Transition Care Program
Service Description
Transition Care Program (TCP) provides short term care to optimise the functioning and independence of older people after a hospital stay. Transition Care is goal-oriented, time limited and therapy focussed. It provides older people with a package of services that includes low intensity rehabilitation. Therapy can be provided in either the person’s home or in residential facility setting or both over the duration on the program. The Program allows support to reach their potential and allows more time to make decisions for their long term care options.
Services Provided
Services that may be provided include case management, physiotherapy, occupational therapy, speech pathology, dietetics, psychology, nursing and social work. Other services which might be provided during the program are showering, cleaning, shopping, transport, prescribed equipment and wound care depending on the needs identified in the assessment.
The Sunshine Coast Hospital and Health Service is the approved provider for the Transition Care Program and employ a multidisciplinary team of case managers who co-ordinate the client’s package of care. Therapy and support services are provided by brokered Service Providers under a contract arrangement with Queensland Health
Eligibility
The person must:
- Consent to participate on the Program
- Have capacity to benefit from a package of services to complete the restorative process, optimise functional capacity and to make long term arrangements for ongoing care
- Be assessed for the Transition Care Program by an Aged Care Assessment Team Assessor while an inpatient in a public or private hospital
- Be an older person (45 for Aboriginal & Torres Strait Islanders)
- Have completed acute care or sub-acute care
- Be medically stable and ready for discharge
Referral
Hospital multidisciplinary team (doctors, nurses and/or allied health)
Area Serviced
Sunshine Coast Hospital & Health Service (Sunshine Coast Council, Noosa Shire Council and Gympie Regional Council)
Age Range
Over 65 years (over 45 years for Aboriginal or Torres Strait Islander)
Cost
The client contribution calculated on 17.5% of a single Aged Pension covers services, equipment hire, continence aids and wound care dressings
How to Submit a Referral
An internal referral from the multidisciplinary team in a public or private hospital is completed and forwarded to the Transition Care Program Intake Officer
