Transition Care Program

TCP Care Coordinators work in collaboration with clients and family/ care providers to determine client- focused goals, develop a personalised care plan and an individualised package of services, which can include: 

• Accommodation in a supported aged care facility or services at home
• Case Management
• Nursing
• Low intensity therapy – such as Occupational Therapy and Physiotherapy
• Social Work support
• Personal care (bathing or showering)
• Domestic home care (cleaning)
• Meal assistance (shopping, meal preparation)
• Support for appointments (may include transport)
• Some equipment needs
• In Home Respite &
• Social Activities

TCP can be offered in a person's home (home-based) or in a residential setting (bed-based) and enables older people to have more time in a non-hospital environment to complete their restorative process or finalise and access their long-term care arrangements.

This is a time-limited program with clients usually on the program for 6 to 8 weeks ( with an upper limit of 12 weeks) depending on requirements. 

The target group for TCP includes:

• older people for whom further improvements to their physical, cognitive and psychosocial functioning are achievable, along with an improved capacity enabling them to live independently.
• older people for whom the focus is on optimising their functioning, while assisting them and their families/carers to make appropriate long-term care arrangements.

If a person is in hospital (emergency department, short stay unit, acute or subacute ward) they can self-refer to TCP or have a referral made on their behalf by hospital staff.

The Aged Care Assessment Service (ACAS) will determine initial eligibility and then a member from the TCP team will meet with the person to discuss the program in more depth.

If the person wishes to go ahead with the program, the TCP Information and Client Agreement document will be signed, individualised client goals will be agreed on and a care plan will be developed.

Is there a cost?

Costs for TCP are covered through a subsidy provided by the Commonwealth and Victorian Governments. However, the Commonwealth Government also requires a daily care fee contribution from people who are able to pay.

The maximum fees are calculated based on the basic single aged pension and are adjusted twice yearly (20 March and 20 September):

• Home Based clients - 17.5% of the current single aged pension
• Bed Based clients – 85% of the current single aged pension

Any financial concerns impacting on a person’s capacity to pay the contribution fee should be discussed with the person’s case manager.

Additionally, the cost of medical services, such as pathology, radiology and pharmacy (prescription) medicines is not included as part of TCP and you will be required to pay for these separately. If you are at your safety net level, please let your care coordinator know.