Transition care

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Transition care helps you recover after a hospital stay. It provides short-term specialised care and support to help you regain your functional independence and confidence sooner, and avoid the need for longer term care and support services. 

Your care is tailored to your needs and goals, and is delivered in the most appropriate place to help you meet them. This could be in an aged care home, in your own home, out in the community, or a mix of these locations, as your needs change with your recovery. 

What help is available?

There is a range of services that transition care can provide. The exact care and services you receive will be based on your specific needs.

Low intensity therapy to help you recover sooner and safer: 

  • physiotherapy
  • occupational therapy
  • podiatry
  • dietetics
  • speech pathology
  • counselling services
  • social work, connecting you to wider community support 
  • social activities such as lifestyle, cognitive, and general exercise programs.
     

Clinical care carried out by a registered nurse: 

  • pain management
  • wound care
  • oxygen therapy
  • medication assistance
  • dementia support
  • catheter care
  • on-call access to specialised nursing services.

Personal assistance with everyday tasks:

  • bathing, showering, personal hygiene and grooming
  • maintaining continence or managing incontinence
  • eating and eating aids
  • dressing, undressing, and using dressing aids
  • moving, walking, wheelchair use, and using devices and appliances designed to aid mobility
  • communication, including addressing difficulties arising from special conditions, such as dementia.

How does it work?

An assessor will visit you in hospital for a face-to-face assessment. You can ask the hospital staff to arrange this assessment, or call My Aged Care on 1800 200 422. If eligible for transition care, you will be able to connect with a transition care provider to get the care you need. Your provider will then assist you with leaving the hospital, as well as entering and exiting care.

Where is the care provided? 

Care can be provided in different locations. Where you receive your transition care depends on what the best place is for your recovery.

  • For high care needs: a short stay in an aged care home where 24/7 care and support is available may be the best place to recover.
  • For a lighter level of care needs: you may receive services at home and out in the community.

You may receive care in a mix of all locations as you recover and your care needs changes. Your transition care provider will coordinate and monitor all aspects of your care and help you transition between locations.

How long is the program?

You can access transition care services for up 12 weeks per year, though the typical length is about seven weeks. There are possibilities for extensions for another six weeks, if required, but this involves further assessment.

What will it cost me?

If you can afford to do so, you may be expected to contribute to the cost of your care and services. You won’t need to complete an income and asset assessment, though providers can request information regarding your ability to make a contribution (within reason). Importantly, your access to transition care will not be affected by your ability to pay fees. 

While providers set their own fees in consultation with you, the government sets maximum amounts. Currently, the maximum amount you may be asked to pay is:

  • $10.63 per day if you receive care while living at home (17.5% of the single aged pension).
  • $51.63 per day if you receive care while living in a residential setting (85% of the single aged pension).

Am I eligible?

You may be eligible for transition care if you are an older person and:

  • are a patient in a public or private hospital
  • have been told that you are ready to leave hospital
  • would benefit from receiving services for a short period of time.

What if I already receive aged care services?

It is possible to access transition care while receiving other aged care services in the following situations:

If you are currently living in an aged care home and are travelling interstate, you can access transition care services elsewhere. Your place in the aged care home is held until you return.

If you have a Home Care Package, your services can be paused until your return from transition care. 

If you receive home support through the Commonwealth Home Support Programme, you can get transition care services at the same time. The two programs must focus on different aspects of your care and be assessed separately to avoid doubling up on services.

However, you cannot access transition care while receiving either respite care or short-term restorative care.