The situation
“Robert”*, in his early 60s, was referred to Aus Care Community Services after leaving hospital following a stroke. No accommodation was available, so he was living in his car. He had no family contact and no support network.
His stroke left him with significant cognitive changes. He couldn’t keep track of the time or the day of the week. He couldn’t manage his own medication, and he had major mobility difficulties.
What we did
- Connected Robert with housing support. We linked him with the Department of Communities and Justice (DCJ) and supported him through their process. DCJ offered Robert social housing despite the complexity of his needs.
- Helped gather NDIS evidence. We reconnected with Robert’s previous GP, who completed detailed medical documentation for his NDIS access request.
- Supported his application. We helped lodge his NDIS access request with a full medical evidence package.
- Kept going through a setback. Robert had a second stroke during the application process. We stayed involved throughout his hospital admission and rehabilitation.
Progress so far
- The NDIA granted Robert access to the NDIS, even with the added complexity after his second stroke.
- An occupational therapy assessment recommended 24-hour support for his mobility and cognitive needs.
- His NDIS plan is under review by the NDIA for funding that matches his current needs.
- We are working with the hospital team on discharge planning, so the right supports can be in place before Robert goes home.
Why it matters for referrers
Discharging a patient with no accommodation and no NDIS plan is one of the hardest situations a hospital team faces. Aus Care Community Services can help coordinate NDIS access evidence and discharge planning, and connect participants with housing services outside the NDIS. We also stay involved when a participant’s needs change partway through the process.
Planning a complex discharge?
*Name changed to protect privacy.
Please note: Aus Care Community Services doesn’t provide or allocate housing. Social housing is provided by the Department of Communities and Justice (DCJ) and community housing providers, who decide eligibility and timeframes. Where it’s funded in a participant’s NDIS plan, we can provide supports related to housing, such as helping participants understand their home and living options, prepare housing applications, and connect with housing services. Rent, bond and everyday living costs aren’t funded by the NDIS. NDIS access and plan funding are decided by the NDIA. Discharge decisions are made by the treating hospital team. Outcomes vary for each person.
