The Transition Care Program - Home-based is a short term support service for older people after they go home from hospital.  

The program 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.

Before the patient is discharged home, our case manager with the Transition Care Program will meet with them and their family and discuss the help they need, develop a care plan and make the necessary arrangements before they leave to go home.

If patients and families are making arrangements to go into residential care for the first time, TCP can provide support and care to make the transition as easy as possible.

When a patient is referred to TCP Home-based, a case manager will usually meet with the patient and family or carer before the patient leaves hospital. The case manager will discuss the help that is needed, develop a care plan and make arrangements with the patient and their family before they are discharged home.

The case manager may arrange various services such as:

  • accessing health services
  • light gardening
  • bathing or showering
  • shopping
  • dressing and undressing
  • social activities
  • light housework and laundry
  • transport in some instances


Eligibility for the TCP Home-based program is assessed by the Aged Care Assessment Service (ACAS). Hospital social workers will discuss this with older patients who are about to be discharged from hospital.

The TCP Home-based program is available to people who live in the local government areas of Moonee Valley, Moreland, Hume, parts of Brimbank and parts of Melbourne. Patients who live outside of these areas may be able to access TCP Home-based through another health service provider. Refer to the Victorian Department of Health TCP Directory for more information.


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
  • your details and provider number
  • patient details including address, date of birth and contact phone numbers