Participant Transition, Transfer and Exit Procedure

PURPOSE

This procedure provides guidance for managing participant commencement, transition, transfer, suspension, and exit activities in a manner that promotes participant rights, protects participant wellbeing, and supports continuity of supports.

DCIRS recognises that periods of change can increase operational, safeguarding and wellbeing risks for participants. Effective transition planning supports participants to make informed decisions, exercise choice and control, maintain continuity of supports, and experience coordinated, respectful, and person-centred service delivery..

Transition, transfer, and exit activities are important safeguarding and quality-management processes. Appropriate planning, communication, risk assessment and oversight assist DCIRS to minimise disruption to supports, support positive participant outcomes and maintain organisational accountability.

SCOPE

This procedure applies to all DCIRS Community Care employees, contractors, volunteers and other persons engaged by or acting on behalf of DCIRS who are involved in participant commencement, service transitions, changes to supports, service transfers, temporary suspension of supports or service exits.

PRINCIPLES

DCIRS recognises that well-planned transitions, transfers and exits are important participant safeguards and quality-management processes..

In implementing this procedure, DCIRS is guided by the following principles:

1. Transitions, transfers and exits will be managed respectfully, transparently, in a coordinated manner and with a focus on participant outcomes.

2. Participant choice and control, dignity, respect, supported decision-making and effective communication will be promoted throughout periods of change. 

3. Participants will be actively involved in decisions affecting their services wherever possible and will be offered reasonable adjustments and communication supports where required.

4. Transitions, transfers, suspensions and exits can create additional risks; planning and oversight will be proportionate to each participant’s circumstances, complexity and level of risk.

5. Continuity of supports is an important safeguard, and reasonable steps will be taken to minimise avoidable disruption and adverse impacts on participant wellbeing. 

6. Privacy and lawful information sharing will be maintained, and information will be transferred only where there is appropriate authority and a genuine need to support safety, continuity and coordination. 

7. Roles, responsibilities, agreed actions, timeframes and escalation pathways will be clearly identified and documented to support accountability.

8. Workers will communicate professionally and keep interactions with participants, representatives, stakeholders and receiving providers focused on participant outcomes. 

9. Workers will use their training, experience and organisational guidance to identify, manage, document and escalate transition-related risks. 

10. Feedback, incidents, complaints, identified service gaps and transition outcomes will inform organisational learning and continual improvement. 

PROCEDURE

The following procedure highlights common activities and subsequent actions to reduce risk during transition, transfer, suspension, and exits. It supports managers and support workers to provide engaged and monitored supports during periods of increased service risk. It is not designed to be exhaustive. Workers must use the principles, their training, and knowledge of individual participant needs to guide outcomes.

Participant Involvement and Supported Decision Making

The procedure is guided by the recognition that meaningful participation supports participant rights, self-determination, choice and control, and assists DCIRS to understand participant preferences and desired outcomes.

Where required, accessible information, communication supports, Easy Read resources, interpreters, advocates, nominees, guardians, representatives and other reasonable adjustments should be utilised.

Examples of Transition, Transfer, and Exit Activities at DCIRS

Transition, transfer, and exit activities may occur in many circumstances, including:

• Commencement and onboarding of new participants.

• Changes to support arrangements or service-delivery requirements.

• Transfers to another provider.

• Temporary suspension of services.

• Planned participant exits.

• Provider-initiated service cessation.

• Emergency or unplanned service exits.

• Supported Independent Living (SIL) transitions.

• Participant relocation.

• Participant death and service closure activities.

Roles and Responsibilities of Support Workers, Managers and Key Personnel

The following role responsibilities apply across commencement, transition, transfer, suspension and exit activities. Specific responsibilities may be assigned in participant records, transition plans, checklists or other approved organisational documentation.

Where participants require support to understand information, make decisions or communicate preferences, workers should utilise supported decision-making practices and reasonable adjustments.

Support Workers

• Provide information within the scope of their role in a clear, respectful and accessible way, and refer questions outside their authority to the responsible Manager or Team Leader.

• Follow current support, risk, safeguarding, communication and transition instructions relevant to the participant.

• Observe the participant during periods of change for signs of uncertainty, distress, emerging risk or disruption to supports, and respond within the scope of their role.

• Document and promptly report changes, concerns, incidents, unmet needs and barriers that may affect participant safety, wellbeing or continuity of supports. 

• Maintain professional boundaries, privacy and respectful communication with participants, representatives, stakeholders and other providers.

Managers and Team Leaders

• Coordinate transition, transfer and exit activities, including identifying responsible persons, confirming actions and timeframes, and ensure appropriate communication and oversight.

• Ensure workers have access to current information, support plans, risk information and instructions necessary to deliver safe and effective supports.

• Review significant changes, transition-related risks and safeguarding concerns, and arrange escalation, specialist input or management review where required.

