If you are about to be discharged from hospital but feel that you may need extra help, the Transition Care Program offers assistance.
Talk to your hospital healthcare team about arranging any services you need on discharge. An Aged Care Assessment Services assessment may be needed.
The Transition Care Program includes a range of allied health services such as dietary advice, physiotherapy, social work, nursing support, social activities and personal care.
Your healthcare team will help you to organise any mobility aids and equipment you may need before you leave hospital.
Your GP will develop a discharge plan for when you leave hospital, which will include details about your ongoing treatment and medication.
Contact your GP or Nurse-on-Call (1300 60 60 24) if you feel you need to check anything with a healthcare professional.
If you are about to be discharged from hospital but you feel that you may need extra support for a while, the Home and Community Care (HACC) Program or the Transition Care Program (TCP) could be good options for you.
Accessing home support services
Transition Care Program
The TCP provides a higher level of support than HACC and requires approval by the ACAS while you are still in hospital.
The ACAS assessor (a doctor, nurse, social worker, physiotherapist or occupational therapist) will visit you in hospital to ask you about how you are managing day-to-day and about your overall health situation. At the visit, the assessors will give you information about the types of services that are available. Whether you are eligible for the TCP will depend on your individual needs, not on your ability to pay.
You can receive the TCP in a bed-based care setting (such as in a nursing home) or in your own home, depending on the type of care you need. Some people may even use the TCP in both settings during their time on the program.
Transition care services include:
case management
allied health services such as physiotherapy, dietetics, podiatry and social work
nursing support
personal care.
For more information:
talk to your discharge planner or hospital social worker
Before you go home from hospital, your healthcare team will work closely with you to find out what aids and equipment you may need when you go home. It’s a good idea to tell your healthcare team if you have any concerns about going back home, as they may be able to address these concerns.
Your healthcare team can help you get certain aids and equipment to help with your day-to-day life, for example, a walking frame or shower seat. They can help you decide what you’ll need, and also give you information about who to contact should you need any extra aids or equipment once you’re home.
Once you get your aids and equipment, your healthcare team will also check in with you regularly to see if the aids and equipment are meeting your needs or whether they need to make any adjustments or changes. Find more information on the Home aids and equipment fact sheet.
Support networks
Recovery at home can be a slow and lonely experience if you do not have family or friends close by. However, there is a wide range of support networks available for people leaving hospital, ranging from social and peer support (such as online and in-person support groups) through to organisations offering support around particular health conditions (such as the Cancer Council Victoria and beyondblue).
Ask your healthcare professional or local doctor about support groups in your area.
Discharge plan
Your doctor will develop a discharge plan for when you leave hospital. This plan will cover:
your expected date of discharge
your living arrangements (if you live alone, if someone can be there to help, what services you currently receive and if you have caring commitments of your own, such as an elderly partner)
any possible restrictions on your activities such as lifting or driving a car
your expected recovery and how long it will take
any extra services you might need at home, such as wound care
any aids and equipment you will need to help you to recover and regain your independence.
Your discharge plan will also be sent to your local doctor. Share this plan with any new healthcare professionals you see during your recovery. If things are not working out
If things are not working out
If you are feeling unwell once you get home or you are not recovering as expected, check your hospital discharge plan to make sure you are following the instructions.
Contact your doctor or Nurse-on-Call at 1300 60 60 24 if you feel you need to check anything with a healthcare professional.
Sometimes the road to recovery can be long and the path ahead unclear. If you find you are struggling with your recovery emotionally, speak with your doctor, social worker, counsellor or community health centre. Your physical recovery will be most effective if you are mentally well.
