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  • Transition Care Program

Transition Care Program

What is Transition Care?

The Transition Care Program helps people over 65 years plan their care after an extended hospital stay.

This short term care is up to 12 weeks (but generally 5 – 8 weeks) and includes case management, nursing, personal care, allied health and social work while a long-term plan is finalised.

The program is available in Hospital/ Residential Aged Care Facility and at home, and often happens as a combination of both.

What is provided in Transition Care?

The type of care you receive will depend on your needs and what setting you receive transition care.

It includes:

  • Case Management
  • Nursing
  • Physiotherapy
  • Occupational Therapy
  • Home help
  • Assistance with Meals
  • Shopping
  • Hygiene assistance
  • Follow up Medical appointments
  • Social support
  • Continence aids
  • In-home respite
  • Equipment loan

What does a Case Manager do?

Your Case Manager will coordinate your care and services. The Transition Care Program Team will meet with you weekly to set goals and plan your care. This is achieved with initial and regular assessments.

Your case manager will:

  • coordinate and monitor your plan of care
  • ensure you have the opportunity to participate in decisions relating to your care
  • provide information and arrange education as required
  • liaise with your GP and specialist
  • act as an advocate on your behalf
  • develop a discharge plan with you to make sure the support and services you need are in place when you are discharged.

Eligibility and Costs

The Transition Care Program receives funding from the Victorian and Australian governments, which covers most of the cost of the program; however, you are also asked to pay a fee to contribute to the cost of your care. TCP is not covered by private health insurance and Department of Veterans’ Affairs recipients are not exempt from the fees unless you were a prisoner of war.

The contribution will be discussed prior to the commencement of the program. If you have difficulty paying fees, please discuss with your Transition Care Case Manager.

Right and Responsibilities

The Department of Health has produced a booklet that provides important information about the Transition Care Program and explains what you can expect when you are receiving care. It explains your rights and responsibilities and the obligations of your Transition Care service.

Download the booklet.

Contact Details

Residents of Hepburn Shire:
Phone: (03) 5321 6596
Fax: (03) 5321 6584
Email: agedcare@hhs.vic.gov.au

Central Highlands Rural Health
PO Box 465
Daylesford Vic 3460

Residents of Macedon Ranges Shire:
Phone: (03) 5422 9911
Fax: (03) 5422 9917
Email: district@kynetonhealth.org.au

Kyneton Health
P.O. Box 34
Kyneton Vic 3444

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Alison Lowe
Ann Mackintosh

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