Holistic Healthcare
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Transition to or from a Provider Policy and Procedure

NDIS Policies and Procedures Manual – Core Module

Document Number: CM-POL-019

Document Control

This table shows a record of significant changes to the document.

Legal Name: Holistic Healthcare Management Services
ABN: 20695058096
ACN: 695058096
Primary address/head office: 15 Agasse Way, Tapping WA 6065
Document Name: NDIS Policies and Procedures Manual – Core Module
Document Number: CM-POL-019
Approved by: Director
Date Approved: February 2026
Version No: 1.0
Comments: Initial Release of the Policies and Procedures Manual
Next Review Date: May 2026

Introduction and Purpose

The purpose of this policy is to ensure that all transitions to or from Holistic Healthcare Management Services are planned, coordinated, and effectively managed to minimise disruption and safeguard the health, safety, and wellbeing of participants. The policy promotes participant involvement, addresses risks associated with transitions, and ensures compliance with NDIS Practice Standards and other regulatory requirements.

Scope

This policy applies to:

  • All participants transitioning to or from Holistic Healthcare Management Services, including temporary transitions.
  • Workers, governing bodies, and external stakeholders involved in transition planning and implementation.
  • Transitions related to a participant’s entry, exit, or temporary relocation, such as hospitalisation or respite care.

Definition

Term Description
Transition A planned or temporary movement of a participant to or from Holistic Healthcare Management Services, which includes both entry and exit processes.
Temporary Transition A short-term relocation, such as hospitalisation, requiring special planning to maintain continuity of supports.
Support Network A participant’s family, carers, or advocates involved in their care and wellbeing.

Outcomes and Indicators

Term Description
Each participant experiences a planned and coordinated transition to or from the provider.
  • A planned transition to or from the provider is facilitated in collaboration with each participant when possible, and this is documented, communicated and effectively managed.
  • Risks associated with each transition to or from the provider are identified, documented and responded to, including risks associated with temporary transitions from the provider to respond to a risk to the participant, such as a healthcare risk requiring hospitalisation.
  • Processes for transitioning to or from the provider (including temporary transitions referred to in subsection (2)) are developed, applied, reviewed and communicated.

Guiding Principles

  • Participant-Centred Approach: All transitions will prioritise the participant’s preferences, goals, and needs to ensure a positive experience (Indicator 1).
  • Risk Mitigation: Potential risks will be identified, documented, and addressed proactively to minimise disruption and harm (Indicator 2).
  • Collaborative Planning: Transitions will involve consultation with participants, support networks, and other stakeholders to ensure seamless coordination (Indicator 3).
  • Clear Communication: Participants and stakeholders will receive transparent, timely, and understandable information about the transition process.

Policy

Planned Transitions

Holistic Healthcare Management Services is committed to ensuring that all transitions, whether to or from the provider, are carefully planned and executed to minimise disruption and maintain participant wellbeing. This includes engaging participants, their families, and support networks in a collaborative process to design personalised transition plans. These plans will outline roles, responsibilities, and timelines, ensuring all parties have a clear understanding of the steps involved in the transition. Communication will be prioritised throughout the process to foster trust, reduce anxiety, and ensure participants feel supported at every stage (Indicator 1).

Risk Management During Transitions

The organisation recognises the inherent risks associated with transitions and is dedicated to identifying, documenting, and addressing these risks proactively. Risk management measures will include conducting detailed assessments to identify potential risks, such as gaps in service continuity, safety concerns, or emotional impacts on participants; developing tailored mitigation strategies, such as appointing backup workers or creating interim care plans; and regularly reviewing and updating risk management plans to ensure effectiveness and accountability (Indicator 2).

Temporary Transitions

Temporary transitions, such as hospitalisations or emergency relocations, require immediate attention and careful coordination. Holistic Healthcare Management Services will ensure participants receive uninterrupted support during these transitions by developing short-term care plans that address their specific needs. Communication with participants and their networks will be frequent and transparent, providing reassurance and updates about ongoing care arrangements. Post-transition reviews will be conducted to evaluate the process and identify areas for improvement (Indicator 2).

