Aged and Community Care

Transition Care Program

The Transition Care Program provides goal oriented, time limited and therapy focused care to help older people at the conclusion of a hospital stay.

Transition Care Program Guidelines

• Transition Care Program Guidelines
  The Transition Care Program Guidelines 2005 is a resource for approved providers, service providers and officers of the Department of Health and Ageing and all State and Territory government health departments.

Transition Care Training Handbook for Aged Care Assessment Teams

• Transition Care Training Handbook for Aged Care Assessment Teams

Note: A series of Frequently Asked Questions is provided in Appendix 6 of the Training Handbook. The Extension Form in Appendix 4 of the Training Handbook is available below. The ACCR in Appendix 5 is available in hard copy to ACAT members through Medicare Australia State Offices.

Transition Care Extension Form

• Transition Care Extension Form
  Transition Care Extension Form for Transition Care Service Providers and Aged Care Assessment Teams (ACATs)

The Claim and Advance Payment Cycle - Information for the Transition Care Program:

Note: Examples of the Transition Care Claim Form and Payment Statement are included at Attachments B and C.

• The Claim and Advance Payment Cycle
• Attachment B – Transition Care Claim Form
• Attachment C – Payment Statement (PDF 79 KB)

National Evaluation of the Transition Care Program

• National Evaluation of the Transition Care Program

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Overview

The Transition Care Program is designed to improve older people’s independence and confidence after a hospital stay.

The Transition Care Program was established in 2004-05 as a jointly funded initiative between the Commonwealth and states and territories. Since 2005 the Commonwealth has provided 2,000 transition care places to all states and territories broadly based on the proportion of non-Indigenous people aged 70 and over and Indigenous people aged 50 and over. In 2007-08 the Government made a budget announcement to provide an additional 2,000 transition care places by 2011-12. The recurrent costs to governments of these places are fully funded by the Commonwealth.

The Transition Care Program aims to help older people leaving hospital to return home rather than prematurely enter residential care.

Transition care is goal-orientated, time-limited and therapy-focussed. It provides older people after a hospital stay with a package of services that includes low intensity therapy (such as physiotherapy, occupational therapy and social work) and nursing support and/or personal care. It helps older people complete their restorative process and optimise their functional capacity, while assisting them and their family or carer to make long-term care arrangements.

The Transition Care Program is for older people who would otherwise be eligible for residential aged care. To enter the Program, clients must be assessed by an Aged Care Assessment Team (ACAT) while they are still an in-patient of the hospital. This can be organised through the hospital where the client has received their acute/sub-acute care. A transition care client can only enter transition care directly upon discharge from hospital.

Transition care can be provided in either a home-like residential setting or in the community. The average duration of care is 7 weeks, with a maximum duration of 12 weeks that may in some circumstances be extended by a further 6 weeks.

States and territories represented by their health departments are the Approved Providers for transition care under the Aged Care Act 1997. This arrangement allows state and territory governments to develop their own service delivery models for transition care that best respond to local circumstances.

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