Long Stay Bed to Home. We Run the Whole Transition.
Dementia Care Queensland specialises in complex hospital to home transitions for people living with dementia. We source the medium term accommodation, build and train the team, run the stakeholder meetings and gather the evidence for the right NDIS plan, from the ward to the front door of a permanent home.
For long stay teams, social workers, discharge planners, NDIA health liaison officers and support coordinators.
- Response to every referral
- Same Day
- To source a medium term home
- 5 to 7 Days
- Staffing in every home we run
- 1:1 and 2:1
- For discharge meetings and case conferences
- No Charge
Ready to Go Home. Still in a Hospital Bed.
- Queenslanders in public hospitals who are clinically ready for discharge
- 1,400+
- How long 15 of them have been waiting
- 700+Days
- Of medium term accommodation the NDIS can fund to get someone home sooner
- 90Days
For a person living with dementia, a long stay is never neutral. A busy ward is loud, unfamiliar and hard to read. Routines disappear, mobility drops and distress rises. The longer the wait, the harder the discharge becomes. Most of these patients don't need more hospital. They need a provider who can take them.
Sources: Queensland Health, Beds blocked: Queensland long-stay patient numbers surge past 1,400 (2 September 2026). NDIS, Our Guidelines: Medium term accommodation.
Why Dementia Discharges Stall.
It's rarely one thing. It's usually four, all at once.
Nowhere to Go Yet.
The permanent home isn't ready, the old one isn't safe, and nobody has a medium term option lined up.
Providers Say No.
Exit seeking, behaviours of concern, overnight needs. Generalist providers read the referral and decline. The patient stays put.
A Plan That Doesn't Fit.
Funding written from a hospital bed, often at a shared ratio, before anyone has seen how the person manages outside the ward.
Too Many Moving Parts.
Hospital, NDIA, coordinator, OT, behaviour support, guardian, family. Everyone is working hard. Nobody is holding the whole thing.
We hold the whole thing.
One Provider. Ward to Front Door.
Most providers meet a new client at the front door. We meet them on the ward. One specialist team carries the person through every stage, so nothing gets lost between handovers.
- Stage 01Day 0
Referral and Ward Visit
We respond the same business day. We meet the patient on the ward, speak with the treating team and the decision maker, and map out what a safe discharge actually needs.
- Stage 02Days 1 to 7
Medium Term Home Sourced
We find a medium term home close to family and services, then work with the treating OT on equipment and modifications before anyone moves in.
- Stage 03Days 2 to 14
Team Built and Trained
We recruit and match a dedicated team. Every worker is dementia trained, then trained on the person's own functional capacity assessment and behaviour support plan before their first shift. Where the hospital allows, they do buddy shifts on the ward, so the person knows their faces before they leave.
- Stage 04Up to 90 Days
Discharge and Medium Term Accommodation
A supported discharge day, then structured support from the first night. Every shift is documented, and the treating team and coordinator get a written update every week.
- Stage 05Ongoing
Evidence and a Permanent Home
We build the evidence for the right plan and support the participant and their decision maker through the reassessment. Then we move them into a permanent home: one of our 1:1 or 2:1 SIL homes, or back to their own home with in-home care.
Timeframes are typical, not guaranteed. Every discharge is different, and we confirm dates at the first stakeholder meeting.
Everything a Complex Discharge Needs. From One Provider.
Medium Term Accommodation, Sourced.
If your patient is eligible for SIL, SDA, ILO or home modifications, the NDIS can fund up to 90 days of medium term accommodation on discharge, even before a permanent home is confirmed. We find the property, set it up with the OT and staff it from day one.
SIL Homes Built Around Dementia.
Small, dementia designed homes staffed 1:1 or 2:1. Real homes, not facilities, with the same consistent team the person met on the ward.
Explore Our HomesStakeholder Meetings, Run Properly.
We attend and coordinate discharge planning meetings, case conferences and MDTs with the hospital team, NDIA, coordinator, allied health, guardian and family. An agenda before. Clear actions and owners after. No charge to attend.
Evidence for the Right Plan.
Structured progress notes and reports for coordinators, social workers, the treating team and the NDIA, so the plan reflects the person rather than a best guess made from a hospital bed.
How We Build the EvidenceAlready have a support coordinator? We work alongside them. Don't have one? Our Specialist Support Coordinators can step in.
Explore CoordinationThe Right Plan. Not Just a Bigger One.
A plan written from a hospital bed is a best guess. It's built before anyone has seen how the person manages at home, overnight, on a bad day or in a new routine.
The 90 days of medium term accommodation are the best chance to replace that guess with evidence, and we use them deliberately. Every shift is recorded against the person's goals and daily functioning. Behaviours, sleep, personal care, mobility and community access are tracked the same way every day, so patterns are clear rather than anecdotal.
