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Transition Care Program (TCP)

Program Description

Transition Care Transition Care Program (TCP) provides time-limited and goal oriented support to optimise the functioning and independence of older people (over 65) on the conclusion of a hospital episode with a personally focused therapy program. Transition Care Program Cairns and Hinterland is offered in both a residential based facility and a home based setting. Some people may move between locations as their care needs change.

Eligibility Criteria

To enter transition care clients must be referred to TCP by hospital staff and be assessed as eligible by an Aged Care Assessment Team (ACAT) and TCP intake officer while they are an in-patient of a hospital. Clients can only enter transition care directly on discharge from hospital. Transition Care is provided for a maximum of 12 weeks with a possible extension if agreed on by both parties.


Services Provided

Transition CareThe services provided as part of the Transition Care Program (PDF 97 kB) are designed to meet a client’s daily care needs and provide additional low intensity rehabilitation care in order that a client can maintain and improve their physical, cognitive and psycho-social functioning thereby improving the person’s capacity to return to independent living.

TCP will provide all clients with a case manager to co-ordinate the client’s package of care. Other services offered to assist clients are physiotherapy, occupational therapy, speech pathology, dietetics, nursing, therapy assistant, social work and personal care worker. These services can include showering assistance, domestic assistance, grocery shopping, and podiatry, transport only if family unavailable, loan of prescribed equipment whilst on the program and wound care depending on the needs identified in the assessment.

Transition Care Residential

Cairns and Hinterland HHS TCP has six beds at Gordonvale Hospital (PDF 244 kB) to assist clients that require home modifications to be completed, are awaiting carer support, or just need additional support before returning home to independent living or transitioning to a care facility.


Transition Care

A client contribution is calculated on 17.5 per cent of a Single Aged Pension. Any financial concerns impacting on a person’s capacity to pay the contribution fee should be discussed with the person’s case manager.

Taking leave while in the TCP

There is no leave provision while in the TCP unless a hospital admission is necessary and the stay is no longer than 24 hours. Where a period of absence from TCP is greater than 24 hours, the program will cease involvement and the person will need to be re-referred if they still need support. Please note: an ACAT reassessment may be necessary if four weeks have passed since the original assessment for TCP was approved, or if the clinical presentation of the person has changed.

Consumer information about the TCP

The Department of Health and Human Services has developed an information booklet for consumers that provides important information about the TCP and explains what people can expect when they are receiving care. It explains people's rights and responsibilities and the obligations of the Transition Care service. This booklet is also a formal agreement between the consumer and their Transition Care service provider as required by the Aged Care Act 1997. The English language version of the booklet is available for download from this page, and is also available in a number of community languages.

Last updated: 19 March 2018

Contact us

Transition Care Program
phone: 07 4226 4563
Fax:     07  4226 4533
address:381 Sheridan street, Cairns QLD 4870