Transition Care Program - Aged Care Assessment Team - Community Health

We provide short-term support to older people at the end of a hospital stay who need more time and care to finish recovering and improve their level of independence. We assist older people to transition home or to a residential care facility. 

Our services 

Our Transition Care Program can be delivered at home or in a residential facility (depending on availability). 

We provide services based on immediate care needs and future planning. Services may include: 

• case management—a health professional to coordinate care, establish support and services 

• nursing care including wound and medication management 

• personal care such as showering and dressing 

• domestic assistance including light housekeeping, laundry, shopping 

• transport to medical appointments (related to your recent hospital admission) 

• physiotherapy, occupational therapy, speech therapy, dietetics, and social work 

• medical management in collaboration with your general practitioner 

The Transition Care Program also offers education and support for carers, including: 

• education and self-management 

• counselling services 

• advocacy 

• contact phone numbers for support, information, and reassurance 

• involvement in developing care plans. 

Who can access this service 

To access the program you must: 

• require care and services that includes at least low level therapy, social work, nursing support or personal care to complete their recovery process, improve functioning and assist in making long term  plans for their care 

• be an older person (younger for Aboriginal and Torres Strait Islander people) 

• be medically stable and ready for discharge from hospital 

• be assessed as eligible by the Aged Care Assessment Service. 

How to access this service 

Referrals can be made by treating teams in a hospital or rehabilitation unit.