We provide short-term support for older adults following a stay in hospital.

Key points

  • 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
Patients need a referral from their GP or healthcare provider. Access referral information

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)
  • Physiotherapy
  • Occupational therapy
  • Podiatry
  • Social activities
  • Exercise programs
  • Discharge planning

Find out more about transition care at My Aged Care and Department of Health: Transition Care Program

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.

Residential care

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

Eligibility criteria

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.

For patients
For health professionals
Contact us
Transition Care Program
(03) 8387 2144
TCP: Bed-based Nurse Unit Manager
The RMH Royal Park
Building 2
34-54 Poplar Rd, Parkville, Victoria
Last updated 18 January 2023