Transition Care Programme

Page last updated: 13 December 2019

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 a client’s independence and functioning in order to delay their entry into residential aged care.

Transition Care service delivery is managed by the state and territory governments. Within the framework of the programme, state and territory governments determine the model of service delivery that best respond to local service and individual care recipient needs. All state and territory governments have partnership arrangements with non-government organisations for the provision of Transition Care.

Key facts on transition care

At 30 June 2019, there were a total of 4,100 operational transition care places nationally.

In 2017-18, a total of 25,311 people received transition care and the average length of stay for completed episodes of transition care was 60 days.

Transition Care guidelines

View the Transition Care Programme guidelines.

Eligibility and transition care extension

The Transition Care Programme supports older people who would otherwise be eligible for residential care. To enter transition care clients must have been assessed as eligible by an Aged Care Assessment Team (ACAT) while they are an in-patient of a hospital. Clients can only enter transition care directly after discharge from hospital.

Transition Care provides short-term care of up to 12 weeks, care is able to be delivered in a hospital, residential or home setting.

Transition Care recipients can have their episode extended by a maximum of 42 days (an additional six weeks) to ensure that their further transition care needs are met. In such cases, an assessment for an extension, specifying the duration of the extension, may be made by an ACAT based on information provided by the Transition care service provider, and other sources as appropriate. The application for the extension must be completed within the initial 12-week episode of transition care.

A Transition Care episode can only be extended by up to 42 days. The transition care service provider, in consultation with the hospital geriatric rehabilitation service where necessary, must complete Part 1 of the Transition Care Extension form and forward it to the ACAT for assessment. Based on the information provided by the service provider, and other sources such as the care recipient and relevant health professionals as appropriate, the ACAT will assess whether or not an extension is required and complete Part 2 of this form.

Funding for the Transition Care Programme

The Transition Care Programme was established in 2004–05 as a jointly funded initiative between the Australian Government and state and territory governments. The Australian Government provides the Flexible Care Subsidy for the Transition Care Programme.

The Aged Care (Subsidy, Fees and Payments) Determination 2014 contains details on the amount of Flexible Care Subsidy for transition care.

Review of the Transition Care Programme

In 2018, the former Minister for Senior Australians and Aged Care, the Hon Ken Wyatt MP, asked the Department to initiate a Review of the Transition Care Programme.

Specific issues examined during the course of the Review included:

  • the ongoing effectiveness, appropriateness and efficiency and delivery of the management of the Transition Care Programme;
  • options for improvement to the Transition Care Programme to address the issues identified at the May 2018 stakeholder workshop;
  • the effectiveness of the Transition Care Programme Guidelines, and their application by state and territories;
  • the expansion of key performance indicators for client outcomes beyond the Modified Barthel Index by including primary diagnosis, secondary diagnosis, and any other relevant indicator;
  • the appropriate point for someone to enter transition care after a hospital admission;
  • the ideal length of time for someone to be in transition care;
  • undertaking a service mapping of the Transition Care Programme; and
  • how Commonwealth and State/Territory funding is being spent.

The Review showed that the Transition Care Programme is an effective and important programme at the interface of Australia’s health and aged care systems. It has resulted in substantial benefits to consumers by improving their functional capacity and facilitating their early discharge from hospital.

The Transition Care Programme Review has now been published.

More information