Understanding the Transition Care Program (TCP)
When an older person leaves hospital, they’re often not quite ready to go straight home — but they may not need permanent residential care either. That’s where the Transition Care Program comes in.
This short-term program provides extra care and support to help older Australians recover safely, regain independence, and make informed choices about their long-term care needs.
In this guide, we’ll explain what the program is, who it’s for, what support it offers, and how to access it.
1. What is the Transition Care Program?
The Transition Care Program (TCP) is a time-limited, goal-oriented program designed to help older people after a hospital stay. It provides short-term care while you recover and plan for the future.
The care is tailored to your needs and can include personal care, therapy, nursing, and case management — all coordinated to support your recovery and help avoid early entry into long-term residential aged care, or an unnecessary readmission to hospital if it doesn’t go well at home.
Think of it as a bridge between hospital and home (or your next stage of care), giving you the support you need to regain confidence, strength, and independence after illness or surgery.
2. Who is the Transition Care Program for?
The Transition Care Program is designed to support older Australians who have been in hospital and need some extra care before they’re ready to return home or move to another care setting.
You may be eligible if:
· You’re an older person who has recently been in hospital
· You’re medically stable, but not quite ready to manage on your own
Importantly, you can still access Transition Care even if you already receive aged care support, such as a Home Care Package. Your existing supports are paused during your time in the program and resume once you complete your transition care.
✅ Key facts:
· You can access the Transition Care Program more than once — but only after each new hospital stay, and you must be reassessed as eligible.
· It is not ongoing care — it’s temporary support to help you recover and plan your next steps.
The aim is to help you regain confidence and independence, so you can return home safely or make informed decisions about long-term support if needed.
Can I Access TCP if I’m in a Private Hospital?
Yes, patients in private hospitals can still access the Transition Care Program — but it’s important to know how the process works.
To be eligible, you must:
· Still be in hospital at the time of referral
· Be medically stable but not ready to return home
· Be assessed by the Aged Care Assessment Team (ACAT or ACAS in VIC) before discharge
While public hospitals more commonly initiate TCP referrals, private hospitals can do so too. However, not all private hospitals routinely offer this pathway, so you or your family may need to advocate for an assessment.
The Transition Care Program must begin immediately after your hospital discharge, so timing is key. If you think you may benefit from TCP, it’s a good idea to speak with a social worker or discharge planner early in your hospital stay to make sure all assessments and referrals happen in time.
3. What Kind of Support Does It Include?
The Transition Care Program is designed to help you recover physically and emotionally after a hospital stay — but it also offers guidance to plan what may come next.
The types of support you receive are based on your individual goals and needs, and can include:
· Nursing care – help with medications, wound care or managing health conditions
· Personal care – assistance with bathing, dressing and day-to-day tasks
· Physiotherapy or occupational therapy – support to regain strength, balance or adapt your home safely
· Meals, domestic help and transport, if you’re receiving care at home
But one of the most valuable parts of Transition Care is the case management.
💡 What does case management mean?
You’ll have a dedicated case manager who works with you (and your family or carer) to:
· Coordinate your care while you're in the program
· Help you understand your options for long-term care at home or elsewhere
· Request a new ACAT/ACAS assessment if your needs have changed and you may need a Home Care Package or other supports.
· Make sure you feel informed and supported in making decisions about the future
In other words, you’re not alone. You’ll have someone in your corner, making sure the care you receive now sets you up well for what comes next.
Whether your goal is to return home with new supports in place or explore other long-term options, your case manager helps you navigate the aged care system with confidence.
4. Two Types of Care: Community or Residential
The Transition Care Program can be delivered in two main settings, depending on your needs, your location, and the availability of services:
🏡 Community-Based Care
This option supports you to recover in your own home. It’s ideal for people who are safe to return home but still need some short-term help to regain independence. You’ll receive a combination of care and support services like nursing, personal care, therapy, and case management — all coordinated to suit your daily routine and recovery goals.
