Transition Care Program Guidelines 2011

Chapter 3: The Transition Care Program

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3.1 What is Transition Care?

On 23 April 2004 all Health Ministers endorsed the definition of Transition Care (its role, functions and target group) developed by the Care of Older Australians Working Group. An extract of the definition is contained below.

"Aim/Objectives
Transition Care provides short-term support and active management for older people at the interface of the acute/subacute and residential aged care sectors⁴. It is goal-oriented, time-limited and targets older people at the conclusion of a hospital episode who require more time and support in a non-hospital environment to complete their restorative process, optimise their functional capacity and finalise and access their longer term care arrangements.

The potential for further recovery will vary according to the individual. Therefore, the services provided will vary from individual to individual, ranging from those that further improve physical, cognitive and psychosocial functioning thereby improving the person’s capacity for independent living, to those that actively maintain the individual’s functioning while assisting them and their family and carers to make appropriate long-term care arrangements.

An outcome of Transition Care is that inappropriate extended hospital lengths of stay and premature admission to residential aged care are minimised. However, it should be stressed that Transition Care’s primary function is therapeutic, rather than administrative.

Mix of Services⁵
Depending on their assessed level of need, Transition Care will offer eligible older people several or all of the following:
• nursing support or personal care;
• low intensity therapy (such as physiotherapy, occupational therapy) and support (such as social work) to maintain physical, cognitive and psychosocial functioning and to facilitate improved capacity in activities of daily living;
• medical support such as GP oversight; and,
• case management, including establishing community supports and services and where required, identification of residential care options."

To access Transition Care, a person must first be assessed and approved for Transition Care by an Aged Care Assessment Team (ACAT). A person must enter the Transition Care Program directly upon discharge from hospital. Transition Care can be delivered in either a facility based residential setting or in a community setting, e.g. the person’s own home. It is possible to receive Transition Care in a residential setting first and then in a community setting, or vice versa. All Transition Care clients can access the Pharmaceutical Benefits Scheme (PBS) and the Medicare Benefits Schedule (MBS).

Note: Some people from overseas do not have access to the PBS and MBS and therefore will need to meet their own medical costs while on the Program (see also section 3.2.5 Older people from overseas).

3.1.1 Services provided through Transition Care

Schedule 1 of the Transition Care Payment Agreement details the range of services that may be provided as part of a care recipient’s Transition Care package.

Transition Care provides older people with a package of services that includes low intensity therapy such as physiotherapy and occupational therapy, as well as social work and nursing support or personal care. Transition Care must be provided in accordance with Schedule 1: Specified care and services for Transition Care Services (see Attachment B).

Schedule 1 is divided into three parts, i.e. care and services to be provided:

1. to all Transition Care clients;
2. to Transition Care clients who receive care in a residential setting; and
3. to Transition Care clients who receive care in a community setting.

Schedule 1 indicates the basic level of care that a Transition Care Service Provider must be able to provide, if required by a client.

The services provided as part of the Transition Care Program are designed to meet a client’s daily care needs and provide additional therapeutic care to enable the client to maintain or improve their physical, cognitive and psychosocial functioning, thereby improving their capacity for independent living.

The therapeutic care will vary from person to person, ranging from services that improve a client’s capacity for independent living to services that enable a client to enter residential aged care at an optimum level of functioning.

In providing Transition Care specified care and services, the Transition Care Service Provider must have systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards, quality frameworks and guidelines relevant to Transition Care provision.
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3.2 Eligible care recipients

Division 22 of the Aged Care Act 1997 sets out how a person becomes approved as a care recipient. Section 5.7A of the Approval of Care Recipients Principles 1997 states the requirements a person must meet to be eligible for Transition Care.

To decide whether a person is eligible for Transition Care, the person must be an admitted patient of a public or private hospital and assessed in hospital by an Aged Care Assessment Team (ACAT).

The ACAT may need to assess the person in consultation with the hospital geriatric rehabilitation service or members of the multidisciplinary team treating the person (which may include a registered nurse, the treating physician, occupational therapist, physiotherapist, social worker or other allied health discipline), as well as carers or family members as appropriate.

