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Transition Care Program - Townsville Hospital and Health Service

Transition Care provides time-limited, goal-oriented and therapy-focused packages of services to older people after a hospital stay.

These packages include low intensity therapy—such as physiotherapy and occupational therapy—social work and nursing support or personal care. Transition Care is designed to improve older peoples’ independence and confidence after a hospital stay. It allows them to return home rather than prematurely enter residential care.

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.


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 the older person to discuss the program.  A client agreement must be signed by the older person (or their representative) prior to discharge from hospital.

Transition Care Program - Referral flow chart

Last updated: 11 June 2018

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