Transition Care Program

Care When You Need It!

Transition Care is a Commonwealth and State jointly funded program which is being rolled out Nationwide, to provide an enhanced quality of life for older Australians, supporting positive and healthy ageing through the provision of high quality and cost effective services for frail older people and their carers.

This District’s Transition Care program will be managed by the Townsville Hospital as a Hub and spoke model and will cover the Townsville, Bowen, Charters Towers and Mt Isa Health Service Districts.
The aim of the program is to reduce extended lengths of stay and premature admissions to residential facilities for older people following an acute or subacute episode in a public or private hospital.

Transition Care will provide short-term support and active management for older people. It is goal oriented, time-limited and targets older people at the conclusion of a hospital episode who require more time and support in a non hospital environment to complete their restorative process, optimise their functional capacity.

Depending on their assessed level of need, transition care will offer eligible older people several or all of the following:

• nursing support;
• low intensity therapy or rehabilitation (such as physiotherapy, occupational therapy and social work) to maintain physical and cognitive functioning and to facilitate improved capacity in activities of daily living;
• personal care;
• medical support such as GP oversight.

Care delivery will reflect the various service capabilities, skill mix and facilities available in the residential care industry, or the community setting in the area covered by the Townsville Health Service District and the other districts the Hub and spoke model covers.

It is expected that initially clients will receive a high level of service provision, which will decrease as clients reach therapy goals.

Care may be provided in the community, a residential facility or a combination of both settings.
For the first 12 months all Residential/Community packages will be delivered in The Townsville Health Service District.

The patient may only enter the program if the eligibility criteria are met:

The patients must meet the following requirements:

• 70 years of age or over and 50 years of age or over for Indigenous patients
• Is a current hospital inpatient
• Has completed acute/sub acute episode of care, is medically stable and would be able to be medically managed by the GP in the community
• Consents to be referred to the Transition Care Program
• Agrees to undergo an ACAT assessment for the program
• Has the capacity to benefit from low intensity allied health and nursing interventions to improve their function
• This improvement can be made within a short timeframe (less than 12 weeks)

Patients are excluded if:

• They have made the final decision to go into residential care
• They do not have the cognitive capacity to learn and retain information and therefore participate in a rehab program
• Other programs would better meet their needs eg: inpatient rehabilitation
• Workplace health and safety issues have been identified and it is deemed that there is a risk for staff to complete rehabilitation in the home (client will be excluded from the community component of the program but will still be eligible for a residential bed).

The Transition Care Core team of Coordinator, Physiotherapist, Occupational Therapist, Social Worker and Clinical Nurse, will liaise closely with hospital staff to provide this coordinated level of care.
Referral to the program can only be made on the Transition Care Program Referral form and faxed to the Program Office on 07 47961861.

All potential clients of the program will need an ACAT assessment to enter the program, and this will require a lead in time of at least a minimum of 4 days. This will enable the core team to gain ACAT approval, develop a care plan and negotiate service providers to be in place to deliver the service upon discharge of the patient from hospital.

The Townsville Health Service is expected to begin providing services in early February 2007.

Referral Form

Commonwealth Guidelines

Last Updated: 01 February 2007
Last Reviewed: 01 February 2007