• Support continuity-of-support arrangements and take reasonable steps to minimise disruption to participant supports, wellbeing and outcomes.

• Support workers to respond appropriately to participant questions, uncertainty, distress, incidents, emerging risks and barriers that arise during periods of change.

• Ensure participant involvement is supported and that participant preferences, decisions and agreed actions are appropriately documented.

• Oversee transition documentation, records-transfer activities and organisational record-keeping requirements associated with commencement, transfer and exit processes.

• Review incidents, complaints, participant feedback and other matters arising from transition activities and ensure appropriate follow-up actions are completed.

• Monitor the effectiveness of transition arrangements and implement corrective actions where participant safety, continuity of supports or transition objectives may be compromised.

• Identify workforce development needs, service-delivery issues and opportunities for continual improvement arising from transition, transfer and exit activities.

• Ensure transition activities are completed in accordance with organisational policies, procedures, safeguarding requirements, legislative obligations and participant rights.

Manager Responsible for Intake, Onboarding and Assessment

• Gather, review and verify the information reasonably necessary to assess service suitability and commence supports safely.

• Confirm participant preferences, communication needs, consent and authority arrangements, support requirements, risks, safeguarding considerations and continuity needs. 

• Coordinate input from the participant, authorised representatives, relevant workers, referrers and previous providers where appropriate authority exists. 

• Ensure identified requirements are reflected in current participant documentation and communicated to workers before supports commence or materially change. 

Risk Focus Areas Requiring Monitoring and Action

Commencement and Onboarding of Services

Before services commence, the Manager responsible for intake, onboarding and assessment must take reasonable steps to gather, review and verify the information necessary to deliver safe and effective supports.

This may include a review of participant goals, support requirements, risk information, safeguarding considerations, consent arrangements, communication needs, behavioural support requirements, health information, and any relevant information provided by previous providers where appropriate authority exists.

Changes to Supports and Service Arrangements

Participants may experience changes to support needs, funding arrangements, goals, living arrangements, risks, communication requirements, support strategies or personal preferences throughout their service journey.

Where significant changes occur, the responsible Manager must coordinate a review of relevant support documentation, risk-management information, safeguarding arrangements and service-delivery requirements to ensure supports remain suitable, safe and responsive to participant needs.

Support workers must assist participants to understand and participate in changes within the scope of their role. The responsible Manager or Team Leader must ensure agreed changes are reflected in relevant organisational records and communicated to workers who need the information.

Continuity of Supports Planning

DCIRS recognises that continuity of supports is an important safeguard throughout participant transitions.

Where a participant may be at risk of service disruption, the responsible Manager must coordinate reasonable steps to identify interim arrangements, alternative supports or other measures to minimise adverse impacts on participant wellbeing and outcomes..

Continuity planning should consider participant goals, support requirements, communication needs, safeguarding concerns, stakeholder involvement, and any barriers to successful transition outcomes.

Service Transfer to Another Provider

Participants have the right to choose their provider and request transfer of services.

Where a participant elects to transfer to another provider, the responsible Manager must coordinate an orderly and respectful transition wherever reasonably practicable.

Transition planning should consider participant preferences, consent arrangements, transfer timeframes, continuity requirements, safeguarding matters, open incidents, outstanding actions, and records-transfer arrangements.

Participant Planned Exit

Where a participant plans to exit DCIRS services, the responsible Manager must coordinate an orderly and respectful exit wherever reasonably practicable.

Exit planning should consider participant preferences, consent arrangements, exit timeframes, continuity requirements, safeguarding matters, open incidents, outstanding actions and authorised records-transfer or service-closure arrangements.

Provider-Initiated Service Cessation

In limited circumstances, DCIRS may determine that continuation of services is no longer appropriate or possible.

Any decision to cease services must be based on objective considerations, comply with contractual, legislative and organisational obligations, and be approved through appropriate senior management review.

Before initiating service cessation, consideration should be given to participant safety, continuity requirements, safeguarding risks, alternative options, communication requirements, and transition-planning obligations.

Emergency and Unplanned Exit Arrangements

Some circumstances may require urgent transition arrangements or immediate cessation of services.

Examples may include significant safeguarding concerns, emergency relocation, provider incapacity, participant withdrawal without notice, tenancy breakdown, serious risks to health or safety, or other unforeseen circumstances.

In these situations, the responsible Manager must coordinate the immediate response and prioritise participant safety, risk management, safeguarding obligations and continuity of supports wherever reasonably possible.

Relevant decisions, communications, actions, and escalation activities must be documented.

Supported Independent Living and Shared Environment Transitions

Transitions within Supported Independent Living and shared support environments may present additional risks relating to tenancy arrangements, compatibility, participant wellbeing, community connections, support relationships, and continuity of daily living supports.