In assessing a person’s eligibility for Transition Care the ACAT must use the eligibility criteria listed at section 3.4.3 Assessment process for Transition Care. The ACAT Delegate will only approve a person for Transition Care if the person meets the eligibility criteria and is able to enter the Transition Care service directly upon discharge from hospital.

3.2.1 Aboriginal and Torres Strait Islander people

The expansion of the Transition Care Program from 2,000 to 4,000 places by 2011-12 includes a commitment to improve access to the Program by Aboriginal and Torres Strait Islander people. The states and territories, as the Approved Providers, must manage the delivery of Transition Care to ensure that Aboriginal and Torres Strait Islander people are equitably represented in the target population of the Transition Care Program.

An expected outcome of the Program in each state and territory is that the proportion of Aboriginal and Torres Strait Islander people assessed as eligible for Transition Care who subsequently receive Transition Care is no less than the proportion of non-Indigenous people assessed as eligible for Transition Care who subsequently receive Transition Care.

3.2.2 Older people with dementia

Older people with dementia who are assessed by the ACAT as able to benefit from the therapies and support provided by the Transition Care Program are eligible to participate in the Program. For older people with dementia who are unable to express their care goals, the development of care goals should involve the person’s family and/or carer.

3.2.3 Existing recipients of residential or community aged care

Existing recipients of Australian Government funded residential or community aged care services are able to access Transition Care if they are assessed and approved as eligible by an ACAT (see also section 3.5.4 Existing recipients of residential or community aged care in Transition Care).

3.2.4 Older people who usually reside interstate

The eligibility provisions for Transition Care under the Aged Care Act 1997 (the Act) do not restrict provision of care based on where care recipients live, or where they are assessed. Older people who are not residents of a particular state, territory or region can therefore access Transition Care services in that state, territory or region in particular circumstances. For example, an older person transferred to a tertiary hospital away from their usual place of residence to access specialist care can be discharged to a Transition Care Service in another location, based on their follow-up arrangements with their family and/or carer. It is important that Transition Care commences immediately on discharge from hospital (see also section 3.5.5 Movement between care settings and services).

3.2.5 Older people from overseas

Older people from overseas can access the Transition Care Program if they are ACAT assessed and approved as eligible using the same criteria as other patients. It is important to note that people who are not permanent residents of Australia may not be eligible for Medicare and subsidised pharmaceuticals and would thus be responsible for meeting their own medical and pharmaceutical expenses while in Transition Care. However, there are several countries with which Australia has reciprocal health agreements, and people from these countries may be eligible for Medicare. Further information is available on the following website: www.medicareaustralia.gov.au/public/migrants/visitors/uk.jsp

3.3 The role of hospitals

The role of hospitals in relation to the Transition Care Program is to:

• provide acute and/or subacute care, including rehabilitation and geriatric evaluation and management prior to referring a client to the Transition Care Program;
• identify and refer potential care recipients to the ACAT for assessment;
• ensure that the older person is medically stable and ready for discharge before they are referred for ACAT assessment;
• ensure that the geriatric and rehabilitation service or members of the multidisciplinary team treating the older person work closely with the ACAT during the assessment process; and
• work with the Transition Care Service Provider, the ACAT, the care recipient and their family or carer to develop a care plan as part of the care recipient’s hospital discharge planning process.

3.3.1 Referral process

ACATs accept referrals from all sources. An older person in hospital may self-refer for assessment by the ACAT, or may be referred by any member of the multidisciplinary team caring for the older person in hospital, or by their carer or family member. Hospital staff and the ACATs should be informed about the local availability of the Transition Care Program and the potential benefits and services offered by the Program.

To avoid disappointment, all potential care recipients in hospital and carers or family members should be informed whether Transition Care is available in the area where the older person wishes to access Transition Care, i.e. in their own home or in the local area of a carer or family member. Potential care recipients should also be made aware that access to a Transition Care place depends on:

• their being assessed and approved as eligible for Transition Care;
• availability of a vacant Transition Care place; and
• whether a Transition Care Service Provider can meet their care needs and accepts the person as a care recipient.

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3.4 Assessment and approval of care recipients for Transition Care

Divisions 19-22 of the Aged Care Act 1997 provide information on the approval of care recipients. Approval of care recipients is also outlined in the Approval of Care Recipients Principles 1997.