🛏️ Residential-Based Care
If you need more intensive support, or your home isn’t yet suitable for your recovery, you may receive Transition Care in a residential aged care facility. This provides a more structured environment while still being temporary. You'll have access to clinical support, daily care, and therapy services in a setting that allows rest and recovery.
⚠️ Important to know: Not all aged care facilities offer Transition Care. Your hospital team or assessor will help find a suitable facility or location based on what’s available in your area.
Whether you recover at home or in a care facility, the focus is the same — to support your recovery and help plan for your next steps confidently and safely. Some people may move between locations as their care needs change.
5. How Long Does It Last & What Happens Next?
The Transition Care Program is designed to be short-term, helping you get the support you need for a safe recovery without rushing decisions about your long-term care.
⏳ How long can you receive Transition Care?
· The program can last for up to 12 weeks (84 days).
· In some cases, an extension of up to 6 weeks (42 additional days) can be approved if it’s needed to meet your recovery goals.
· This means a maximum total of 18 weeks of support.
Your progress is reviewed regularly during the program, and your care team — including your case manager — will talk with you about what happens next.
How to Request Transition Care While in Hospital
If you think you or a loved one will need extra support after being discharged, it’s important to start the TCP process before you leave hospital. Here's what to do:
✅ 1. Speak to the hospital care team
Let your nurse, doctor, social worker or discharge planner know as soon as possible that you’re interested in Transition Care. The hospital staff will assess whether TCP is suitable for your situation.
✅ 2. Get an ACAT (or ACAS in Victoria) assessment
To access TCP, you need to be assessed and approved by an Aged Care Assessment Team (ACAT) or Aged Care Assessment Service (ACAS) in Victoria.
The hospital will arrange this for you before discharge.
You must be medically stable, but still need support to continue recovery.
✅ 3. Wait for approval and program availability
Once approved, the hospital and local TCP provider will help organise either:
Community-based support in your home, or
A residential stay in an aged care facility (if needed)
✅ 4. Transition directly from hospital into TCP
To be eligible, you must start TCP immediately after discharge. You can’t go home for a while and then begin TCP later — it must be a direct transition.
Tip: It’s a good idea to ask early, especially if hospital discharge is coming soon. This gives time for assessments and planning. You can also involve family or an advocate to support the request.
6. Why TCP and Not Respite Care After Hospital?
If you or your loved one needs support after leaving hospital, Transition Care can be the better option, not respite care, because it’s specifically designed to:
· Support recovery and rehabilitation after a hospital stay
· Delay or avoid permanent aged care placement
· Provide clinical and allied health support like nursing, physio, or occupational therapy
· Include case management to help make decisions about long-term care needs
Unlike respite care, which offers temporary relief for carers, Transition Care is goal-focused and recovery-driven, it’s there to help older people regain confidence and independence after hospital discharge.
7. Will I Have to Pay?
Yes, there may be a small daily fee to access the Transition Care Program (TCP), but many people pay little or nothing — especially if you receive the aged pension.
The fees are means-tested and capped, so you’ll never pay more than a set amount, even if you receive lots of support.
If you're worried about costs, don't stress. Talk to the TCP case manager or hospital worker, they can help if you're unable to afford the fee or if there are financial concerns. You’ll need to sign a contract prior to commencing the program so any fees are agreed to prior. There are no nasty surprises at the end.
🔄 What happens after Transition Care ends?
As your time in the program comes to an end, your case manager will help you plan for the future. This might include:
· Returning home with ongoing support through a Home Care Package or other services if required
· Moving into residential aged care, if needed
· Linking you with other local services or supports suited to your situation
The goal is to make sure you're set up for success, with the right care in place to continue living as independently and comfortably as possible.
Need Help Navigating Transition Care? We’re Here When It Matters Most.
We know hospital discharges can happen quickly — often outside of regular business hours. That’s why Brightway is available after hours and on weekends to provide guidance, advocacy, and support when you or your loved one need it most.
Whether you’re trying to access TCP from a private hospital or want to make sure nothing is missed in the rush to discharge, we can help you avoid an unsupported transition home.
📞 Get in touch anytime — we're ready to help you plan with confidence.
