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Care Alliance Allied Health & Supports

Nursing & complex care

Hospital Discharge & Transition

Leaving hospital is where complex care most often breaks down. Our Registered Nursing Leads sit in the discharge planning meetings alongside the treating team, then lead the transition home — so the standard of care doesn't drop on the day someone is discharged.

Support coordinator or referrer? Make an online referral →

Our registered nurses are in the room

Every discharge we support includes one of our Registered Nursing Leads in the planning meetings at Rankin Park, John Hunter Hospital. Not a coordinator taking notes to pass along afterwards — a registered nurse hearing the clinical picture first-hand from the people treating it.

Discharge planning is where the detail lives: wound management, PEG feeding, catheter care, seizure protocols, medication changes, the equipment someone goes home with, and the early signs that mean somebody needs to call for help. Second-hand summaries lose exactly that detail, and it is the detail that keeps people safe at home.

Nurse to nurse, so nothing is lost in translation

When Hunter New England Health nursing staff hand over to a registered nurse rather than to a non-clinical staff member, both sides are speaking the same clinical language. Questions get asked and answered properly while everyone is still in the room, and the plan that leaves the hospital is the plan that gets delivered at home.

That continuity is the entire point. The clinical reasoning behind a person's care travels with them, instead of being reconstructed from scratch once they are through their own front door.

Our nurses lead the transition, not just the paperwork

Our registered nurses write the care plan from what they heard in the hospital, train the support workers who will deliver it, and stay involved while the person settles. The training is built around one individual's needs, not delivered as a generic course and hoped to fit.

The result is evidence-based care that holds its standard on both sides of the discharge — in the hospital, and in the community afterwards.

A landscaped courtyard garden at John Hunter Hospital

Registered for high intensity support

Care Alliance is an NDIS-registered provider approved to deliver High Intensity Daily Personal Activities, and approved under Module 2a. That registration is what allows us to take on the most clinically complex discharges rather than only the straightforward ones.

It also means the clinical oversight does not stop once someone is home. Our registered nurses supervise the supports that follow, and our 24/7 on-call team includes RN support, so families and staff can reach clinical guidance at any hour.

An allied health team behind every support worker

Our registered nurses, psychologists, occupational therapists, behaviour support practitioners and physiotherapists are all in-house, and they train our support worker teams directly.

It means the worker in someone's home is delivering care shaped by the clinicians who actually assessed them — whatever the diagnosis, and however complex the needs.

Transport is never the reason a discharge stalls

We run thirteen wheelchair-accessible vans. Getting someone home from hospital, and to every appointment after that, is something we schedule rather than something a family has to solve.

A Care Alliance wheelchair-accessible van with its rear ramp lowered

Common questions

Which hospitals do you work with?

Our discharge work centres on Rankin Park at John Hunter Hospital, where our Registered Nursing Leads attend planning meetings. We also support discharges from other hospitals across Newcastle, Lake Macquarie, Maitland and Port Stephens — call us and we will tell you what we can put in place.

When should we contact you about a discharge?

As early as possible, ideally while discharge planning is still being discussed rather than once a date is set. The earlier our nurse is in the room, the more of the clinical picture we can carry into the community, and the more time there is to train the team who will deliver it.

Can you support someone with high or complex clinical needs?

Yes. We are NDIS-registered for High Intensity Daily Personal Activities and approved under Module 2a, with registered nurses providing clinical oversight of every support we deliver.

Who trains the support workers?

Our own clinicians. Registered nurses lead the clinical training, and our allied health team — psychologists, occupational therapists, behaviour support practitioners and physiotherapists — contribute to it, so what a worker is taught reflects the person they are supporting.

Do you provide the transport home from hospital?

Yes. We have thirteen wheelchair-accessible vans and experienced support staff, so transport home and to appointments afterwards is part of what we arrange.

Your team

The people delivering Hospital Discharge & Transition

Meet the 7 practitioners who deliver this service. Our intake team will match you with the right one for your goals.

  • Photo of Sarah

    Sarah

    Registered Nursing Lead

    Sarah is Care Alliance's Registered Nursing Lead — a permanent RN with over 16 years of nursing experience across the NDIS, community, public and private healthcare sectors. Sarah brings a diverse clinical skillset spanning complex health needs and high-intensity supports, and is passionate about person-centred care that helps people live independently. Sarah leads and mentors our nursing and support-worker teams, ensuring safe, high-quality, clinically informed care across the organisation.

    Focus: Community Nursing, High Intensity Supports, Complex Care, Wound Care, Disability Support

  • Photo of Rebecca

    Rebecca

    Registered Nurse

    Rebecca is a Registered Nurse with experience in perioperative care at Hunter Valley Private Hospital, supporting patients through surgical procedures with a strong focus on safety, comfort, and communication. Rebecca is experienced in clinical assessment, care planning, and coordinating with doctors, allied health teams, and support workers to deliver high quality care, and also monitors complex clients, including those with diabetes. Rebecca has worked with the NSW Health Workforce Surge Team, where they developed strong skills in infection control, documentation, and multidisciplinary teamwork. Rebecca's experience as a Disability Support Worker has further strengthened their ability to provide personalised, compassionate care and build meaningful connections with clients.

