Renae Diggles

May 27, 2024

Transition Care Program After Hospital

Renae Diggles

May 27, 2024

Transition Care falls under the umbrella of flexible care for aged care services in Australia. It is a short-term therapeutic program, intended to offer additional recovery time when you’re ready to leave hospital. The delivery of care occurs in your home, or a non-hospital care setting.

What is Transition Care?

As you age, there could be a need for additional recovery time after a hospital stay. The therapeutic care occurs once you’re discharged from hospital and continuing your recovery. It ensures that patients reduce their hospital stay for an extended period of time, while continuing to get the therapy and support they need.

Transition care is a short-term programme that may involve low-intensity therapy such as allied health, social work, nursing or personal care. The aim of the programme is to allow more recovery time with support, after you’re discharged from hospital. It allows  many older Australians to continue living within the community, by maintaining or improving functionality.

Via this program, entry into an aged care facility may be delayed, either temporarily or indefinitely.

Where do I Stay When I Enter This Program?

You may be cared for in your home or in some cases you may need extra support in an aged care home, or a combination of both. Transition care is not intended to be delivered in a hospital type of environment.

How Long Does Transition Care Last?

The program delivers short-term care for a period of up to 12 weeks. Under certain circumstances, there is a possibility of extension of the program for up to 18 weeks. An additional assessment determines wheteher there’s a need for more care/ therapy, and whether you meet the eligibility requirements.

Am I Eligible?

To be eligible for transition care you need to be an older person who is an inpatient at a hospital and has been told that you are ready to leave the hospital. To arrange this flexible care, ask to speak to a social worker at the hospital where you are an inpatient.

Next, you’ll need an assessment by the Aged Care Assessment Team (ACAT). Approval by the ACAT assessor to enter into transition care remains valid for 4 weeks after they sign off on the approval.

If you meet the eligibility requirements, transition care arrangements are made prior to your discharge from hospital. The program commences within 48 hours of hospital discharge to the home. When receiving transition care via a short stay in a residential aged care environment, delivery of care commences immediately after being discharged from hospital.

Notably, transition care eligibility will also be affected if a person is already accessing other forms of aged care support services. Additionally, you can’t access this type of flexible care while receiving respite care or short-term restorative care.

The Assessment Process With the ACAT

The Aged Care Assessment Team (ACAT) meets with you for an assessment. You can give the assessor permission to talk with your support people (e.g. a family member or carer) and you might want to have a support person present during your meeting.

You will develop a support plan with the assessor during your meeting. The support plan will include the services and care that best meets your needs, based on your current circumstances. The assessor will then make a decision about your care needs, your eligibility to receive care and the level of care that best meets your current care and support needs.

How Much Will it Cost?

Service providers may charge a care fee to contribute to the cost of care. The maximum contribution is currently 17.5% of the single age pension if you’re receiving transition care at home. The maximum contribution is currently 85% of the single age pension if you’re reciving transition care in a residential setting.

Service providers can waive care fees when a care recipient is financially disadvantaged. Discuss this with your service provider before you start receiving transition care. For more information about care costs, go to the My Aged Care website.

The Success of the Programme

In a 2019 review of the Transition Care Program, it was found that the program aided in the early discharge of older Australians form hospital and aided in the delay of entering into a residential aged care facility.

Disclaimer: This is intended as a guide only. For accurate, indepth, up-to-date information regarding the transition care program, please refer to the Transition Care Programme Guidelines at the Australian Government Department of Health and Aged Care.

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