Care Continuity practical toolkit

Need help urgently in Australia? Call 000 for an immediate life-threatening or time-critical emergency. For health advice when it is not an emergency, healthdirect connects you with a registered nurse on 1800 022 222.

This toolkit helps you organise questions and next steps. Your treating team makes clinical decisions. For urgent concerns, contact the appropriate human service directly.

I am leaving hospital today.

Start with these three steps. You can ask a chosen supporter to help you explain the concern.

Tell your treating team what is still unclear now. For example: where you are going, support there, medicines, follow-up or a result you are waiting for.
Ask who can coordinate the next step. Ask your ward contact about the responsible clinician or discharge coordinator, where available. Ask for an explanation in a form you can understand.
Ask who to contact if the plan is missing or changes. If you cannot raise the concern with the team, or it remains unresolved, ask for the hospital's patient liaison or consumer feedback contact.

“I am due to leave today and I still need to understand ______. Please ask the responsible member of my treating team to talk through the plan with me. Who will take the next action, and how can I contact them?”

Write a short note to take to the conversation · Find the health feedback route

These steps help you raise the concern. Your treating team must assess the individual care and discharge arrangements; this page cannot make that assessment.

No one has agreed, no one has answered, or a service refused.

You do not need to invent an accepted action or an agreed date to use this toolkit.

No one has accepted the next action.

Record “not yet confirmed”. Ask the service who can consider the action and how you can reach that person or team. If the first contact cannot help, ask for the appropriate team lead or contact route.

An answer or promised update has not arrived.

Use the contact route you were given. State what you asked, when you asked and what is still needed. Ask whether the action has been accepted and when you can expect an update. There is no need to wait for a date that was never agreed.

The service says it cannot help.

Ask what it can explain about the reason, whether a review is available and which service has the right role. Check whether another service has actually accepted work before recording a handover.

“I contacted ______ about ______ on ______. I still need ______. Has anyone accepted this action? Who should I contact next, and when should I expect an update?”

If you still cannot find a workable next step, consider an independent advocate or the appropriate human help route. For a hospital concern, use the health feedback route. Tell the treating service about an urgent care concern now; use emergency help when there is immediate danger.

A record does not arrange care or monitor a reply. Ask an appropriate professional about any legal or clinical deadline. This page does not create a waiting period or pause an existing deadline.

Start with what matters to you

Prepare for an appointment or hospital stay.

You can ask these questions yourself, or with a supporter you choose. Share only the information needed for the conversation. Staff should hear from the person receiving care.

1. Help people understand me

What makes communication easier?

Would plain language, pictures, extra time or a quieter space help?
How do I show that I am in pain, worried or do not understand?
Who would I like involved, and what may be shared with them?
Can the team explain the plan directly to me and check my understanding?

“I understand best when you use ______. Please speak with me directly. I would like ______ involved if I choose.”

2. Find out what happens next

What do I need to ask the care team?

What is the plan, and which choices need my involvement?
What should I understand about tests, medicines or follow-up?
Who can explain something again in a way I can use?
Who will tell me about results or changes, and how can I contact them?

“Please explain the next step, the choices I have and who I can contact if I am unsure.”

3. Before leaving hospital

Ask for a plan you can understand and use.

Where am I going, and who will provide the support needed there?
Has the receiving person or team actually agreed to the next action?
Have medicines, follow-up and any ongoing care been explained by the appropriate clinician?
Which results, referrals or questions still need follow-up?
Who should I contact if the plan is unclear, changes or does not happen?

These are preparation questions drawn from official inclusive-care and transitions guidance. They do not determine whether a discharge is clinically safe or guarantee a service will be available.

Keep my questions and next action in one note

Make a handover clear.

A sent message and an accepted action are different things. Use this checklist to ask what has actually been agreed.

My goal: what does the person want to happen?
The next action: what still needs doing?
Acceptance: who has agreed to do it? If no one has agreed, record that clearly.
The next update: when is a reply expected? Say whether the date is agreed or only requested.
A change of person: who will be contacted if the responsible person leaves or becomes unavailable?
The result: what actually happened, and does the person feel the issue has been resolved?

“Please confirm the action you have accepted, who will do it, when I should expect an update and who I should contact if the plan changes.”

This is an organising checklist. It does not create a legal duty, allocate a worker or verify that care has been provided.

Choose a human help route.

Not sure which disability service to ask? Call Disability Gateway on 1800 643 787 and explain the kind of help you are looking for. You can ask about an independent advocacy service. Check its opening hours on the official website.

Start with the service whose role matches the help you need. Ask what it can accept, any eligibility rules and what happens next before sharing detailed records.

I need help finding disability services.

The Disability Gateway helps people with disability, families and carers find information and services.

Call 1800 643 787

Use its contact route. It is a navigation service; it does not investigate complaints.

I want an independent advocate.

The National Disability Advocacy Program supports access to disability advocacy. Use the official linked finder to look for a suitable local service.

Find disability advocacy

Choose who needs help and enter a suburb or postcode.
Open a service result and check the area and kind of help it covers.
Contact the service using its own phone or contact link. Ask whether it can accept your situation.