Transition Process Development and Review

Holistic Healthcare Management Services is committed to creating, implementing, and regularly reviewing structured processes for transitions to ensure they are effective and participant-focused. Feedback from participants, workers, and external stakeholders will be actively sought and incorporated into process improvements. These processes will be supported by robust training programs for workers, equipping them with the knowledge and skills needed to manage transitions effectively and compassionately (Indicator 3).

Communication and Stakeholder Engagement

Effective communication is fundamental to successful transitions. Holistic Healthcare Management Services will provide participants with written transition plans in formats tailored to their preferences, ensuring accessibility for all. The organisation will also establish clear communication protocols with external providers, support networks, and other stakeholders to facilitate seamless service delivery. Comprehensive documentation of all communication activities will be maintained to support accountability and continuous improvement (Indicator 1).

Procedure

Transition Planning

Transition planning begins with a comprehensive consultation involving the participant and their support networks. This consultation includes assessing individual needs through detailed discussions about goals, preferences, and support requirements; developing personalised plans outlining specific actions, responsibilities, and timelines; and establishing contingency measures and backup plans to address potential disruptions (Indicator 1).

Risk Identification and Mitigation

Risk management is integral to every transition and includes identifying potential risks such as service gaps or safety concerns; developing mitigation strategies like assigning backup workers or interim care plans; and maintaining ongoing monitoring and adaptation throughout the transition process to ensure participant safety (Indicator 2).

Managing Temporary Transitions

Temporary transitions, such as hospitalisations or short-term relocations, require immediate and flexible responses. Holistic Healthcare Management Services will develop interim care plans detailing interim arrangements, coordinate closely with hospitals or respite facilities to ensure seamless care, and provide follow-up support once the temporary transition is complete to review the process and address any concerns (Indicator 2).

Communication and Stakeholder Engagement

Effective communication is critical during transitions and includes participant communication using preferred formats and plain language; stakeholder coordination with external providers and support networks through multidisciplinary meetings; and complete documentation of all communication activities and consultations (Indicator 3).

Process Review and Feedback

To promote continuous improvement, workers will conduct detailed post-transition reviews with participants and networks, incorporate feedback from all stakeholders into process improvements, and update policies and procedures to reflect best practices and regulatory requirements (Indicator 3).

Roles and Responsibilities

Ref No Roles Responsibilities
1 Board and Senior Management
  • Oversee the development and implementation of transition policies and procedures.
  • Allocate resources to support effective transition planning and risk management.
  • Monitor compliance with regulatory standards and organisational objectives.
  • Use feedback and data from transitions to drive organisational improvements.
2 Workers
  • Collaborate with participants and their networks to plan and implement transitions.
  • Conduct risk assessments and develop tailored mitigation strategies.
  • Coordinate with external providers and stakeholders to ensure seamless service delivery.
  • Document all transition activities, including plans, risks, and outcomes, to support accountability and learning.
3 Participants and Support Networks
  • Actively participate in planning and decision-making processes related to transitions.
  • Provide feedback to improve the transition process and highlight areas of concern.
  • Communicate any changes in circumstances that may impact their transition needs.

Record Keeping

  • Transition Plans: Maintain detailed records of all transition plans, including participant preferences, agreed actions, and timelines, ensuring secure storage and accessibility.
  • Risk Management Documentation: Document all risk assessments, mitigation strategies, and monitoring activities during transitions, reviewing records regularly to identify trends.
  • Temporary Transition Records: For temporary transitions, records include short-term care plans detailing interim arrangements, communication logs, and post-transition reviews.
  • Feedback and Review Documentation: Maintain comprehensive records of participant and stakeholder feedback on transitions, documenting changes made to policies or training programs.

Related Documents

  • Service Agreements Policy
  • Risk Management Policy
  • Incident Management Policy
  • Emergency and Disaster Management Policy

References

  • NDIS Practice Standards
  • National Disability Insurance Scheme Act 2013
  • Additional legislative or regulatory references applicable to the provider

Policy Review

This policy will be reviewed annually or as required to incorporate regulatory changes, organisational developments, or feedback from participants and stakeholders.