If you end up in hospital for a time due to a health problem and are soon to be released back to your home, you may want to engage the Transition Care Program which can assist you in transitioning back into everyday life.
Last updated: January 5th 2021
Health & Specialised care
Key points:
Transition care aims to delay an older persons need for longer term care options
The program lasts for up to 12 weeks with an opportunity to extend a further six weeks if necessary
Transition care provides a range of nursing care, personal care and low intensity therapy services
The Transition Care Program provides short term support and assistance for older people after completing any necessary acute and sub-acute care in a hospital.
It aims to help in improving an individual’s independence and confidence, especially if you are still feeling a bit fragile from being in hospital.
It's a wish of the Australian Government to support older people in remaining at home for longer and feeling safe in that decision. Transition care can delay an older person's need for longer term care or moving into an aged care facility.
The program provides goal oriented, time limited and therapy focused care for older people at the end of a hospital stay. The care you receive will be tailored around your personal needs.
It can be delivered in an individual’s own home, out in community, in a ‘live in’ setting which must be a home-like, non-hospital environment with space available for therapy, or a mix of all of these locations.
To be eligible for transition care, an older person must be an inpatient of a hospital and have been assessed by the Aged Care Assessment Team (ACAT), or Aged Care Assessment Service (ACAS) if you live in Victoria.
Transition care can be provided for a period of up to 12 weeks, with a possibility to extend to 18 weeks if assessed as requiring an extra period of therapeutic care. Seven weeks is the expected average.
Transition care provides a package of services which include a range of low intensity therapy services, nursing support and/or personal care services.
Low intensity therapy services may include:
Physiotherapy
Occupational therapy
Dietetics
Speech therapy
Podiatry
Counselling
Social work
Social activities
Nursing support is provided by a registered nurse, including:
Pain management
Wound care
Catheter care
Dementia support
Oxygen therapy
Medication assistance and management
On-call access to nursing services
Personal care services may include:
Assistance with showering and dressing
Eating and eating aids
Managing incontinence
Transport to appointments
Mobility and communication
Dressing or assistance in using dressing aids
You can access transition care after seeing an assessor for a face to face assessment while you are in hospital.
If you want to organise this assessment, you can either ask the hospital staff to arrange it for you or contact My Aged Care on 1800 200 422 to enquire about it further.
The assessment will confirm you are a patient in a hospital and have been told you are ready to leave soon, and will determine if transition care would benefit you for a short period of time.
Once your eligibility for the program has been established, you can organise transition care from a provider.
That provider should be able to support you in heading back home after your hospital stay, this includes if you end up entering an aged care facility or exiting a facility.
An approved provider may charge a contribution fee to the cost of your care.
If you are receiving care in a 'live in' setting, such as a residential aged care facility, the maximum fee is 85% of the basic daily rate of a single pension, or $52.25 per day. (January 2021 rates).
If you receive this care while at home, the maximum fee is 17.5% of the basic daily rate of single pension, or $10.75 per day. (January 2021 rates).
Access to transition care is decided on a needs basis, not on an individual’s ability to pay fees.
You cannot receive transition care if you are currently receiving respite care or short-term restorative care, however, you can still access the program if you are receiving a Home Care Package, Commonwealth Home Support Programme services or are living in an aged care home.
Talk to your hospital social worker or discharge planner to find out more details about the Transition Care Program.
When you leave hospital after a brief stay, do you believe the transition care program would have you more at ease while back at home? Tell us in the comments below.
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The Transition Care Program provides a range of short-term care services to eligible older people following a hospital stay to help them regain as much independence as possible.
Services include therapy, nursing support and /or personal care that will help eligible older people regain as much independence as possible and assist them in making long term care and support arrangements.
The program is jointly funded by the Australian Government and the South Australian Government to provide older people with short term assistance following a hospital stay.
Fact sheets
Introduction to the Transition Care Program (PDF 87KB)
Information for older Aboriginal people (PDF 142KB)
Information for older culturally and linguistically diverse people (PDF 86KB)
Fact sheets in languages other than English
How does the Transition Care Program work?
Services are provided for up to a 12 week period with the aim to optimise the function of the eligible patient and can be provided in selected residential care beds or in the person’s home (or a combination of both).
The program also provides dedicated resources for short term therapy and support to assist older people achieve their best health outcomes. This can be a combination of a range of care services and could, for example, include:
- nursing
- physiotherapy
- occupational therapy
- speech therapy
- social work
- dietary advice.
Care is provided either in the person’s own home or a home-like environment within a residential setting such as an aged care home or similar facility.
Who is eligible for the program?
An older person is eligible for the Transition Care program if they are:
- in hospital and nearing the end of their hospital stay
- able to benefit from a program that can help improve recovery and restore independence as much as possible.
- have been assessed by and Aged Care Assessment Team (ACAT) as being eligible, and wish to be part of the Transition Care Program.