Where participants are entering, exiting or changing arrangements within SIL or shared environments, transition planning should consider the needs of the participant concerned and the impact on other participants where relevant.

Participant Records and Information Transfer

Participant information must only be transferred where lawful authority, participant consent, representative authority, or another approved basis for disclosure exists.

Information shared during transition activities should be limited to information reasonably necessary to support continuity of supports, participant safety, and effective service coordination.

Records-transfer activities must be undertaken in accordance with the NDIS Privacy and Confidentiality Policy and the Participant Records and Information Management Procedure.

Service Exit and Review Closure

DCIRS may utilise transition or exit checklists to support consistency, accountability, and quality assurance throughout transition activities.

Checklist activities may include a review of participant consultation, support requirements, consent arrangements, identified risks, records-management activities, authorised transfer of information, incidents, complaints, outstanding actions and service-closure requirements.

The use of checklists does not replace professional judgement, participant consultation, or risk-assessment requirements.

Participant Death, Bereavement and Service Closure Arrangements

Where DCIRS becomes aware of the death of a participant, the organisation will respond respectfully, sensitively and in accordance with applicable organisational, legislative, safeguarding and reporting requirements.

Appropriate communication should occur with authorised representatives, family members, and stakeholders where authority exists and communication is appropriate.

Workers must comply with applicable incident-reporting, safeguarding, records-management, and privacy requirements.

Relevant actions, decisions, notifications, and follow-up activities should be documented in approved organisational systems.

Service closure activities should include a review of participant records, completion of outstanding actions, management of organisational property where relevant, records-retention requirements and secure archiving processes.

Risk Assessment and Review Factors

Transition Risk Assessment and Review

A transition risk assessment should be undertaken where a participant has complex support needs, behavioural support requirements, significant health concerns, safeguarding risks, communication barriers, tenancy-related matters, provider-transfer arrangements, or other circumstances that may affect continuity of supports.

Transition risk assessments should consider participant safety, continuity of supports, safeguarding concerns, health requirements, communication needs, stakeholder involvement, environmental changes, transport arrangements, and identified transition barriers.

Where required, transition risks should be incorporated into existing risk-management, safeguarding or support-planning documentation.

Transition Planning Documentation

Transition planning activities should be documented in a manner proportionate to the participant's circumstances, complexity, and level of risk.

Documentation may include participant preferences, transition objectives, identified risks, agreed actions, communication arrangements, stakeholder responsibilities, continuity planning activities, records-transfer requirements, timeframes, and review activities.

Where multiple parties are involved, responsible persons should be clearly identified to support accountability and coordination.

Documentation should demonstrate participant involvement wherever possible and reflect any supported decision-making arrangements implemented throughout the transition process.

Additional Risk Factors for Consideration

As well as the general environment in which supports are delivered, other factors can increase the risks associated with participant transitions, transfers and exits.

Additional risks may arise where participants have complex support needs, communication barriers, behavioural support requirements, safeguarding concerns, significant health needs, tenancy-related matters, restricted support options, limited informal supports, or circumstances that may affect continuity of supports.

Periods of service commencement, provider transfer, service suspension, and exit can present increased risks relating to communication, information sharing, participant wellbeing, service coordination, and the continuity of supports.

When Risk is not Acceptable

Workers must use their training, experience and available organisational guidance to identify when transition-related risks become unacceptable.

Examples may include significant safeguarding concerns, inability to maintain participant safety, serious continuity-of-support risks, unlawful information-sharing requests, unmanaged health risks, tenancy breakdown, escalating behavioural concerns, or circumstances where a participant may be exposed to harm. Where significant concerns are identified, workers must cease activities where appropriate and escalate the matter in accordance with safeguarding, incident-management, risk-management or management-review requirements.

Oversight, Review and Continual Improvement

Transition activities, participant feedback, complaints, incidents, safeguarding concerns, continuity issues, and identified service gaps may inform quality reviews, risk reviews, workforce development activities, and continual-improvement initiatives.

ASSOCIATED DOCUMENTS

• Continual Improvement Policy

• Incident and Risk Reporting Policy

• NDIS Feedback and Complaints Policy

• NDIS Privacy and Confidentiality Policy

• NDIS Safeguarding Policy

• Participant Records and Information Management Procedure

• Risk Management Policy

• Service Agreement

VERSION AND REVIEW INFORMATION

DCIRS reserves the right to amend and vary this procedure from time to time.

Version 1.0:18 August 2026 | Review Date: 18 August 2028

© 2026 DCIRS Community Care Pty. Ltd. All rights reserved. This procedure is the intellectual property of DCIRS Community Care. No part of this document may be reproduced, distributed, copied, or transmitted in any form or by any means, including photocopying, digital scraping, or other electronic methods, without the prior written permission of the copyright owner.