Transition Care Program

We provide short-term support to older people who require more time and care in a non-acute hospital environment. We assist older people to transition home or to a residential care facility.

Our services

We offer two programs to help clients transition:

• Community Transition Care Program—provides short term care in the client’s home.
• Residential Transition Care Program—provides short term care in a residential facility.

Eligible clients will be provided services based upon their immediate care needs and future planning which could include:

• case management—a designated health professional to coordinate, establish support and services
• nursing care including showering assistance, wound and medication management
• domestic assistance including light housekeeping, laundry, shopping
• transport to medical appointments (related to your recent hospital admission)
• additional therapeutic care including physiotherapy, occupational therapy, speech therapy, dietetics and social work
• medical management in collaboration with your general practitioner
• nursing services available 7 days per week including public holidays
• allied health service available Monday to Friday excluding public holidays.

How to access this service

Referrals can be made by treating teams in a hospital or rehabilitation unit. You must be assessed as eligible by the Aged Care Assessment Service. Referrals can be coordinated by discharge planners or in public hospitals by the Geriatric Rehabilitation and Liaison Service.

To be accepted to a transition care program you will need to:

• be medically stable
• be able to participate in a structured therapy program
• be able to participate in goal setting
• be motivated to participate in the program.