Transition Care Program

Our Transition Care Program provides short-term care and support after a hospital stay. The program helps you continue your recovery in a non-acute setting, with the goal of improving function and independence.

Transition care is designed for older adults who need extra support after discharge from hospital, but who are not ready to return home or enter residential aged care. 

To be considered for a Transition Care Program, you must:

• be an inpatient of a hospital, having completed your acute stay and any necessary sub-acute care (rehabilitation)
• be medically stable
• agree to admission into the program
• have a completed, current and delegated aged care client record (ACCR) – flexible care or a Transition Care Program must be a recommended service
• have potential goals and be able to benefit from a period of stay on the Transition Care Program.

The Transition Care Program provides you with:

• low-intensity therapy (such as physiotherapy or occupational therapy)
• medical services (including geriatrician review)
• 24-hour nursing care
• allied Health (physiotherapy, occupational therapy, speech pathology, dietetics, podiatry)
• social activities
• a dedicated Case Manager to assist you and your family finalise your long-term care and living arrangements.

For patients who have gone home following a stay in hospital and need extra support to help settle back in, our Community Based Transition Care Program offers low-intensity therapy, and assistance with organising and coordinating support services.

It gives you more time to recover in an environment more like home, offering you a place to stay while on the next step in your recovery.

The Transition Care Program is jointly funded by the Commonwealth and the Victorian State Department of Health. 

Clients in the Transition Care Program also contribute a client daily co-payment, which is set at 84% of the single persons aged pension levels.

Pharmacy supplies are funded by Transition Care Program clients, and these are supplied by a community pharmacy in Williamstown. 

The Community Based Transition Care Program has a daily fee contribution, set at 17.5% of the aged pension.

If you know a current hospital inpatient who may benefit from the Transition Care Program, please email [email protected] or contact the SNAP helpline on (03) 8345 7695 to discuss your referral or any questions you may have.

All areas of the referral form​ must be completed by a health professional and preferably a social worker. We also have a consent form, Bed Based TCP fee form and a Community Based TCP fee form which should be completed as part of the referral process.

To learn more about the Transition Care Program at Western Health, please contact:

Phone: 0435 962 477