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Transition Care Program

Service Description

Transition Care provides short term care that seeks to optimise the functioning and independence of older people after a hospital stay. Transition Care is goal orientated, time limited and therapy focused.  It provides older people with a package of services that includes low intensity therapy such as physiotherapy and occupational therapy, case management as well as social work, nursing support or personal care. Transition care can be offered in a person's home (community based) or in a residential setting (bed based).

The Program facilitates a continuum of care for older people who have completed their hospital episode, including acute and sub acute care (eg rehabilitation, geriatric evaluation and management), and who need more time and support to make a decision on their long term aged care options.

It seeks to enable older people to return home after a hospital stay rather than enter residential care prematurely.


To be eligible for Transition Care, the person must be an admitted patient of a public or private hospital and assessed in hospital by an Aged Care Assessment Service (ACAS).


A client contribution set by the Commonwealth Government is required for the Transition Care Program.


The Grampians Region has Transition Care Programs situated in six Health Services, offering a varied range of services, with each program servicing their own specific regional area.

Ballarat Health Services 5320 3851
Hepburn Health Service 5345 9143
Wimmera Health Care Group 5381 9085
Stawell Regional Health 5358 8535
Ballan Health Service 5368 1100
Beaufort and Skipton Health Service 5349 1665

Team of Staff

The TCP team is a multi disciplinary team including Case Management, Nursing, Social Work, Occupational Therapy, Physiotherapy and Dietetics, as well as other Allied Health Services as required.

TCP Guidelines