Woman being assisted by nurse

After-hospital care (transition care)

When you have been in hospital, often the most desirable place to go when you leave is to your own home, rather than an aged care home. But sometimes you might need extra help to recover. This is where transition care may be able to help.

What is transition care?

Transition care is for older people who have been in hospital, but need more help to recover and time to make a decision about the best place for them to live in the longer term. Transition care may be provided either in your own home or in a 'live-in' setting. This setting can be part of an existing aged care home or health facility such as a separate wing of a hospital. You can only access transition care directly from hospital.

What types of services are provided?

Transition care provides short-term care that is:

  • focused on your individual goals
  • focused on particular therapies
  • for a short time only.

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

  • low-intensity therapy such as physiotherapy (exercise, mobility, strength and balance) and podiatry (foot care)
  • access to a social worker
  • nursing support for clinical care such as wound care
  • personal care.

How do I know if transition care is right for me?

Ask yourself these questions:

  • Are you a patient in a public or private hospital, or receiving some form of care under a hospital-in-the-home programme?
  • Have you been told that you are ready to leave hospital?
  • Will you benefit from help such as low-intensity therapy, nursing support or personal care?
  • Will you benefit from short-term care to help you be as independent as you can be, while also giving you time to think about where you will live in the longer term?
  • Do you want to go into transition care?
  • If you don't go into transition care, will you be eligible for residential care?

If you answer 'yes' to these questions, then maybe you or your carer should apply for transition care.

Who pays for transition care services?

The Australian Government subsidises a range of aged care services in Australia. If your circumstances allow, it is expected you'll contribute to the cost of your care if you can afford to do so.

The organisation that provides your transition care services (your service provider) may charge you a daily care fee for the services you need. They should explain their fees to you, and the amount you are going to be charged should form part of the agreement between you and the service provider.

The fee is calculated on a daily basis for every day you receive services through transition care. The maximum basic daily rate for transition care delivered in a:

  • community setting, including in your own home is $10.32 per day (from 20 March 2018 to 19 September 2018).
  • residential setting is up to $50.16 per day (from 20 March 2018 to 19 September 2018).

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

If you are an older person and already receiving residential care services, and you are also paying the maximum basic daily fee, you cannot be asked to pay the same amount to your transition care service provider.

What you pay is discussed and agreed upon between you and your service provider. The rate is set before you receive the relevant services.

Who provides transition care services?

The day-to-day running of transition care is managed by the state and territory governments. Transition care is often provided by non-government organisations.

Where do I receive transition care?

Transition care is provided in your own home or in a 'live-in' setting. This setting can be part of an existing aged care home or health facility such as a separate wing of a hospital.

How long will I receive transition care?

Transition care can be provided for a period of up to 12 weeks. This may be extended to 18 weeks if you are assessed as needing more help while in transition care.  

What if I'm already receiving services through a different programme?

If you're already receiving subsidised residential care in an aged care home, but you need to go somewhere else for transition care, your place in the aged care home is held until you return, or until another care place that meets your needs is found.

If you are already receiving a Home Care Package, your place is held until you return from transition care.

Extra assistance when calling us

Extra assistance is available if you are hearing and speech impaired, or where translating services are required.

How do I get these services?

You will need to be assessed and approved as eligible by an Aged Care Assessment Team (ACAT, or ACAS in Victoria) while you are still in hospital. They will work out if you will benefit from transition care, and explain your options to you. It's all about what's best for you.

Talk to the hospital staff to arrange for an assessment for transition care or find a local ACAT.

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Last reviewed: 19 March, 2018.