Community Based Transition Care Program

Services can include:

• Case management
• Nursing – medication management, wound care
• Domestic home care
• Personal care
• Organisation of appointments
• Low intensity therapy – Physiotherapy/Occupational Therapy/Speech Pathology/Dietetics
• Continence assessments/aids
• In-home respite
• Geriatrician review (if required)
• Neuropsychology & clinical psychology input (if required)

For most people the goals for TCP with revolve around transitioning home with case management and low intensity allied health goals.

Inclusion criteria

• People over the age of 65 or Aboriginal and Torres Strait Islander people over 55 years.
• The person has goals that encompass both case management and low intensity therapy.
• Live within Western Health Catchment.
• The person is medically stable to be at home, and able to safely manage at home with support from carer/family if needed.
• The home environment is suitable and safe for the patient’s level of function and for staff to visit.
• The person consents to participate on the program.
• Pay the patient daily contribution fee where required (equivalent to 17.% of the Aged pension).
• The person is medically or mentally unwell and requires management within an inpatient hospital ward environment.
• The care needs and goals are greater than what the program can provide, including requirement for twice daily nursing, complex wound management or daily care visit.
• The person is undergoing a Victorian Civil and Administrative Tribunal (VCAT) process for the appointment of a decision maker.
• Lives in a residential care facility or outside of Western Health catchment area.
• The home environment is unsuitable for the person to return home or for staff to visit.

Exclusion criteria

Patients require an Aged Care Assessment approval.

Williamstown Office: (03) 9393 0388

Service Manager: 0435 962 477