If the finder is difficult or does not load, read the official provider list by state or territory, or call Disability Gateway on 1800 643 787 for help finding an advocacy route.

Finding a listing does not arrange an advocate. Local eligibility and capacity differ. If the service cannot help, use the refusal and next-contact prompts.

I have a concern about hospital or health care.

Ask the treating team or the hospital's patient liaison or consumer feedback service about the concern. The Australian Commission's guide also explains health complaint routes when an issue remains unresolved or cannot be raised there.

Find the right health feedback route

I have a concern about an NDIS provider or worker.

The NDIS Quality and Safeguards Commission takes reports about unsafe or poor-quality NDIS supports. Its role differs from the NDIA's access and funding decisions.

Check the NDIS complaint route

Call 1800 035 544. If you disagree with an NDIA access or funding decision, use the separate decision-review route below.

I disagree with an NDIS access or funding decision.

The NDIA makes NDIS access and funding decisions. Its decision-review process is separate from reporting a provider or worker to the NDIS Commission.

Check the NDIA decision-review route

Check whether your decision is reviewable, which process applies and the deadline. Some decisions use other change or variation routes. Call the NDIA on 1800 800 110 to ask about your decision, or find an independent advocate to help you understand the route.

Keep the decision and date received somewhere private. If a deadline may be close, ask for qualified help promptly; an ordinary enquiry or referral does not itself request a review or pause the deadline.

Police are involved, or I need legal help.

Find legal help in my state or territory

Choose your state or territory, then use that legal aid commission's own contact route to ask what help is available. National Legal Aid lists the commissions; it does not give legal advice itself. This route is available even when the Care Continuity police guide does not cover your location.

Choose the state before using police information. The existing Care Continuity guide covers police pathways in Western Australia and Victoria, WA legal-aid grant review and selected referral routes. A communication supporter and a lawyer have different roles.

Read the source guidance Choose a covered situation

Original sources: Legal Aid WA police information, Victoria Legal Aid cognitive-disability support, WA grant review and Law Access WA referral limits.

Check any legal deadline directly with an appropriate lawyer. A referral, complaint or request for review does not itself appoint a lawyer or pause another deadline.

What can I ask if a service cannot help?

“Is the issue the kind of work, eligibility, current capacity, a conflict or something else? Can you give me the reason in a form I can keep? Is a review available, or is there another appropriate route?”

Ask whether the next service has actually accepted work or is only being suggested. A service may be unable to disclose confidential conflict details.

For example, Law Access WA is a referral service and does not act as your lawyer. Justice Connect's referral route is for professionals such as caseworkers, social workers and lawyers; program coverage and eligibility vary.

For your own use

My continuity note

A short start is enough: write your goal, the next action and the person or team you will ask. Add other details only if they help. You can leave fields blank.

Write only what is useful. A role or team name can be enough. Keep completed notes private, and involve a supporter only as you choose.

This page keeps current entries in page memory. It does not save, submit or send your notes. Browsers may restore page or form state. A downloaded or printed copy stays with you; clear or close the page when you finish.

Open a blank print sheet

The blank sheet is a separate short page that works without JavaScript. Use your browser's Print command and write by hand. You can also type in the fields below; download and copy buttons are optional JavaScript features. For this worksheet's own print layout, open the worksheet print view, then use Print and check its preview.

What I want to happen

What helps me understand and communicate

Who I choose to involve, if anyone

My questions for the conversation

The next action still needed

Person or team I asked, or who agreed

What is the acceptance status?

Expected update and contact route

If that person is unavailable

What happened, and what remains open

A request I can use

The request follows the notes you enter. Change your notes to change it. You choose whether to copy, download, print or read it to someone. Nothing is sent from this page.

Please help me understand the next step. Please confirm what action you can accept, who will do it, when I should expect an update and who I can contact if the plan changes. Please explain this in a way I can understand and involve the supporter I choose.

Use your note in three short steps.

Choose the person or service you want to contact. Use the human help routes if you need a starting point.
Copy, download, print or read your request through that service's own contact route. This page does not send it.
Ask what the service has accepted and how you should follow up. Update your own note with the answer, or use the next-step prompts if you are still stuck.

This is a personal organising aid, not a clinical record, consent form, complaint submission or instruction to a service. Check care decisions with the treating team and legal questions with an appropriate lawyer.

Where the guidance comes from.

Source notes checked 25 October 2026. The existing guide's next editorial review is due 22 November 2026; making this toolkit does not extend that date. Source availability and editorial checking are separate from independent legal, clinical and disability-led validation.

Australian Commission: intellectual disability and inclusive health care, including communication, reasonable adjustments and involving the person.
Australian Commission: transitions of care fact sheet, used by the existing guide's handover and discharge cards.
Australian Commission: giving feedback and making complaints.
Human service routes are linked directly in the cards above. The Australian Government's Triple Zero information explains emergency calling.
Care Continuity's public guidance, original sources and review documents. The worksheet and request wording here are new organising aids based on that work. They do not claim accreditation, endorsement or independently demonstrated care outcomes.

Care Continuity's research papers describe proposed improvements. The fictional workflow example on the main website is a separate illustration. The source links, preparation questions, human-help routes and blank worksheet on this page are real resources you can use now.