To access Transition Care, older people must first be assessed and approved by an ACAT as requiring the type and level of assistance Transition Care delivers, as set out in section 5.7A of the Approval of Care Recipients Principles 1997 (see Attachment C).

3.4.1 The Aged Care Assessment Team (ACAT)

The role of an ACAT is to assess the medical, physical, cultural, psychological and social care needs of frail older people and to assist them to gain access to the most appropriate aged care services, including approval for Australian Government subsidised residential, community or flexible care services, such as Transition Care.

Depending on the needs of the person, this may need to be in consultation with the hospital geriatric rehabilitation service and the multidisciplinary team treating the older person. As with any other ACAT assessments, the ACAT should give consideration to people with special needs under section 11-3 of the Aged Care Act 1997, i.e. Aboriginal and Torres Strait Islander communities, people from non-English speaking backgrounds, people who live in rural and remote areas, people who are financially or socially disadvantaged, veterans, homeless people and care-leavers⁶.

If the ACAT assessor establishes eligibility, a completed Aged Care Client Record (ACCR) for the person will be submitted to an independent ACAT Delegate for approval. The ACAT assessor will provide the person with information about aged care services and make the necessary referrals to an appropriate Transition Care Service Provider. The ACAT should also liaise with the Transition Care Service Provider to ensure the types of services required can be provided and the service is available and appropriate for the older person (see also section 3.4.4 Approval for Transition Care).

During the Transition Care episode, the ACAT should assist the Transition Care Service Provider, if necessary, in reviewing a care recipient’s needs, re-assessing appropriate care options or referring to a more appropriate service (see also section 3.5.2 The Transition Care Service Provider). The ACAT also assesses a care recipient’s need for an extension on the request of the Transition Care Service Provider (see also section 3.5.7 Extensions).

3.4.2 Who should participate in an ACAT assessment?

As with all ACAT assessments, where appropriate, and with the older person’s permission, the assessment should involve:

• the older person and his or her carer, family or representative;
• an interpreter or an Aboriginal or Torres Strait Islander health worker or liaison officer as required, in accordance with the individual’s preferences; and
• other health and rehabilitation professionals, as appropriate.

3.4.3 Assessment process for Transition Care

When considering a person’s suitability for Transition Care, the ACAT assessor must consider the eligibility criteria for Transition Care and several additional factors, i.e. the ACAT must ascertain that the person:

• is a public or private hospital in-patient, or is receiving acute or subacute care under a hospital-in-the-home or equivalent program where the patient is classified as an in-patient;
• has completed his/her episode of acute and/or subacute care, is medically stable and ready for discharge at the time of assessment;
• wishes to enter Transition Care;
• would otherwise be eligible for at least low level residential care;
• would have the capacity to benefit from a package of services that includes, at least, low intensity therapy and nursing support or personal care; and
• would have the capacity to benefit from goal-oriented, time-limited and therapy-focussed care necessary to:
  • complete their restorative process;
  • optimise their functional capacity; and
  • assist in making long-term arrangements for their care.

In addition, the ACAT must consider the following factors:

• The intent of Transition Care is to benefit older people through time-limited, low-intensity therapy and support immediately after a hospital episode.
• Transition Care is designed to improve older people’s capacity for independent living and to maintain their functioning, while assisting them and their family and carers to make appropriate long-term care arrangements.
• The therapeutic care provided by the Program will vary from individual to individual, ranging from services that improve an older person’s capacity for independent living, to services that enable a person to enter residential aged care at an optimum level of functioning.
• The ACAT, in consultation with the hospital geriatric rehabilitation services or equivalent, and other members of the multidisciplinary team caring for the patient, needs to ensure that the full range of clinical and/or rehabilitation support to be provided by the hospital has been completed before a person enters Transition Care.
• Entry to Transition Care must immediately follow the person’s discharge from hospital.
• Close co-operation and liaison between the hospital discharge planner, the ACAT and the Transition Care Service Provider is required to ensure a Transition Care place is available in a timely manner, to benefit the older person.
• As part of the comprehensive ACAT assessment, the older person and their carer and/or family as appropriate, should be fully informed of the range of other available aged care services that may be appropriate for them. The ACAT should assess the person’s eligibility for those options and approve them if clinically appropriate.
• If the person is only approved as eligible for Transition Care at the time of the initial ACAT assessment, it is likely that they will need a re-assessment before the completion of their Transition Care episode, to establish their long-term care requirements. Where this is necessary, the ACAT will take into account any changes to the person’s care needs and ensure that the long-term care recommendations reflect the revised level of need and the person’s preferences.

