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Transition Care Program - Townsville Hospital and Health Service

Transition care is designed to improve older peoples independence and confidence after a hospital stay.  It allows them to return home to complete their recovery and gives them time to make decisions about the best place for them to live in the longer term.   Transition care can only be accessed from hospital.

Transition Care Program - brochure |  Transition Care Program - handbook

Target group

The target group for transition care services includes:

  • Older people where further improvements to their physical, cognitive and psychosocial functioning and improved capacity are achievable, enabling them to live independently.
  • Older people for whom the focus is on optimising their functioning while assisting them and their families/careers to make appropriate long term care arrangements.

Transition care services

Transition care offers short term access to a package of services that may include:

  • Low intensity therapy such as physiotherapy and other allied health disciplines
  • Case Management
  • Nursing support such as wound care
  • Personal care

Transition care is time limited.  Most people stay on the program for six to eight weeks and the limit is 12 weeks. 

Additional time (up to 6 weeks) may be approved by the Aged Care Assessment Team (ACAT) if further functional improvements are possible.

Transition care services will be suspended or ceased if a person returns to hospital.

Program costs

The Commonwealth Government requires a daily care fee contribution from people who can afford to do so. The maximum daily rate for transition care is:

  • Community based – 17.5% of the single aged pension
  • Residential  based – 85% of the single aged pension

Rates increase in March and September each year in line with changes to the Aged Pension.

Services will not be denied if people are unable to contribute.


If an older person is in hospital, they can self-refer to the Aged Care Assessment Team (ACAT) or have a referral made on their behalf by hospital staff.

My Aged Care hospital referral form

Email completed referral form to the Townsville ACAT team

Eligibility for transition care is determined by the ACAT. Once approved, a member of the transition care team will meet with the person to discuss the program in more depth.

Transition Care Program - Patient flyer

Transition Care Program -  Hospital flyer

Transition Care Program - Referral flow chart

A client agreement will also be signed by the person (or their representative) and a transition care staff member prior to discharge from hospital.

Last updated: 13 September 2016

Contact us

Email:Transition Care Program


+61 7 4433 4500
+61 7 4433 4501
Hours:0730 to 1600 Monday to Friday

Transition Care Program Guidelines 2015