Aged Care Services

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, the TCP allows older people to continue their recovery out of the hospital setting. Longer-term care arrangements are determined and arranged during the time in TCP.

To receive TCP you will need to be assessed and approved by the Aged Care Assessment Service while you are in hospital. To access TCP you are required to be an inpatient in a hospital setting.

How can the TCP help you? 

While in the program, you can access a range of health and lifestyle services designed to meet your needs. Services are offered as part of an ongoing care plan, giving you and your family time to consider and plan for your long-term care needs; this may include returning home with community support or becoming a resident in an aged care facility.

The average length of stay in the program is five to six weeks. Both the home- based and residential-based programs offer a combined maximum of 12 weeks.

You will be supported by a Care Coordinator during your time in transition care. The role of your Care Coordinator is to work with you and your family to identify what services you require, to meet your goals and assist you and your family with your discharge plans.

Services may include personal and/or nursing care (showering and dressing assistance), medical care, meals, transport to/from appointments, lifestyle activity program, and low-level therapies such as physiotherapy, occupational therapy, speech therapy, podiatry and dietetics.

Where is the Transition Care Program located?

TCP can either be provided in a bed-based care setting (such as in a residential aged care facility or in a hospital) or in your own home. Where you receive care will depend on the type of care you need.

Barwon Health’s residential TCP is provided at Alan David Lodge in Charlemont. This setting provides accommodation within their accredited facility. 

How do I access the TCP?

Before accessing TCP, the Aged Care Assessment Service (ACAS) will complete an assessment with you to determine if you are eligible. You and your family will also meet with a Care Coordinator to discuss your long term care plan. During this time, a number of agreed goals will be identified with you. These goals will be revisited during your time in transition care. If you agree TCP is right for you, your PaRT member or social worker will be able to provide you with further details.

Fees and charges

The care fee for transition care is calculated on a daily basis for every day the care recipient receives transition care. In line with the Transition Care Program Guidelines the maximum value of the care fee is 85 per cent of the basic daily rate of single pension for residential-based transition care. For home-based transition care, the maximum value of the care fee is 17.5 per cent of the basic daily rate of the single pension. Transition care fees can be negotiated in special or hardship circumstances. Evidence of hardship may be asked to be provided to assist decisions regarding fee payment.

How are fees collected?

You will be provided with information about how to pay your fees. Usually you will receive an invoice once you begin the program.

If you are unable to pay your fees on time please discuss this with your Care Co-ordinator.

Referrals

Discharge planners within the hospital will assist with a referral to the Aged Care Assessment Service when you are ready to plan the next stage of discharge.

Once the Aged Care Assessment Service has determined your eligibility, they will assist in referral to the Transition Care Program.

What if my care needs change?

It is expected that your care needs will change while you are receiving TCP. As your health needs change you may require less or different services. This will be reviewed regularly with your Care Co-ordinator (or care team).

If your care and service needs increase significantly, your Care Co-ordinator will discuss with you whether TCP can provide the care you need. Your Care Co-ordinator will also speak with the people involved in your care to work out how TCP can best assist you. This may include changing from TCP at home to TCP in a bed-based care setting.

If TCP is no longer able to meet your care needs, TCP will finish and your Care Co-ordinator will work with you to make alternative arrangements. These arrangements will be confirmed in writing.

What happens if I need to return to hospital during TCP?

If you are only going to be in hospital for a day or overnight then you can return to TCP when you are discharged from hospital.

If you require a longer hospital stay then your TCP will end.

If you need to return to TCP then the hospital will check whether there is a place available and whether you require re-assessment by the Aged Care Assessment Service.

What are my rights and responsibilities?

When you are receiving TCP you have the right to:

• Be treated as an individual, with dignity and respect
• Be supported in decision-making processes and have someone to speak on your behalf if you wish
• Information to assist you to make decisions about your care
• Take part in the planning and decision making about your care
• Talk freely, and in confidence, with your care coordinator about any aspect of your care requirements
• Access an interpreter and culturally appropriate services.

You also have the responsibility to:

• Actively participate in achieving your care plan goals
• Accept personal responsibility for your own actions and choices, even though these may involve an element of risk.
• Speak to your Care Co-ordinator about your care needs and any changes that may be needed to your care plan
• Respect the rights of the people who are employed to provide your care and treat them with the same dignity with which you wish to be treated
• Provide the people who are employed to work in your home with a safe and healthy place to do their work.

(An assessment of your home may be conducted to ensure it is safe and that recommended equipment is installed according to your care needs. If there are ongoing safety concerns, it may not be possible to provide TCP in your home.)