Transition Care
Patient information
What we do
The Transition Care Program (TCP) provides short-term care and services for older people after they leave hospital. By offering maintenance (low level) therapy and support, TCP allows older people to continue their recovery out of hospital while appropriate long-term care and or services are arranged.
To receive TCP you will need to be assessed and approved by the Aged Care Assessment Service while you are in hospital.
TCP can be delivered in your home or in a residential care setting. If your care needs change, you can transfer from one setting to another within a permitted timeframe. For example, you may start Transition Care in a residential care setting and then go home, and continue to receive services in your home to assist with your final recovery period.
Bayside Health (Alfred Care Group) delivers bed-based Transition Care at 2 different sites:
Coppin Centre 45 Moubray Street, Melbourne, 3004
Hammond Care 294 Kooyong Road, Caulfield, 3162.
To view any of these sites, please discuss with your Social Worker or call the TCP Office to speak with the Manager or a TCP Senior Clinician to arrange a tour.
Who we care for
We provide care and support for people staying in hospital (public or private) who are :
- Are 65 years and over, or
- Aboriginal or Torres Strait Islanders who are 50 years and over
Who are staying in any hospital (public or private).
What to expect
Access to TCP services is usually recommended by the treating hospital team and discussed with you and your family/carers while you are still in hospital. With consent, the treating team will then refer you to TCP.
Services which may be provided include home-based and bed-based care.
Home based care
You will receive care in your home with services including:
- Nursing and in-home respite
- Help with cleaning, meals or bathing
- Setting up medical appointments
- Assistance with travel to appointments
- Therapy from allied health staff, such as a physiotherapist
- Support equipment can be hired during your TCP stay
Bed based care
You will receive care the residential care facilities that partner with Bayside Health (Alfred Care Group).
Services could include:
- Nursing and on-call support
- Medication assistance
- Help with everyday tasks like bathing or walking
- Dementia support
- Setting up and assistance with travel to medical appointments
- Therapy from allied health staff, such as a physiotherapist
- Lifestyle activities
It is unlikely you will need all of these services.
The services you receive and where they are provided, will be based on your care needs and will be limited to the funding available.
The program does not include services such as:
- Pathology or radiology (like blood tests or x-rays)
- Ambulance travel to or from hospital
- Prescription medicine or pharmacy fees
- GP appointments
Commonly asked questions
TCP is a form of Flexible Care and is legislated under the Aged Care Act 1997. We are a jointly funded Australian and State Government program.
You can only access TCP with a valid TCP approval from the Aged Care Assessment Service (ACAS), which the treating or TCP team can arrange for you. This approval is valid for 28 days and we expect you will be offered TCP services within this time period.
You may require a period of leave whilst in TCP for either medical or social reasons. The program permits up to 7 nights leave per TCP episode and your Case Manager will discuss leave arrangements with you if it is necessary.
While in hospital, your treating team may recommend and discuss the Transition Care Program with you if they determine you will benefit from entering the program.
Alternatively, you can refer yourself by discussing your eligibility with the treating team or an Aged Care Assessor.
TCP is a short-term program of up to 12 weeks to assist you with reaching your individual care goals. It is expected you / your nominated support person will work with the TCP Case Manager and team to reach your individual care goals within this timeframe. In exceptional circumstances, where your care goals have not been reached, your Case Manager can discuss the option of applying to My Aged Care for a further 6 week extension.
The Commonwealth government has set a daily fee which is calculated at 85% of the single aged care pension for bed based care and 17.5% for home based care. The daily fee is indexed according to CPI on the 20th of March and September each year. An adjustment may be made by the Bayside Health Invoicing team following these dates.
Providing there is no duplication of services, you can use your current Support at Home services with TCP.
What to bring
We recommend you bring
- Comfortable day clothes and footwear (preferably not slip on shoes) and night / sleep wear
- Personal hygiene items, such as shampoo, shaving equipment, toothpaste and deodorant
- Something to do, like a book to read, a magazine or an iPad or tablet with headphones
What not to bring
- Large amounts of cash
- Valuables, such as expensive jewellery.