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Nurse-Led Screening

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One appointment to make a plan.

A nurse-led screen is a short, structured check that works out what is going on with someone’s health and who should look at it next. An AHPRA-registered nurse works through evidence-based screening tools with you, writes down what they find, and connects you with the right practitioner.

Sometimes you know something has changed, but you are not sure what to do about it. Maybe a new NDIS plan has arrived and the list of possible supports is long. Maybe a participant has come on board with a health history that needs a closer look. Maybe someone just is not quite themselves lately. A screen is a straightforward way to find out what is going on and who needs to be involved. That is the whole service. No jargon, and no long report you have to decode.

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Funding Your Screening

Nursing supports may be funded through an NDIS plan, depending on how that plan is set up. Plan-managed, self-managed and agency-managed participants can all access our nurses, and we handle the service agreements and the reporting either way.

Providers can also engage us directly. This is common where a screen is part of onboarding a new participant, or where an organisation wants a health picture before it commits to a support arrangement. In that case the work sits with the provider rather than the participant’s plan.

Not sure if you are funded? We will help you check. Tell us the situation and we will talk you through which of the two pathways fits, before anyone commits to anything.

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What We Screen For

You can have one screen, several, or all of them. Tell us what you are worried about and we will work out which ones are worth doing.

Falls Risk and Mobility

How someone is getting around, and what might be getting in the way. Footwear, home layout, confidence, and the movements that have started to feel harder. Where a falls risk or a mobility issue turns up, we may refer to Occupational Therapy or Physiotherapy for a full falls risk assessment, depending on the level of risk and what is affecting the person’s movement.

Mealtime and Nutrition

Weight, appetite, and how mealtimes are actually going. Where a screen picks up signs of difficulty with eating or drinking, or a choking risk, we can refer to Speech Pathology for a swallowing assessment. Where the concern is nutrition, we can refer to Dietetics. Our nurses spot the risk and get it to the right practitioner.

Continence

Bladder, bowel, and how toileting is working day to day. What the routine looks like now, what products are in use, whether they suit, and whether anything has changed recently. Continence is one of the most common things people put up with quietly, and one of the most changeable once someone looks at it properly.

Skin Integrity

Skin condition, positioning, pressure care equipment, and who is doing the skin checks. For anyone spending long periods sitting or lying, this is the screen that catches a pressure injury before it becomes one. We look at the equipment already in use as well as the skin itself, and where the risk is significant, we can refer to Occupational Therapy or Physiotherapy, depending on the individual person’s needs.

Oral Health

Teeth, mouth, dentures, and daily oral care. Who is helping, how often, and whether the routine is working. Oral health gets missed more than almost anything else on this list, and it connects to eating, comfort, and infection risk.

Pain

Where it is, when it happens, and what makes it better or worse. This screen includes people who cannot easily tell you they are in pain. Our nurses use observation-based tools alongside conversation, and they talk to the people who see the person every day, because behaviour changes are often the first sign.

Polypharmacy & Medication Risk

How many medicines someone is on, who gives them, and when they were last reviewed. The NDIS Quality and Safeguards Commission usually defines polypharmacy as five or more regular medicines, or two or more psychotropic medicines. That is common and not a problem in itself, but it does make an accurate, regularly reviewed medication list more important.

INSIDE THE CLINIC

A Typical Screening Appointment

A nurse meets you in clinic, at home, or by telehealth. Telehealth can be video or phone, whichever suits you better. Family or support workers are welcome, and often helpful, because they notice the day to day things that do not show up in one appointment.

The nurse works through the screening tool with you. It is a conversation with some observations, not an examination. You will be asked about what has changed, what the routine looks like now, and what you are worried about. Most screens take between 45 and 60 minutes, and you can do more than one in the same appointment.

You get a written record of what the screen found, and a referral to any practitioner the screen points to. With your consent, we send a copy to your GP.

