The Transition Care Program (TCP) - Bed-based offers short-term flexible care for older people following a stay in hospital.

Therapy is based on individual patient needs. The program is helpful when patients need a bit more time in care, or low intensity therapy before going home or when patients have complex discharge planning needs.

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.

Patients are able to stay in TCP for up to 12 weeks if necessary. TCP is not a hospital or rehabilitation program and eligible people need to be well enough to stay in the program. Hospital staff work with the patient and their family to provide the best care possible and support the person’s transition back home, or to residential care.

A range of healthcare and support services are available. Services are tailored to the patient and may include:

  • social work
  • chaplaincy
  • occupational therapy
  • medical and nursing care
  • physiotherapy
  • podiatry

There are special considerations for certain patients. Please contact the unit about these types of patients:

  • Bariatric patients
  • Patients on IV therapy or IV antibiotics
  • Complex wounds
  • Specialised clinical care
  • High falls risk patients
  • Challenging behaviours such as intrusiveness or absconding

Eligibility

There are Government requirements for entry to TCP. For older people to be eligible, they must:

  • have completed their hospital stay
  • be medically well enough to attend the program
  • be assessed and approved by the Aged Care Assessment Service (ACAS) that they would benefit from the program
  • have agreed to participate in the program

If a patient is eligible for entry to the program, the hospital social worker will place their name on the TCP waiting list. As soon as a room becomes available the hospital will move the patient to building 24 on the Royal Park campus site where the program is run.

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