Transition Care Program

About the program

The Transition Care Program (TCP) is a specialist aged care program for older people leaving hospital.

The program provides short-term support for older people who require more restorative support after a hospital stay. This additional support reduces their length of stay in hospital and provides a little more time to understand their long-term care. The program can be in-home or in a residential setting.

TCP is person-centred and collaborative, aiming to achieve the best possible outcome for the individual. Older people, and their representatives, take part in discussions, planning and decision-making.

Key details

1. TCP is a short-term program not intended for ongoing care.

• It provides support for a defined period.
• The duration of services is tailored to a person’s needs, up to a set maximum.
• If further support is needed and aged care services are not already in place, TCP will help people with referral for ongoing care.

2. TCP is goal-oriented and therapy focused.

• The person’s care plan includes physical, cognitive or psycho-social goals.
• Services may include physiotherapy, occupational therapy and case management.
• Therapy is low-level and restorative, to keep or improve a person’s function physically and/or cognitively without being a rehabilitation program.

3. TCP is a state-wide program

• There are 17 providers of TCP across Victoria, in both metropolitan and regional areas.
• TCP is provided in a person’s home, or if they need a higher level of care, through temporary admission to a residential environment.

Eligibility and suitability

TCP eligibility is determined by an Aged Care Assessment, completed while the person is an admitted hospital patient. This includes admission to a public or private hospital or a hospital-in-the-home or similar program.

The TCP Provider will also assess whether the program can suitably meet the individual’s care needs.

Step 1: A referral is generally made by hospital staff. People can also self-refer with the assistance of hospital staff.

The referral may be made to:

• the TCP associated with the hospital; or
• to one that provides services in the area where the person lives or intends to live following hospitalisation.

A referral for an Aged Care Assessment is also needed. Find out more about My Aged Care assessment services .

Step 2: The Aged Care Assessment will decide the person’s eligibility. The TCP referral process will assess the program’s suitability for the individual.

Step 3: If the person wishes to go ahead, goals will be agreed on and these will inform the care plan. A client agreement must also be signed by the person (or their legally recognised representative) and a TCP staff member.

Fees and charges

Most of the costs of the TCP are covered by the Commonwealth and Victorian Government subsidies paid to the TCP provider. However, there is a daily care fee.

If a person cannot pay the daily care fee, this can be discussed with the person’s case manager.

The daily maximum fee is a percentage of the basic single aged pension:

• community (at home) clients - 17.5 per cent.
• residential clients - 85 per cent.

Medication charges also apply where the person is receiving residential TCP.

Program breaks

People on the program can take up to 7 days leave for social or medical reasons, including being admitted to hospital, and still stay on the program. The program’s daily fee still applies.

However, the program will end if the leave totals more than 7 days.

A person can access TCP multiple times throughout a year, if suitable and eligible.

Interstate and overseas

The program is available nationally. This means a person visiting Victoria and requiring TCP following a hospital admission can either be:

• referred to a service closer to their usual place of residence interstate, or
• supported by a Victorian service if they are staying in Victoria.

An older person visiting from overseas can also access TCP if:

• they are recommended, following an Aged Care Assessment, and
• the program can support their care requirements while they are in Australia.

However, if they are not permanent residents, they will not have Medicare or subsidised pharmaceutical entitlements. They will, therefore, be responsible for any out-of-pocket expenses.

People from countries with reciprocal health care agreements with Australia may be eligible for Medicare. For more information visit the About reciprocal health care agreements page on the Services Australia website.

TCP and other aged care programs

People receiving Support at Home, Commonwealth Home Support Program and Residential Aged Care, may be eligible to also receive TCP. This can be discussed with the TCP team and the providers of the persons aged care service. It is important there is no duplication of care and that TCP is providing restorative care related to the program.

In most cases, TCP can be provided alongside the other services. However, for residential care, the person must take a ‘leave’ from their residential care home, and their bed will be held during their time in TCP. There are funding implications that must be considered for both the providers and the person in care.

TCP cannot be accessed alongside respite care.

TCP and Department of Veterans’ Affairs

A Department of Veterans’ Affairs recipient can access TCP. Recipients (except for prisoners of war) are expected to pay the TCP daily care fee. The TCP provider will work closely with the Department of Veterans’ Affairs to ensure the care requirements of the veteran are adequately addressed.

TCP and Transport Accident Commission (TAC)

An applicant or existing client of the TAC can access TCP. A TCP provider can ask that TAC cover the subsidy normally provided by the Commonwealth and State governments for the purposes of transition care. This includes the client contribution fee, as would be the case if such a patient were in hospital. It is recommended that this be agreed upon before the TAC recipient is admitted to the program.

TCP and WorkSafe Victoria

A recipient of WorkSafe Victoria can access TCP. A TCP provider can ask that WorkSafe Victoria cover the subsidy normally provided by the Commonwealth and State Governments for the purposes of transition care. This includes the client contribution fee, as would be the case if the person were in hospital. It is recommended that this be agreed upon before the WorkSafe Victoria recipient is admitted to the program.

TCP and younger people

TCP is an aged care program and is not available for younger people. People aged under 65 years (or under 50 years of age for Aboriginal and Torres Strait Islander Peoples) can contact the National Disability Insurance Scheme (NDIS).

People who are not eligible for supports through the NDIS may be eligible via the Home and Community Care Program for Younger People (HACC-PYP) .

Victorian TCP providers