3.4.4 Approval for Transition Care

A person must be approved under Divisions 19-22 of the Aged Care Act 1997 (the Act) before an Approved Provider can be paid flexible care subsidy for the provision of Transition Care. Division 23 of the Act deals with how an approval can cease to have effect. Division 85 of the Act deals with reconsideration and review of decisions.

An ACAT approval to enter Transition Care is valid on the date the ACAT Delegate signs the approval, and then for four weeks (28 calendar days) after the date of signing. The person must enter the Transition Care Program within this four week ‘entry period’. If the person does not enter the Program within the four week period, their approval will lapse and they will need a re-assessment for Transition Care, if appropriate.

As Transition Care places may become vacant at short notice, ACATs should approve eligible clients for Transition Care even if there is not an immediate vacancy at the time of referral. As with all ACAT approvals, clients should be reminded that approval as a care recipient does not guarantee a Transition Care place, particularly if a vacancy does not present itself during the person’s stay in hospital.

The result of an ACAT assessment, and the decision to approve or not approve a person to receive Transition Care, must be provided to the person who has applied for the care (or their representative) in writing and provide the reasons for the decision. A decision to reject a person’s application for Transition Care is a ‘reviewable decision’ under section 85-1 of the Act. The relevant Aged Care Assessment Program guidelines on reviewable decisions are available on the Department of Health and Ageing website.

3.4.5 Assessment and approval in a short stay unit of an Emergency Department

Where appropriate, older people may access the Transition Care Program from a short stay unit or equivalent in an Emergency Department, provided:

• they have been admitted to hospital (i.e. are classified as hospital in-patients);
• they are medically stable and have been ACAT assessed and approved as meeting all other eligibility criteria for Transition Care under section 5.7A of the Approval of Care Recipients Principles 1997; and
• it is not more appropriate for the patient to receive subacute care such as rehabilitation or geriatric evaluation and management⁷.

The care provided while the older person is an in-patient of the short stay unit should involve discussion between the treating multidisciplinary team, geriatrician, and Transition Care service staff, as well as a comprehensive assessment by an ACAT to ensure that the person is medically stable and not identified prematurely for the Program.

3.4.6 Hospital and assessment information for care plan development

For those people approved as eligible for Transition Care, the hospital geriatric rehabilitation service and the ACAT assessment are key information sources for the development of a care plan to guide the therapy services delivered through Transition Care. It is important that the ACAT attaches a copy of all relevant assessment documentation to the copy of the Aged Care Client Record given to the Transition Care Service Provider.
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3.5 Entry to Transition Care

A care recipient can only enter Transition Care directly upon discharge from hospital in order to derive maximum benefit from a time-limited episode of low intensity therapeutic interventions.

An ACAT approval to enter Transition Care is valid on the date the ACAT Delegate signs the approval, and then for four weeks (28 calendar days) after the date of signing (see also section 3.4.4 Approval for Transition Care).

Older people who are receiving care under a hospital-in-the-home or equivalent program cannot commence their Transition Care episode while they are still classified as an in-patient of the hospital.

Older people who are discharged from hospital and have returned to their usual place of residence before commencing the Program are no longer eligible to enter the Program.

3.5.1 Duration of care

The average duration of a Transition Care episode is seven weeks, according to 2009 Department of Health and Ageing data. Flexible care subsidy will be paid for all Transition Care recipients up to a maximum of 12 weeks and in exceptional circumstances, where an extension has been granted, up to a further six weeks (see also section 3.5.7 Extensions).

To ensure that the limited Transition Care resources benefit as many older people as possible, there should not be an assumption that the Transition Care Program is a ‘twelve-week program’ for every care recipient. Care is provided based on each care recipient’s care needs.
While some care recipients may require the maximum 12 weeks of care and an extension of up to six weeks, the majority of care recipients do not require the maximum period of care.