Sometimes the evidence shows a person needs more support than their plan funds. Sometimes it shows they need less. Either way, the participant, their decision maker and their coordinator go into the reassessment with a plan built on facts.
We don't write reports to a number. We write them to the person.
What the Evidence Pack Includes
- Structured daily progress notes written to the person's goals
- Behaviour and incident records showing frequency, triggers and what worked
- Overnight records covering sleep, wake ups and support given
- Functional observations across personal care, mobility, meals, safety and community access
- Support delivered compared with support funded
- Summary reports for the coordinator, social worker, treating team and NDIA
- Input for the OT's functional capacity assessment and the behaviour support practitioner's plan review
Funded for Shared Support? Refer Anyway.
Where a person's presentation points to 1:1, we can take them through medium term accommodation while the evidence is gathered. If the reassessment confirms shared support is the right fit, we'll support a proper handover to a provider who runs shared homes.
Built for the People Holding the Discharge.
Long Stay and Patient Flow Teams
One referral. One point of contact. A realistic discharge date and a provider who turns up to every meeting. We report progress in the language your team already uses: barriers, actions, owners and dates.
Refer a PatientWhy Complex Discharges Need a Specialist.
A dementia discharge isn't a standard discharge with extra steps. It needs a provider built for it.
| Generalist Provider | Dementia Care Queensland | |
|---|---|---|
| First contact | At the front door, on discharge day | On the ward, before discharge |
| Accommodation | Waits for something to come up | Sources a medium term home in 5 to 7 days |
| Training | General disability induction | Dementia training, plus the person's own FCA and behaviour support plan before the first shift |
| Behaviours of concern | Often the reason to decline | Planned for with the behaviour support practitioner |
| Progress notes | Written for billing | Written as evidence |
| Housing model | Shared houses by default | 1:1 and 2:1 homes |
| Discharge meetings | Billed as provider time | Attended at no charge |
Who We Take Referrals For.
NDIS participants, and patients the NDIA hospital discharge team is assessing for access, who are living with:
Complexity We're Set Up For
Unsure if your patient fits? Call us. You'll get a straight answer on the first call.
Our Commitments to Hospital Teams.
- A response to every referral the same business day
- A medium term home sourced within 5 to 7 days
- A dedicated team trained on the person before their first shift
- Buddy shifts on the ward before discharge, where the hospital allows
- Discharge planning meetings, case conferences and MDTs attended at no charge
- A written progress update to the treating team and coordinator every week during medium term accommodation
- One named contact from referral to permanent home
Refer a Patient. We'll Take It From Here.
Call or Send the Referral.
Phone 0439 143 082 or use the form.
Same Day Response.
We call you back the same business day to talk through the patient and the timeline.
Ward Visit and First Meeting.
We meet the patient, the treating team and the decision maker.
A Transition Plan With Dates.
You get a written plan covering accommodation, the team, meetings and a target discharge date.
Have These Handy (But Don't Wait for Them)
- NDIS number, or the status of the access request
- Current NDIS plan, if there is one
- Discharge summary or medical clearance
- OT, behaviour support and nursing reports
- Decision maker, guardian or EPOA details
Missing something? Send what you have. We'll chase the rest.
Send a Referral
Loading the form…
Questions Hospital Teams Ask Us.
No. If the NDIA hospital discharge team is still working through access or planning, we can start in parallel by meeting the patient, scoping accommodation and preparing a support model, so we're ready to commence the day the plan is approved.
Yes, for hospital discharge. If the participant is eligible for SIL, SDA, ILO or home modifications, the NDIS can fund medium term accommodation without a confirmed long term home. It's funded for up to 90 days, with extensions only in limited circumstances, which is why we plan the permanent home from day one.
Under current NDIS rules, an unscheduled plan reassessment can only be requested by the participant, their plan nominee or child representative. We prepare the evidence, brief the coordinator and support the participant and their decision maker through the process.
Yes. Where the presentation points to 1:1, we can take the person through medium term accommodation while the evidence is gathered. If the reassessment confirms shared support is the right fit, we'll support a proper handover to a provider who runs shared homes.
No. We attend discharge planning meetings, case conferences and MDTs at no charge.
Yes. This is the work we're built for. We implement behaviour support plans, including regulated restrictive practices where they're authorised, and we work closely with the behaviour support practitioner from the first meeting.
Our coordination and home care services operate statewide. Medium term accommodation and SIL depend on location, so call us and we'll tell you on the first call what we can do in your patient's area.
If they're already an NDIS participant, yes. People who are 65 or over and aren't NDIS participants usually need the aged care pathway instead. Call us and we'll point you in the right direction.
More questions? Call us on 0439 143 082