and costs before setting a start date
An expected plan change is different from funding available for the proposed supports. State the current position clearly and ask what CCS needs to assess a workable arrangement. If support needs have changed during the hospital admission, identify which requirements are covered and which remain unresolved.
Ask for a proposed support schedule and an explanation of the associated charges. Check how daytime, overnight and any individual support are described. Clarify how the quote relates to the funding period and the actual assistance the person will receive.
Accommodation and ordinary living costs should be explained separately. The participant and their chosen supporters need to understand personal contributions, payment arrangements and any proposed commitments before a move. Avoid allowing urgency around discharge to obscure these questions.
The NDIS guide to using funding explains why a plan's support categories and conditions matter. A provider's acceptance of an enquiry does not change those conditions or create additional funding.
Where a plan manager or support coordinator is involved, ask them to assist with the relevant funding questions within their role. CCS should be approached as the potential direct support provider in this process. The final arrangement should identify what will be delivered, how it will be paid for and what needs to happen if the support requirement changes.
Build a practical arrival and first-week plan
The first day should be understandable to the participant before it happens. Discuss the expected arrival time, who will be present and how the person will be introduced to the home. Explain which belongings and equipment are coming with them, and who is responsible for bringing each item.
A short arrival plan can cover the immediate essentials: a place to rest, food preferences, personal care, communication supports and the evening routine. Keep the schedule manageable. A person may need time to become familiar with the environment before meeting every member of a support team.
Check that current instructions reach the workers who need them before they perform the relevant tasks. Confirm how the provider will obtain clarification if information is inconsistent or incomplete. The handover should also identify the appropriate clinical and service contacts for issues within their respective roles.
Plan for the ordinary commitments that continue after discharge. If the person needs assistance travelling to follow-up appointments, discuss CCS transport support and confirm the specific arrangements. If reconnecting with a familiar activity is a priority, explore community access support when planning the first weeks.
Agree when the participant's experience will be reviewed and how they can raise a concern before that meeting. Ask questions that invite real feedback: Was the morning pace comfortable? Did staff explain what was happening? Was the person able to make choices about their day? Those answers help refine the arrangement after the initial handover.
Resolve common referral gaps with a specific next action
Several common difficulties can be addressed more effectively when the next action is clear. If the discharge date is uncertain, record a target and the decision that will confirm it. If an equipment need has changed, identify who will assess and communicate the updated requirement.
If a suitable household has not been confirmed, keep the accommodation search open while the provider assesses its options. Do not treat a preliminary discussion as a reserved place. Ask what a confirmed offer would involve and which matters remain subject to assessment.
When the referral contains conflicting information, bring the relevant people together to clarify the specific issue. For example, different descriptions of overnight needs should be resolved before a staffing arrangement is accepted. A concise clarification can be more useful than forwarding another large collection of documents.
If the person is anxious about meeting a new provider, ask how the introduction can be adjusted. This might involve a chosen supporter, shorter conversations or a written explanation of the next step. The CCS mental health and autism support page may help frame questions about practical support approaches, while clinical care remains with the appropriate professionals.
These actions do not remove every delay. They make the source of uncertainty visible and help the participant and referrers understand what can happen next.
A fictional example of a clearer discharge referral
Sam is preparing to leave hospital and wants to remain near family in the Canberra region. The initial enquiry requests an urgent SIL bed and includes several reports, but does not explain the proposed overnight support or the status of equipment delivery.
A revised summary sets out Sam's preferred location, communication needs, daily assistance and overnight requirements. It identifies the hospital contact, confirms consent to discuss the referral and states which funding information is available. Two outstanding actions are listed: confirming the equipment delivery date and assessing the bathroom in any proposed property.
The provider can now respond to a defined request. It can discuss potential suitability, identify whether the support is within scope and explain what further information is required. Sam can also understand why a particular step is needed, rather than hearing that the referral is simply waiting.
This fictional example illustrates a planning approach, not a CCS case study or a promised outcome. A strong referral connects the person's preferences to practical requirements and gives each unresolved issue an owner.
Hospital-to-SIL referral questions
Can a hospital social worker or occupational therapist refer to CCS?
Yes. Referrers can use the CCS referral pathway with the participant's consent or appropriate authority. Include your role, contact details, the service being requested and the person's involvement in decisions. Identify any assessment information that is relevant to the proposed home or support arrangement.
Can CCS confirm an immediate discharge placement?
An immediate placement should not be assumed. CCS needs to assess the enquiry, available options, staffing, funding and suitability. Share the requested timeframe at the start and ask for a clear statement of what can be considered. Clinical readiness and the hospital's discharge responsibilities remain part of the wider process.
Should we send the full hospital record with the first enquiry?
Begin with a relevant summary and ask which documents are needed and how to share them appropriately. The receiving team needs accurate information for its role, rather than unrestricted access to every historical document. Confirm consent, current versions and the purpose of sharing sensitive information.
What if the participant wants to return to their existing home?
Make that preference explicit. Ask whether scheduled direct support can meet the identified needs and what other services or environmental changes are required. A hospital discharge enquiry does not automatically mean SIL is the right destination. The support discussion should follow the person's circumstances and goals.
Can families contact CCS before the discharge plan is final?
Yes, they can begin an enquiry with the person's consent or relevant authority. Explain what is known and what is still being assessed. An early discussion can clarify the information CCS needs, while a confirmed start depends on the necessary decisions and arrangements being completed.
Send a hospital-related SIL referral to CCS
Prepare a short summary of the person's preferred location, support requirements, consent, funding status and target discharge timeframe. Identify the main hospital or community contact and any assessments still underway. State clearly that you are enquiring about a transition from hospital so the purpose is immediately understood.
Refer to CCS for a SIL suitability discussion or contact CCS on 1800 320 810. Ask what information is needed to assess the next step and how current availability will be confirmed. A clear referral gives the participant, their supporters and the receiving team a practical starting point for planning together.