Additionally, there must not be a gap between residential and community based Transition Care services where both forms of Transition Care are provided during the one episode of care.

3.5.2 The Transition Care Service Provider

Transition Care Service Providers manage the day-to-day operations of a Transition Care service⁸. This includes:

• assisting in the admission of clients to Transition Care, their return to hospital if required and their transfer to their preferred long-term care option;
• liaising with their local ACAT and/or Transition Care coordinator and advising of the capacity of the service to accept new care recipients, and any Transition Care vacancies in the region;
• offering and remaining ready at all times to enter into a Transition Care Recipient Agreement with eligible clients (see also section 4.2 Transition Care Recipient Agreement);
• having appropriate processes in place to receive, record and resolve complaints and handle them fairly, promptly, confidentially and without retribution (see also section 6.1.5 Complaints); and
• reporting (activity, financial and quality) as per Transition Care Program and contract requirements to the Approved Provider.

Transition Care Service Providers are responsible for providing services appropriate to the needs of their care recipients for the period the care recipients are under their care. Transition Care must be provided in accordance with Schedule 1: Specified care and services for Transition Care services at Attachment B and Chapter 6: Quality Assurance in Transition Care.

The Transition Care Service Provider, following consultation with the referring hospital, will make the final decision as to whether the person’s care needs can be adequately met in their facility or by their community service and whether they have any places available.

The Program is organised on a calendar day basis. As it is a time-limited program, services should be provided according to the care plan on a 7-day a week basis, including weekends and any public holidays falling within the Transition Care period.

Care planning

The Transition Care Service Provider develops a care plan for a care recipient which should incorporate a therapeutic care plan developed through the care recipient’s hospital discharge planning, the ACAT assessment process and in consultation with the care recipient, carer or family, where appropriate. For older people with dementia who are unable to express their care goals, the development of a care plan may need to involve the person’s family and/or carer.

Case management

The Transition Care Service Provider has a responsibility to assist in the admission of a client to the Transition Care Program, in their return to hospital should this be required, and in their subsequent transfer to their preferred long-term care option at the end of their Transition Care episode. The Transition Care Service Provider plays a significant role in the care recipient’s case management, including establishing community support and services and, where required, identification of residential care options.

Cooperation with ACATs

To facilitate the best outcome for each care recipient, both during and after the assessment process, Transition Care Service Providers should have an effective working relationship with their local ACAT.

• Service providers should liaise with the ACAT and keep them informed about the capacity of their service to accept new care recipients, and any Transition Care vacancies in the region.
• Service providers may involve the ACAT in reviewing the care recipient’s needs, re-assessing appropriate care options and/or referring the care recipient to a more appropriate service.
• The Transition Care Service Provider may also identify care recipients who potentially require an extension to their Transition Care episode and submit an Transition Care extension application form to an ACAT for review (see also section 3.5.7 Extensions).

3.5.3 Residential based Transition Care

Providers of residential based Transition Care are expected to provide services that reflect the intent of the Transition Care Program to optimise the older person’s health and independence. Residential based Transition Care services should be provided in a more home-like, less institutional environment, including:

• communal living space/living room environment which is completely separate from sleeping areas and the location of acute/subacute care provision, i.e. a space that encourages family, carers and visitors to spend time with care recipients;
• a dining area and care recipients being encouraged not to eat in bed;
• care recipients being encouraged and supported to dress every day;
• facilities for care recipients to prepare snacks for themselves and their visitors;
• privacy, particularly for personal care and bathing arrangements;
• space for care recipients to mobilise, especially outdoors;
• physical arrangements which support the involvement of carers in the therapeutic activities; and
• a model of care and staff knowledge that supports the intent of the Transition Care Program to promote the older person’s health and independence.

Transition Care services may also be provided in rural and remote hospitals when appropriate. The requirements for the more home-like environment may be relaxed on a case by case basis in these locations, if relevant (see also Transition Care Program Quality Standards at Attachment A - Appendix 1).

