We provide short-term support for older people returning home from hospital who require more time to address their functional, physical, cognitive and psychosocial goals.

Key points

  • Short-term support service for people after they leave hospital
  • Support is tailored to the needs and goals of the client
  • The Aged Care Assessment Service determines a person’s eligibility for TCP

What we do

Our Transition Care Program (TCP): Home-based service supports older people to recover from their hospital stay. 

We provide specialised care and support in the client’s home to help them regain their function and independence.

The case manager may arrange various services such as:

  • Allied health (occupational therapy, physiotherapy, podiatry, speech therapy, dietetics)
  • Nursing support
  • Transport to appointments
  • Assistance at home such as personal care, shopping or light housework
  • Social activities
  • Support for carers such as respite
  • Specialised equipment 

Who can use our service

Refer to Transition Care Progam for eligibility criteria.

Time limited service

The amount of time required will depend on the client’s situation and goals however, the limit is 12 weeks. Within this time, most people have access to suitable ongoing care and support services. 

If the TCP case manager has been advised the client has further therapy goals, they may apply to the Aged Care Assessment Service for a further six week extension of the program. 

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

The cost of TCP is subsidised by the Commonwealth and Victorian governments, however clients are asked to contribute a maximum equivalent of 17.5% of the single aged pension. 

Fees can be negotiated if a client is in financial hardship. 

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
Patient using Telehealth


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Last updated 18 January 2023