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.
About 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 it is 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 30 June 2020, we provided 4,180 transition care places nationally.
- In 2019-20, a total of 24,775 people received transition care.
- On average, transition care lasts for 60 days.
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.
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 (this includes people receiving hospital-in-the-home)
- have been told that they’re ready to leave hospital
- would benefit from receiving services for a short period of time.
If eligible, and care is to be delivered in a residential care setting, a person must enter care directly upon discharge (within 24 hours).
Alternatively, if a person is to receive care in their own home, they will have 48 hours from their date of discharge from hospital, to enter care. Please note that health services remain responsible for ensuring safe discharge practices are followed, and as such, should be confident that the discharging patient will be adequately supported for the period prior to entry into home-based TCP.
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 it works
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.
This fact sheet provides information on the introduction of TCP leave provisions and flexibility to episode commencement timeframes, which commenced from 1 July 2021.
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.
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.
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.
Following a request for ten additional permanent transition care places by the Northern Territory Government in September 2021, Minister Colbeck signed a Ministerial Determination under sub-section 12-3(1) of the Aged Care Act 1997 on 11 October 2021 to create these additional places. These new places have now been allocated and operationalised by the Northern Territory Government.
To help relieve pandemic related capacity pressures in hospitals across other jurisdictions, Minister Colbeck signed another Ministerial Determination on 20 December 2021 to create an additional 317 and 230 time-limited places in 2021-22 and 2022-23 respectively. These places will expire on 30 June 2023.
Following an application process 240 permanent transition care places were created for states and territories in April 2022. View the Ministerial Determination creating these places under subsection 12-3(1) of the Aged Care Act 1997.
These will replace the 240 temporary places originally allocated in 2019 and 2020, which are due to expire on 30 June 2022