3.5.4 Existing recipients of residential or community aged care in Transition Care

Existing recipients of Australian Government funded residential or community care services are able to access Transition Care if they are assessed as eligible. The Australian Government has created a category of leave to enable this to occur. An existing recipient of residential aged care, a Community Aged Care Package (CACP), an Extended Aged Care at Home (EACH) or EACH Dementia (EACH D) package can be on leave for the purposes of Transition Care, as long as they are in receipt of Transition Care.

The Australian Government subsidy continues to be paid to the original aged care provider during periods of leave for Transition Care. However, for residential aged care residents, after 30 consecutive days of either hospital leave or leave for Transition Care (which must be preceded by hospital leave), the subsidy to the aged care home drops by 50% for residents who have a classification under the Aged Care Funding Instrument (ACFI) and are being paid the ACFI subsidy. The reduction in subsidy of 50% also applies to residents who have an ACFI classification but are still being paid a grandparented subsidy rate under the old Resident Classification Scale (RCS).

The Transition Care Service Provider should notify the residential aged care provider, CACP, EACH or EACH D service provider when existing recipients of such services enter Transition Care.

When an existing recipient of residential care is accepted into the Transition Care Program, the older person must be provided with the full package of Transition Care services to be provided in a residential setting, in accordance with Schedule 1: Specified care and services for Transition Care services at Attachment B and Chapter 6: Quality Assurance in Transition Care.

Similarly, when an existing recipients of a CACP, EACH or EACH D package is accepted into the Transition Care Program, the older person must be provided with the full package of Transition Care services to be provided in the community setting, in accordance with Schedule 1: Specified care and services for Transition Care services at Attachment B and Chapter 6: Quality Assurance in Transition Care.

In both cases, the Approved Provider (state or territory health department) must have a discrete contract with the residential or community aged care provider engaged to provide Transition Care services.

In exceptional cases, an older person who is an existing recipient of residential aged care may be discharged home from hospital to receive interim community based Transition Care with support from their family or carer before returning to residential aged care.

A community based Transition Care package cannot be provided into a residential based setting.

3.5.5 Movement between care settings and services

To facilitate client-centred Transition Care delivery, it is possible for care recipients to move from one setting to another within the same Transition Care episode, i.e. from residential to community setting or vice versa. Care recipients do not require an ACAT re-assessment to enable this move.

Where available and appropriate, the step-down from residential to community based care within a Transition Care episode should be encouraged to maximise the care recipient’s opportunities to return to independent living in the community.

Care recipients are also able to transfer from one Transition Care Service Provider to another (within their state or territory or interstate), provided there is no break in care, i.e. there is no day during which the care recipient does not receive Transition Care services from the first or the second service provider.

Where a care recipient transfers between Transition Care Service Providers within their own state or territory, there is no need to enter into a new Transition Care Recipient Agreement, because the same state or territory government is the Approved Provider. However, if a care recipient moves to a new Transition Care Service Provider in a different state or territory, a new Transition Care Recipient Agreement must be offered to the care recipient, reflecting the period remaining in the episode of care (see also section 4.2 Transition Care Recipient Agreement).
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3.5.6 Re-admission to hospital from Transition Care

If the hospital re-admission is for a day procedure or for an overnight stay, the service provider must provide Transition Care up to the point of admission and then again from the point of discharge on the same day or the next day. This will ensure that there is no break in the service provider’s eligibility for flexible care subsidy under the Act.

If a Transition Care recipient requires re-admission to hospital for longer than an overnight stay, the Transition Care episode will cease, i.e. the care recipient must be discharged from the Transition Care Program.

However, if a care recipient is re-admitted to hospital for longer than an overnight stay and the re-admission falls within the four week ‘entry period’ for which the ACAT approval to enter Transition Care is valid, the care recipient may be able to enter a new Transition Care episode without the need for an ACAT re-assessment, if clinically appropriate.

An ACAT re-assessment is only required if the care recipient wishes to re-enter the Transition Care Program after the four week entry period has expired, and the re-admission to hospital may have changed the person’s eligibility status since the last approval for Transition Care services.

