Transition Care Programme
This program helps older people get back on their feet after a hospital stay. It provides short-term care for up to 12 weeks, including social work, nursing support, personal care and allied health care. State and territory governments are the approved providers of transition care.
What is the program?
Transition care provides short-term care for older people to help them recover after a hospital stay.
Transition care can last up to 12 weeks and take place in:
- an aged care (nursing) home
- a person’s home
- the community
- a mix of all of these
If you’re an older person and want to find out more, go to transition care (after a hospital stay) on the My Aged Care website.
Why is the program important?
We know that many older people want to stay in their own home as they age.
Because of this, we want to help older people:
- avoid the need for longer-term care
- delay moving to an aged care home for as long as possible
Helping them to get back on their feet after a hospital stay is one way to do this.
Did you know that:
- at 1 November 2019, we provided 4,100 transition care places nationally
- in 2018–19, a total of 24,432 people received transition care
- on average, transition care lasts for 61 days
What services does the program provide?
The program provides different kinds of care and support, such as:
- low-intensity therapy including allied health services (physiotherapy, podiatry, social work and occupational therapy)
- nursing support
- personal care
Who is eligible?
A person must get an assessment with an Aged Care Assessment Team (ACAT). They may be eligible if they’re an older person and:
- a patient in a public or private hospital
- have been told that they’re ready to leave hospital
- would benefit from receiving services for a short period of time
If eligible, they must enter transition care as soon as they leave the hospital.
Who provides the services?
State and territory governments are the approved providers of transition care. They:
- partner with service providers (non-government organisations) to provide transition care services
- manage the delivery of transition care services
If your organisation is interested in providing transition care under this program, contact your state or territory government.
How does the program work?
These guidelines are for state and territory governments (as the approved providers of transition care) and service providers. The guidelines explain how services should be provided, the responsibilities of approved providers and the aged care principles that govern the program.
Extensions to transition care
Service providers can request an extension of up to 42 days.
You must apply within the first 12 weeks of transition care. You will need to:
- complete Part 1 of the Transition Care Extension Form
- ask the care recipient or their representative to sign the declaration
- give the form to ACAT for assessment
How is the program funded?
The Australian Government provides funding through flexible care subsidies. The Government pays these to state and territory governments as the approved providers.
The state and territory governments, as the approved providers, must provide a
co-contribution. They can do this through:
- in-kind contributions
- direct funding to the contracted services or sub-contracted services
Service providers can also request fees from care recipients, if they can afford to contribute to the cost of their care.
For details on the subsidy amount, read Part 3 — Amount of flexible care subsidy — transition care in Chapter 4 of the Aged Care (Subsidy, Fees and Payments) Determination 2014.
Who oversees the program?
The Australian Government develops program policy and allocates transition care places to state and territory governments.
State and territory governments are responsible for:
- implementing the program
- deciding on the best way to meet local service needs and individual care needs
In 2018, the Minister for Senior Australians and Aged Care asked the Department of Health to review the program.
The review showed that the program plays an effective and important role where Australia’s health and aged care systems meet. It has supported the early discharge of older people from hospital and can help delay their entry into residential care.
To find out more, read the Transition Care Programme Review.