Transition Care

What we do

The Transition Care Program (TCP) provides short-term care and services for older people after they leave hospital. By offering maintenance (low level) therapy and support, TCP allows older people to continue their recovery out of hospital while appropriate long-term care and or services are arranged.

To receive TCP you will need to be assessed and approved by the Aged Care Assessment Service while you are in hospital.

TCP can be delivered in your home or in a residential care setting. If your care needs change, you can transfer from one setting to another within a permitted timeframe. For example, you may start Transition Care in a residential care setting and then go home, and continue to receive services in your home to assist with your final recovery period.

Alfred Health delivers bed based Transition Care at 2 different sites:

Coppin Centre 45 Moubray Street, Melbourne, 3004
Hammond Care 294 Kooyong Road, Caulfield, 3162.

If you would like to view any of these sites please discuss this with your Social Worker or phone the TCP Office and ask to speak with the Manager or a TCP Senior Clinician to arrange a tour.

Who we care for

We provide care and support for:

people who are 65 years and over, or
Aboriginal or Torres Strait Islanders who are 50 years and over

Who are staying in any hospital (public or private).

What to expect

Access to TCP services is usually recommended by the treating hospital team and discussed with you and your family/carers while you are still in hospital. With consent, the treating team will then refer you to TCP.

Services which may be provided include:

Home based care

You will get care in your home and services could include:

Nursing and in-home respite
Help with cleaning, meals or bathing
Setting up medical appointments
Assistance with travel to appointments
Therapy from allied health staff, such as a physiotherapist
Support equipment can be hired during your TCP stay

Bed based care

You will get care in the residential care facilities that partner with Alfred Health.

Services could include:

Nursing and on-call support
Medication assistance
Help with everyday tasks like bathing or walking
Dementia support
Setting up and assistance with travel to medical appointments
Therapy from allied health staff, such as a physiotherapist
Lifestyle activities

It is unlikely you will need all of these services.

The services you receive and the location of those services will be based on your care needs and will be limited to the funding available.

The program does not include services such as:

Pathology or radiology (like blood tests or x-rays)
Ambulance travel to or from hospital
Prescription medicine or pharmacy fees
GP appointments

Commonly asked questions

What is TCP?

TCP is a form of Flexible Care and is legislated under the Aged Care Act 1997. We are a jointly funded Australian and State Government program.

You can only access TCP with a valid TCP approval from the Aged Care Assessment Service (ACAS), which the treating or TCP team can arrange for you. This approval is valid for 28 days and we expect you will be offered TCP services within this time period.

You may require a period of leave whilst in TCP for either medical or social reasons. The program permits up to 7 nights leave per TCP episode and your Case Manager will discuss leave arrangements with you if it is necessary.

Does it cost to enter TCP?

Yes, the Australian government has set a daily fee requirement of:

85% of the Single Aged Care Pension for bed based TCP and
17.5% of the Single Aged Care Pension for community based TCP

The daily fee is indexed on the 20th March and September each year. Your fee will be adjusted accordingly by the Alfred Health Invoicing Department.

How long can I receive TCP services?

TCP is a short-term program to assist with attaining your individual care goals. Most people stay on the program for about 6 weeks. The limit is 12 weeks.

How to access this service?

While you are in hospital, your treating team will discuss with you and refer to TCP as is deemed appropriate and with your consent. You will transfer to TCP directly from an inpatient stay.

What to bring

We recommend you bring

Comfortable day clothes and footwear (preferably not slip on shoes) and night / sleep wear
Personal hygiene items, such as shampoo, shaving equipment, toothpaste and deodorant
Something to do, like a book to read, a magazine or an iPad or tablet with headphones