We provide care and restorative services to older people who would benefit from extra support after a hospital stay.
Key points
- Short-term support service for older adults after a hospital stay
- Available as home-based care or bed-based in residential care
- The Aged Care Assessment Service (ACAS) determines eligibility
- Patients need a referral from their GP or healthcare provider, or their treating team at the RMH
What is transition care?
Transition care helps you recover after a hospital stay.
It is short-term specialised care and support to:
- help patients regain functional independence and confidence sooner
- avoid the need for longer term care and support services
Transition care is helpful if you need a bit more time in care, low-intensity therapy before going home, or have complex discharge planning needs.
Transition care is not a hospital or a rehabilitation program. You need to be well enough to stay in the program.
Hospital staff work with you and your family to support the safest possible transition back home, or into residential care.
We can provide:
- nursing and personal care
- medical care from a geriatrician, aged care registrar or resident medical officer (RMO)
- physiotherapy
- occupational therapy
- podiatry
- social activities
- exercise programs
- discharge planning
Types of transition care
Our program can provide care in the following ways:
- Home-based - a case manager develops a care plan and arranges support in your own home, starting before you're discharged
- Bed-based - a private room at BaptistCare Westhaven, Footscray
The Transition Care Program offers a combined maximum of 12 weeks for both types of services.
Short-term, flexible care for older people after a stay in hospital. Delivered in a residential care community, the bed-based program helps people transition home or into long-term residential care.
Find out moreShort-term support for older people returning home after a stay hospital. Our services can help patients transition home and reach their functional, physical, cognitive and psychosocial goals.
Find out moreWho can use this service
To be eligible for the Transition Care Program, you must:
- have completed your hospital stay
- be medically well enough to take part
- be assessed and approved by the Aged Care Assessment Service (ACAS) as likely to benefit from the program
- have agreed to take part in the program
The program is available to:
- people aged 65 and over, or Aboriginal and/or Torres Strait Islander peoples aged 50 and over
- people living in the local government areas of Moonee Valley, Moreland, Hume, and parts of the City of Melbourne
Referrals
See Bed-based or Home-based for the referral process for each program stream.
After referral
If you're eligible, a hospital social worker will place your name on the Transition Care Program waiting list.
Moving into residential care
If you and your family are arranging residential care for the first time, our Transition Care Program staff can support and care for you to make the move as easy as possible.