Mildura Base Hospital
Part of Ramsay Health Care

Transition Care Program (TCP)

Description of Service

The Transitional Care Program (TCP) is a short term program providing a package of care and restorative services for older people who have been in hospital. The program is aimed at those people who require more time and support in a non-hospital environment to complete their recovery process, optimize their functional capacity and finalize their longer term care arrangements.

The TCP is time limited to a twelve week program with an average of eight weeks’ duration; it is therapy focused and based on an individualized care plan developed with the older person and their family/carer(s).  The TCP can be provided in either the older person’s own home or in a care setting. The location of where TCP care is provided will depend on the type of care one needs, and will be decided in consultation the client and his/her family. Some people may even move from one transition care setting to another while receiving TCP.

The program provides a package of service to older people that include low intensity therapy such as physiotherapy, occupational therapy and social work, nursing support and/or personal care.  The costs to the care recipient in the TCP will vary according to the setting, however, no-one will be refused a service on the basis of their capacity to pay.

The Transition Care Program:

  • increases care choices for older people, their families and carers
  • provides a flexible program addressing gaps in care for older people, and
  • minimizes inappropriate extended length of stay in hospital

Type of services

Flexible service as indicated by individual needs, May include but not limited to:

  • Personal Care
  • Home Help
  • Respite Care
  • Shopping assistance

Maximum time of service

12 weeks. Average 6-8 weeks

Location of service

The Mildura Base Hospital manages 16 TCP places either in:

  • The person’s home environment for those who those who are able to complete their recovery in their home environment
  • Local aged care facilities for those who require 24 hour care

Target population

To access the program, people must:

  • At least 65 years of age or have an aged related illness
  • Medically stable and ready for discharge
  • be able to make some functional gains or benefit from a period of active management to complete the restorative process
  • ACAS approval for admission to TCP.
  • At risk of, or eligible to enter low or high permanent residential care
  • wish to enter the program

Referrals

The TCP intake co-ordinator will respond to all referrals to assess the patient for suitability for TCP care and allocate the setting according to the person’s individual needs, and can be contacted on 0448700226

Costing

Fees are discussed with the individual and determined in consultation with the client.

Maximum fees are as per TCP Guidelines:

  • 84% of the basic daily rate of single pension for care provided in residential care facility
  • 17.5% of the basic daily rate single pension for care provided in the client’s home.

Approximate waiting time

Dependant on client needs and service demands