The Transition Care Program (TCP) is a short term support service for older adults following a stay in hospital.

The TCP aims to provide additional support to help with the transition from hospital to home and support people while they wait for their long term care arrangements to start.

Services available in the TCP include:

  • Nursing and personal care
  • Medical care (via Geriatrician, Aged Care Registrar and RMO)
  • Physiotherapy
  • Occupational therapy
  • Podiatry
  • Social activities
  • Exercise programs
  • Discharge planning

Eligibility

The Royal Melbourne TCP Program is available to people who live in the following local government areas:

  • Moonee Valley
  • Moreland
  • Hume
  • Brimbank
  • Melbourne

If patients live outside of this area they may be able to access TCP Home-Based through another health service providers.

TCP is not a hospital environment and patients must be medically stable to access and remain in the program. The TCP Home-Based program can only provide a limited number of services which may not meet all of the patient's care needs. Patient's family, friends or neighbours may need to supplement their care.

Referrals

We accept GP and specialist referrals for this service.

The ACAS Intake & Response Team welcomes phone calls to discuss potential referrals or to discuss queries in regards to existing referrals.

Referrals are triaged depending on priority.

To refer a patient, complete and fax your referral to ACAS on (03) 9388 1752.

You can use the following forms:

You can also refer your patient online using eReferral.

Referrals should include:

  • relevant clinical history for the patient
  • the reason for referral
  • patient details including address, date of birth and contact phone numbers

Special referral instructions

For older adults about to be discharged from hospital to be eligible to enter TCP you must have an assessment approved by the North West Aged Care Assessment Service (ACAS). The ACAS supports people in their own homes and communities by linking them to health services which promote, as far as possible, rehabilitation and restoration of function. The ACAS can also refer people to community services which will maximise their independence and safety.