We provide short-term support for older adults following a stay in hospital.
- Short-term support service for older adults following a hospital stay
- May be bed-based or home-based care and support
- The Aged Care Assessment Service determines a person’s eligibility for TCP
What we do
Our Transition Care Program (TCP) provides additional support to patients to help with the transition from hospital to home and support people while they wait for their long-term care arrangements to start.
What is transition care?
Transition care helps you recover after a hospital stay. It provides short-term specialised care and support to help you regain your functional independence and confidence sooner, and avoid the need for longer term care and support services.
Transition care is helpful if you need a bit more time in care, or low intensity therapy before going home or if you 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 provide the best care and the safest care possible and support your transition back home, or to residential care.
We care for patients who may require:
- Nursing and personal care
- Medical care from a geriatrician, aged care registrar or resident medical officer (RMO)
- Occupational therapy
- Social activities
- Exercise programs
- Discharge planning
Types of care
Transition care may be:
- Bed based - based at Baptcare Westhaven, Footscray
- Home-based - where a case manager will develop a care plan and make arrangements with the patient and their family before they are discharged home
The Transition Care Program offers a combined maximum of 12 weeks for both bed-based and home-based services.
If you and your family are making arrangements for you to go into residential care for the first time, staff in the Transition Care Program can provide support and care to make the transition as easy as possible.
Who can use our service
There are Government requirements for entry to the Transition Care Program (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
The Transition Care Program is available to people who live in the local government areas of Moonee Valley, Moreland, Hume and parts of City of Melbourne.
If a patient is eligible for entry to the program, a hospital social worker will place their name on the TCP waiting list.
HealthPathways Melbourne provides guidance on best practice assessment and management of common medical conditions, including when and where to refer patients.
Parkville Connect is a secure web-based portal providing GPs, specialists and other health professionals with information in the Parkville electronic medical record (EMR).
Interpreters & cultural support
We provide qualified, professional interpreters to help you communicate with us at any time during your stay and at your clinic appointments.
- Μάθετε περισότερα γιά διερμηνείς & υποστήριξη κουλτούρας
- Scopri di più sugli interpreti e sul supporto culturale
- Tercümanlar ve kültürel destek hakkında daha fazla bilgi edinmek için
- Tìm hiểu thêm về thông dịch viên và hỗ trợ văn hóa
- لمزيدٍ من المعلومات عن خدمة الترجمة الشفهية والخدمات الثقافية