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We aim to support older individuals to recover after a hospital stay to achieve further improvements in function with the plan to continue to live independently.

What is the Transition Care Program (TCP)?

We provide short-term care and services for people aged over 65, as they transition from an acute hospital to either home or long term care.

What do we do?

TCP can be offered in your home (home-based) or in our hospital (bed-based) and can help you to have more time in a supported environment before returning home or into long term accommodation. Where you receive transition care will depend on what the best place is for your recovery.  It is also possible to transfer from one care setting to the other. Our bed-based service is offered at both our Beaufort and Skipton facilities.

TCP can provide you with a package of services after your hospital stay, this may include:

  • Accommodation in a supported acute care facility or services at home
  • Case Management
  • Nursing
  • Allied Health services
  • Social Work support
  • Personal care
  • Cleaning
  • Meal assistance
  • Support or transport for appointments
  • Some equipment needs
  • In home respite
  • Social activities

What can you expect?

To qualify for TCP you will need to be assessed and approved by the Aged Care Assessment Service (ACAS) while in hospital.

You will be allocated a Case Manager from our TCP team.  As a goal-based program, your Case Manager will work closely with you, your family or carer, to set your individual goals and choose services that will best suit your needs. We aim to assist you to achieve further improvements in function with the plan of continuing to live independently, or, alternatively make appropriate long-term care arrangements.

The average duration of the program is seven weeks, with a maximum duration of 12 weeks. This may be extended in exceptional circumstances.

Is there a cost?

There is a small daily fee charge. Your Case Manager will discuss your fees and any other additional costs with you.

Home based clients daily rate is 17.5% of current single pension.

Bed based clients daily rate is 85% of current single pension.

Contact us

For more information please contact our Transition Care Program Coordinator on 5340 1173

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