Post Hospital Care in Melbourne

Specialised support for NDIS participants with high medical needs

Bulk-billed GP

Registered NDIS Provider

Group 3

Post Hospital Support

The team at SeenCare includes bulk-billing GPs, in-home nurses and specialist disability support workers. This allows us to deliver unique, comprehensive and coordinated post-discharge services for NDIS participants with high medical needs.

No matter whether a person with disability is dealing with a new injury, acute illness, or chronic condition, we can help.

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What Is Post Hospital Care?

The post discharge period is considered a “high-risk” time in every patient’s care journey.

Research shows that during the first days and weeks after leaving hospital, people are at significantly increased risk of health complications that can lead to harm and bring them back to hospital.

Therefore, post hospital care (also known as post discharge support) can refer to a range of activities designed to support an individual's transition from hospital to living in the community.

Post hospital care is especially important for people living with disability, as they often face additional barriers to accessing adequate medical care and support compared to the general population.

Our Range of NDIS Hospital Discharge Services

At SeenCare, our mission is to make high-quality community nursing and medical support more accessible for NDIS participants.

Some of the most common post discharge supports in Melbourne we provide are listed below.

At Home Wound Care

For people with limited mobility or cognitive impairment, getting to a medical clinic for regular wound care can be challenging, time-consuming and stressful.

Our experienced registered nurses can:

  • Undertake regular dressings changes, wound cleaning and monitoring
  • Manage a range of wounds, such as pressure ulcers, burns and surgical wounds
  • Quickly escalate any issues of concern to our home visiting GPs

Management of High-Risk Medications

Being unable to safely manage high-risk medications—such as blood thinners (warfarin) and diabetes medications (insulin)—can lead to poor health outcomes and extended hospital admissions.

The team at SeenCare is able to:

  • Develop a plan for managing high-risk drugs in the home/community environment
  • Safely administer medications like warfarin and insulin
  • Monitor patients at home and provide feedback to hospital specialists

Coordination of Rehabilitation Programs

A well-executed home rehabilitation program can enhance recovery and reduce the time a person needs to spend in hospital.

To give people with disability the best chance of maintaining independent living, we can:

  • Partner with rehabilitation teams to coordinate care at home
  • Upskill our support workers to assist with rehab activities and home exercise plans
  • Provide “step-down” care for patient’s transitioning from hospital services

Chronic Disease Management

Deterioration in chronic conditions like COPD, heart disease and diabetes often result in avoidable readmissions to hospital.

We support NDIS participants to:

  • Develop and follow care plans to manage chronic conditions
  • Implement action plans to deal with “flare ups” or worsening symptoms
  • Enhance self-management strategies and preventative care

Shared Care with other Health Professionals

Serious and/or ongoing health conditions often require input from several doctors and health professionals.

SeenCare is a registered NDIS service provider that improves outcomes by:

  • Supporting people with disability to engage with relevant health professionals
  • Partnering with specialists to deliver shared or joint care
  • Providing through handover to other practitioners where required (with client consent)

Monitoring and Observations

Proactive monitoring can make the difference between a person staying well and remaining at home or ending up back in hospital.

The GPs, nurses and support workers on our team can:

  • Keep track of important health markers, like blood sugar levels and blood pressure
  • Quickly deal with small problems to prevent them from getting worse
  • Get additional support from specialist health services when required

If you don’t see what you need, please give us a call.

We can develop individually tailored packages of care for people with unique medical needs.

The Importance of Transitions of Care

The NDIS describes transitions of care as the movement of people between places or services providing care, such as disability support services and hospitals.

They further explain:

“Transitions of care are key points where there is risk of harm to participants. In Australia, problems in transition of care have been associated with risks of harm to people who have a disability.”

Problems In Transitions of Care

Most problems in transitions of care centre around poor communication.

Some examples include:

  • A hospital not receiving accurate information about a person’s regular medications
  • Details about necessary follow up care for an NDIS participant not being given to support services post hospital discharge
  • A person with disability being left in the emergency department without a support person to give a proper handover

How SeenCare Manages Transitions of Care

Because the leadership team at SeenCare have experience working in both hospital and disability services, we understand how to safely manage transitions of care.

Our disability support workers all receive specialised training and supervision for working with people with medical needs. We’re also a fully registered NDIS provider with the NDIS Quality and Safeguards Commission. And we have robust policies and procedures in place to ensure effective transitions of care with hospitals and healthcare services.

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Benefits of Integrated Health & Disability Care

The model of integrated health and disability supports delivered by SeenCare has several distinct benefits for hospitals and NDIS participants.

For Hospitals:

  • Treating teams can confidently discharge NDIS participants in the knowledge that they will receive adequate follow up and support
  • Patients who would otherwise remain in hospital can be discharged into the community (with adequate NDIS funding)
  • When an NDIS participant is admitted to hospital, the treating team can get a full handover of all relevant information

For NDIS Participants:

  • People with disability and high medical needs may be able to remain living independently in the community
  • The amount of time spent in hospitals and medical clinics can be reduced
  • When medical conditions are well managed, people have more time to pursue meaningful goals

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