3.5.7 Extensions

In exceptional circumstances, a care recipient may require an extension to a Transition Care episode where their care will need to exceed the 12 week maximum. To apply for an extension, the Transition Care Service Provider must complete a Transition Care extension application form with the care recipient (or representative) within the initial 12 week episode of Transition Care. Once the Transition Care Service Provider has completed the form, they must forward it to an Aged Care Assessment Team (ACAT) for review. This form is available from the Department of Health and Ageing website at http://www.health.gov.au/internet/main/Publishing.nsf/Content/ageing-policy-transition.htm.

ACATs should only grant extensions if care recipients have further therapeutic care needs and wish to receive further Transition Care to achieve a better outcome. In such cases, an assessment for an extension to Transition Care, which specifies the duration of the extension, may be undertaken. The maximum duration for an extension is six weeks (42 days) and only one extension may be granted per Transition Care episode.

Based on the information provided by the Transition Care Service Provider, and other sources such as the care recipient and relevant health professionals as appropriate, the ACAT will assess whether or not an extension is required.

It is not necessary for an ACAT to comprehensively re-assess a Transition Care recipient if the service provider has identified that the person requires an extension and provides the following information:

• reasons why goals were not achieved in 12 weeks;
• physical, cognitive and psychosocial goals that the care recipient would be working on during the extension;
• team action required to achieve care recipient goals and discharge;
• action required by external services to achieve care recipient goals and discharge;
• relevant information from other sources such as the care recipient (or representative) or health professionals; and
• the proposed number of days of extension.

However, the ACAT may undertake a comprehensive re-assessment of the care recipient if they are not satisfied with the information provided by the Transition Care Service Provider. The extension form does not need to be signed by the same ACAT who undertook the initial assessment for eligibility for Transition Care.

The Transition Care Service Provider should allow sufficient time for the ACAT to review the status of the care recipient if it is likely that a more comprehensive re-assessment is required. Whilst a decision to extend or not extend a care recipient’s episode of Transition Care is not a ‘reviewable decision’ under the Act, the Department of Health and Ageing offers a right of review to any person whose request for an extension is denied. In the first instance, the decision should be discussed with the ACAT, then a request for a review should be made to an officer of the Department of Health and Ageing by writing to the state manager of the relevant state or territory office of the Department of Health and Ageing. The review would be conducted by the state or territory office’s aged care assessment area and would follow the same process as for reviewable decisions under the Act. The relevant Aged Care Assessment Program guidelines on reviewable decisions are available on the Department of Health and Ageing website.

3.5.8 Accessing long-term care after Transition Care

A person cannot commence both Transition Care and another form of Australian Government funded aged care, such as residential care, respite, CACP, EACH or EACH D packages, on the same day.

Pre-entry leave for residential aged care

In accordance with section 42-3(3) of the Act, a residential aged care service may claim up to seven days of residential care subsidy as ‘pre-entry leave’ for an older person who has accepted an offer of a place in that residential aged care service. This includes older people receiving Transition Care who are about to be discharged to residential aged care (see also section 4.6.2 Determining care fees).

Residential aged care services cannot claim pre-entry leave for an existing residential aged care recipient who is on leave from residential care and is receiving Transition Care.

Accessing community care

Transition Care recipients can only commence Australian Government funded community care (such as Community Aged Care Packages (CACP), Extended Aged Care at Home (EACH) and EACH Dementia packages) after they have completed their Transition Care episode, i.e. no Australian Government subsidy is paid to CACP or EACH providers until the care recipient has completed their Transition Care episode.

For care recipients who have not yet met their therapeutic goals but wish to end their Transition Care episode early in order to accept a CACP, EACH or EACH D package, their Transition Care discharge plan should include strategies to help the care recipient and their carer or family to meet these goals after discharge from the Program.
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4. While the definition is accurate in terms of specifying the interface between the acute/subacute and the residential aged care sectors, and while the program applies to older people assessed as otherwise eligible for residential care, it also includes Transition Care provided in a community setting.
5. A detailed list of services to be provided is included in Schedule 1: Specified care and services for Transition Care services at Attachment B.
6. ‘Care-leaver’ is defined as a person who was in institutional care or other form of out-of-home care, including foster care, as a child or youth, or both, at some time during the 20th century.
7. A definition for subacute care is included in the Glossary at the end of these Guidelines.
8. Definitions for Transition Care service and Transition Care Service Provider are included in the Glossary at the end of these Guidelines.

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