    Focus: Personal Care, Complex Care, Nursing Care, Aged Care, Home Care, Palliative Care

  • Photo of Samantha

    Samantha

    Registered Nurse

    Samantha is a dedicated and compassionate Registered Nurse with experience across Theatre, Anaesthetics, Surgical, Respiratory, and Paediatric care. Samantha currently works at John Hunter Hospital and John Hunter Children's Hospital, supporting patients and families through a wide range of clinical needs, including care for children and individuals with additional needs. Samantha is confident working in fast-paced environments and brings strong skills in medication administration, patient monitoring, and multidisciplinary teamwork. Previous experience as an Assistant in Nursing has strengthened Samantha's hands-on care and attention to detail. Samantha takes pride in being adaptable, professional, and focused on delivering safe, person-centred care.

    Focus: Personal Care, Complex Care, Nursing Care, Aged Care, Home Care, Palliative Care

  • Photo of Madelyn

    Madelyn

    Registered Nurse

    Madelyn is a passionate and dedicated Registered Nurse with experience across emergency, rehabilitation, community health, and aged care settings. Previous work as an AIN has provided Madelyn with valuable hands-on clinical experience, which they combine with their RN qualifications to make informed clinical assessments and deliver effective care. Madelyn works closely with participants to monitor progress, evaluate outcomes, and support the ongoing development of their care plans. Madelyn is confident in high pressure environments and brings strong skills in medication administration, vital sign monitoring, and holistic health management. With hands-on experience in both nursing and support roles, Madelyn is adaptable, proactive, and committed to delivering safe, high quality care.

    Focus: Personal Care, Complex Care, Nursing Care, Aged Care, Home Care, Palliative Care

  • Photo of Emma

    Emma

    Registered Nurse

    Having worked as a support worker and now as a Registered Nurse, Emma brings strong hands-on disability and aged care experience to clinical practice, including conducting health assessments, monitoring client wellbeing, identifying changes in condition, and coordinating care plans with NDIS services. With a strong background in customer-focused roles, Emma remains calm and responsive in fast-paced and sensitive situations. Emma brings a professional, empathetic approach to their work and is passionate about building meaningful connections with clients while contributing to safe, consistent, and high-quality care.

    Focus: Personal Care, Complex Care, Nursing Care, Aged Care, Healthcare, Compassionate

  • Photo of Caitlin

    Caitlin

    Registered Nurse

    Caitlin is a Registered Nurse with three years of diverse clinical experience across emergency, inpatient, and procedural care. Caitlin currently works in the Emergency Department at John Hunter Hospital, where they have developed strong skills in resuscitation, team coordination, and delivering care in high-pressure environments. Caitlin takes a collaborative, evidence-based, and person-centred approach, with a strong focus on safety, compassion, and clear communication. Caitlin is passionate about supporting both adults and children through critical moments with confidence and empathy.

    Focus: Emergency Nursing, Resus Care, Paediatric Nursing

  • Photo of Bree

    Bree

    Registered Nurse

    Bree is a dedicated and compassionate Registered Nurse with experience across disability support, aged care, and clinical nursing practice. Bree is committed to delivering high-quality, person-centred care that prioritises dignity, safety, and individual wellbeing. Bree has experience supporting individuals with complex needs, including personal care, mobility, and daily living supports, and works collaboratively with clients, families, and multidisciplinary teams, bringing strong communication, organisation, and problem-solving skills. Bree is known for being calm, adaptable, and focused on providing safe, compassionate care.

    Focus: Personal Care, Complex Care, Nursing Care, Aged Care, Home Care

Meet the whole Care Alliance team →

Supervised practice, inside and out

Our clinicians don't practise in isolation. Supervision here is matched to the discipline and to each practitioner's stage of development. Our behaviour support practitioners and occupational therapists, for example, receive both internal supervision with senior clinicians in our team and external supervision with independent specialists outside the organisation.

It keeps skills growing, brings fresh thinking to complex situations, and means the support you receive reflects current best practice — not just one person's opinion.

Registered NDIS providerNo. 4050102760

Approved under Module 2a for regulated restrictive practices

Psychologist-led · Registered nurse oversight

Enquire about Hospital Discharge & Transition

Leave your details and our intake team will call you — usually within one business day — to talk through what you need and next steps.

Either a phone number or an email address is fine — whichever suits you.

  • Registered NDIS provider
  • Psychologist-led
  • RN clinical oversight
  • 24/7 on-call team

We use your details only to respond to this enquiry. Prefer to talk now? Call 1300 206 309.

Ask us about Hospital Discharge & Transition

Call, email or send an online referral and our intake team will talk you through availability and next steps.