To be eligible, the older person must be in hospital and have an ACAT assessment approving them to access the program. Each person receives an individualised package of care that addresses areas of concern as identified by the person or their carer.
Eligibility and assessment fact sheet (PDF 109KB)
Further information
If you would like more information about the Transition Care Program in your area please contact:
Adelaide metropolitan
- Southern Transition Care Team
Telephone: (08) 8204 7640 Fax: (08) 8204 4627Email:
- Central Transition Care Program
Telephone: (08) 8222 8864
Fax: 1300 724 900 - Northern Transition Care Program
Telephone: (08) 7321 4066
Fax: (08) 7321 4081
Country Health SA
Country Referral Unit Address: 14 Scholz Avenue, Nuriootpa Postal: PO Box 858, Nuriootpa SA 5355 Telephone: (08) 8561 2186 Fax: (08) 8561 2128
Email:
If you are about to be discharged from hospital but you feel that you may need extra support for a while, the Home and Community Care (HACC) Program or the Transition Care Program (TCP) could be good options for you.
Accessing home support services
The kind of support you are eligible for will depend on your age and health.
The HACC Program provides basic support and maintenance services while the TCP provides short-term care through tailored support services for older people after they leave hospital. This allows older people to continue their recovery out of hospital while appropriate long-term care is arranged.
When you are about to be discharged from hospital, your healthcare team at hospital will arrange any support programs you need. They can also provide you with information about care services if you want to organise extra support once you return home.
Home and Community Care (HACC) Program
If you think you might benefit from getting some help in the home or from allied health services, talk to your doctor about how you can get local support services through the HACC Program.
You do not need a Aged Care Assessment Services (ACAS) assessment to receive HACC services as the organisations that provide these services conduct their own assessments to work out if you are eligible and how much it will cost.
To get an assessment for HACC services, contact your local council or ask your doctor for a referral.
Services available through HACC include:
- housework
- home maintenance
- transport
- personal care
- nursing
- respite care
- social activities
- allied health services.
For more information see the Home and Community Care fact sheet.
Transition Care Program
The TCP provides a higher level of support than HACC and requires approval by the ACAS while you are still in hospital.
The ACAS assessor (a doctor, nurse, social worker, physiotherapist or occupational therapist) will visit you in hospital to ask you about how you are managing day-to-day and about your overall health situation. At the visit, the assessors will give you information about the types of services that are available. Whether you are eligible for the TCP will depend on your individual needs, not on your ability to pay.
You can receive the TCP in a bed-based care setting (such as in a nursing home) or in your own home, depending on the type of care you need. Some people may even use the TCP in both settings during their time on the program.
Transition care services include:
- case management
- allied health services such as physiotherapy, dietetics, podiatry and social work
- nursing support
- personal care.
For more information:
- talk to your discharge planner or hospital social worker
- visit the My Aged Care website.
Aids and equipment
Before you go home from hospital, your healthcare team will work closely with you to find out what aids and equipment you may need when you go home. It’s a good idea to tell your healthcare team if you have any concerns about going back home, as they may be able to address these concerns.
Your healthcare team can help you get certain aids and equipment to help with your day-to-day life, for example, a walking frame or shower seat. They can help you decide what you’ll need, and also give you information about who to contact should you need any extra aids or equipment once you’re home.
Once you get your aids and equipment, your healthcare team will also check in with you regularly to see if the aids and equipment are meeting your needs or whether they need to make any adjustments or changes. Find more information on the Home aids and equipment fact sheet.
Support networks
Recovery at home can be a slow and lonely experience if you do not have family or friends close by. However, there is a wide range of support networks available for people leaving hospital, ranging from social and peer support (such as online and in-person support groups) through to organisations offering support around particular health conditions (such as the Cancer Council Victoria and beyondblue ).
Ask your healthcare professional or local doctor about support groups in your area, or search our Health Services Directory .
Discharge plan
Your doctor will develop a discharge plan for when you leave hospital. This plan will cover:
- your expected date of discharge
- your living arrangements (if you live alone, if someone can be there to help, what services you currently receive and if you have caring commitments of your own, such as an elderly partner)
- any possible restrictions on your activities such as lifting or driving a car
- your expected recovery and how long it will take
- any extra services you might need at home, such as wound care
- any aids and equipment you will need to help you to recover and regain your independence.
Your discharge plan will also be sent to your local doctor. Share this plan with any new healthcare professionals you see during your recovery. If things are not working out
If things are not working out
If you are feeling unwell once you get home or you are not recovering as expected, check your hospital discharge plan to make sure you are following the instructions.
Contact your doctor or NURSE-ON-CALL (1300 60 60 24) if you feel you need to check anything with a healthcare professional.
Sometimes the road to recovery can be long and the path ahead unclear. If you find you are struggling with your recovery emotionally, speak with your doctor, social worker, counsellor or community health centre. Your physical recovery will be most effective if you are mentally well.
Where to get help