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