Hospital Discharge & Rehabilitation

Overview

Create Allied Health provides rapid-response discharge planning for patients across Sydney's major hospitals, including private and public hospitals across Greater Sydney. Our clinical social workers work directly with hospital teams to remove barriers to safe, timely discharge and ensure patients transition successfully into community living across Greater Sydney and regional NSW.

Urgent Discharge Assessment

When discharge is urgent, we respond within 24–72 hours to get things moving. Our clinical social workers attend the bedside or connect via telehealth to conduct a rapid psychosocial assessment, identify the specific barriers preventing safe discharge, and provide the treating team with clear, actionable pathway recommendations. This early engagement helps prevent unnecessary extended stays and reduces the risk of readmission by ensuring supports are in place before the patient leaves hospital.

• Rapid psychosocial assessment at the bedside or via telehealth
• Identification of barriers preventing safe discharge
• Clear pathway recommendations for the treating team

Comprehensive Discharge Planning

For patients with complex needs — including those with housing instability, mental health complications, family conflict, substance use, or insufficient community supports — we provide end-to-end discharge planning that addresses every dimension of a safe return to the community.

• Full psychosocial evaluation of the patient's circumstances
• Housing pathway assessment and accommodation planning
• Service coordination across multiple providers and systems
• Family engagement, education, and conflict resolution
• Mental health support and crisis prevention strategies
• Detailed post-discharge planning with community follow-up

Housing & Accommodation Support

Housing is one of the most common barriers to hospital discharge. We provide specialist support including:

• Housing options assessment based on the patient's clinical needs and capacity
• Crisis housing intervention for patients with no safe accommodation
• Aged care placement assessment and family consultation
• NCAT applications for guardianship and accommodation decisions

Family Liaison & Mediation

Family dynamics can significantly impact discharge outcomes. Our social workers provide:

• Clear, compassionate communication between families and hospital teams
• Conflict resolution when families disagree on care plans
• Support with complex decision-making around capacity and guardianship
• Carer education and realistic expectations setting
• Facilitation of family meetings with treating teams

Service Coordination

We coordinate the full spectrum of community services to support a smooth transition, including:

• Community mental health teams
• NDIS providers and support coordinators
• Aged care services and My Aged Care assessments
• Home care packages
• Specialist medical and allied health providers

Capacity Assessment

When questions arise about a patient's decision-making capacity, we provide:

• Clinical evaluation of decision-making capacity
• NCAT guardianship application support when required
• Collaboration with medical teams on capacity determinations

Post-Discharge Follow-Up

Our work does not end at discharge. We provide ongoing support to prevent readmission and ensure long-term stability. Follow-up typically begins within the first week after discharge, with the frequency and duration tailored to each patient's level of need and risk.

• Community check-ins via phone, telehealth, or home visit
• Crisis prevention and early intervention
• Ongoing service coordination and advocacy
• Connection to long-term supports and community programs

Funding

Hospital discharge services can be funded through:

• iCare (workers compensation and motor accident schemes)
• WorkCover
• Private hospital discharge budgets
• Department of Veterans' Affairs (DVA)
• Private fee-for-service

Response Times

• Urgent referrals: Within 24 hours
• Standard referrals: 48–72 hours

Last reviewed: April 2026