Where a screen identifies a need, we can refer you on and pass the findings directly, so you are not starting from scratch. Optimum Health Solutions has Physiotherapy, Occupational Therapy, Speech Pathology, Exercise Physiology, Dietetics, Podiatry and Behaviour Support in the same organisation, which makes that handover simple. If you would rather not stay with us, we can share the results with you, your GP or your Support Coordinator, with your consent, so you can find your own practitioner.

An important note on what a screen is.

Screening may identify whether you should see someone. It is not a diagnosis, and it is not a full assessment. If a screen flags something, the next step is a practitioner who can look at it properly.

Our nurses will tell you clearly what they found and who they think should see you, and then help you get there.

NDIS

Screening Through the NDIS

If you are new to the NDIS and the list of possible supports feels long, a screen is a practical place to start. It gives you a written record of what is actually going on, which is something concrete to take into planning conversations.

For providers, a screen at onboarding tells you what you are taking on before you build a roster around it, and gives you documentation for the participant’s file from day one.

When support needs have changed. Where a participant’s health, mobility, safety, nutrition, continence or other support needs have changed, a nurse-led screen can help identify and document those changes.

A screening is not an NDIS assessment and does not determine funding decisions. The findings may still help participants and their support teams identify areas requiring further assessment, and gather evidence to support a Change of Circumstances application or plan reassessment where appropriate. A screen documents what a nurse observed. It does not decide funding, and we cannot promise a particular plan outcome. What it does is put clear, written information in front of the people who make those decisions.

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COMMON QUESTIONS

Common Questions About Nurse-Led Screening

What is the difference between a screening and a full assessment?

A screen is a short, structured check that flags whether something needs a closer look. An assessment is the closer look. A screen might take 45 minutes and cover several areas at a surface level. An assessment goes deep on one thing and usually ends in a plan. Screening is the cheaper, faster way to find out where to spend the assessment.

I just got my NDIS plan. Where do I start?

A screen is a reasonable first step, because it tells you what is actually going on before you commit funding to any one support. You come away with a written record and, where something turns up, a referral to the practitioner who handles it. If you would rather just talk it through first, call us and we will help you work out whether a screen is worth doing.

Can my provider request a screen on my behalf?

Yes, with your consent. Providers and Support Coordinators refer participants to us regularly, often when someone is being onboarded with a complex health history. The provider can arrange it and we will still talk directly with you about what the screen found.

What happens after a screen identifies something?

The nurse writes down what they found and refers you to the practitioner who should look at it. Because Physiotherapy, Occupational Therapy, Speech Pathology, Exercise Physiology, Dietetics, Podiatry and Behaviour Support all sit inside Optimum Health Solutions, that handover is internal and the findings go with you. If you would prefer someone outside our organisation, we will share the results with you or your GP so you can take them anywhere.

Can a screen support a Change of Circumstances application?

It can contribute to one. A screen documents what a nurse observed and puts it in writing, which describes what is happening rather than what someone remembers. That written record can be useful evidence at a plan reassessment or alongside a Change of Circumstances application. What we cannot do is promise a funding outcome. A screening is not an NDIS assessment, and decisions about funding sit with the NDIA.

Can a screen be done by telehealth?

Some of it, yes. A conversation-based screen works well by telehealth, whether that is video or phone. Screens that rely on the nurse looking at something, skin integrity being the clearest example, work better in person. Tell us which screens you want and we will tell you plainly which parts have to happen face to face.

CLINICALLY REVIEWED BY

Renata Bell

RN, BNSc, GradCertPH, Cert II Business

HEAD OF CLINICAL DEVELOPMENT (Nursing and compliance)
OPTIMUM HEALTH SOLUTIONS

Renata is a Registered Nurse with extensive experience across disability, aged care, emergency, urgent care, community, primary health care and clinical governance. Renata has worked in various clinical settings in Australia and the UK and has a passion for Chronic and Complex Healthcare. She reviews all Nursing content for clinical accuracy and compliance.