The Transition Care Program (TCP) provides short-term care to help with the functioning and independence of older people after a hospital stay.  The program facilitates care for older people who have completed their hospital stay and need more time and support to make a decision on their long term aged care options.

It provides older people with a package of services that includes low intensity therapy, eg physiotherapy and occupational therapy, as well as social work, nursing support or personal care. It seeks to enable older people to return home after a hospital stay rather than enter residential care prematurely.

TCP at Bendigo Health operates two programs;

• Transition care: A Commonwealth and Victorian funded program for older people to allow more time for recuperation following hospitalisation and prevent premature admission to residential care. People must be admitted directly from hospital discharge
• Restorative care: a Victorian Department of Health funded program to assist with patient flow and reduce demand on hospitals. People may be admitted from hospital, the Emergency Department or the community.

TCP is a regional service with 32 places based in Bendigo and 50 places based in the region. TCP is managed from Bendigo Health.

TCP at Bendigo Health has two settings of care:

• TCP @ Home for people able to return home to continue recovery.
• TCP @ Bentleys with 24 hour nursing care for people who are unable to return home from hospital.

 The TCP places based at the following health services

Eligibility for TCP

• At least 65 years of age or have an aged related illness
• Medically stable and ready for discharge
• At risk of, or eligible to enter low or high permanent residential care
• ACAS approval for admission to TCP.

Restorative care
Bendigo Health TCP manages restorative care. People may be admitted to restorative care from hospital including the Emergency Department or from home. The aim of restorative care is to reduce demand on hospital beds by providing alternative accommodation and support services.
There are:

• Seven bed based places for people of any age who are unable to return directly home from hospital or who are not managing at home and require alternative accommodation and additional support to minimise or avoid the risk of a hospital presentation. The bed based places are situated at Bentleys Aged Care
• Four home based places for people who require additional support and services at home following discharge from hospital and also to assist recuperation to minimise or remove the risk of a hospital presentation.

Mix of services
Depending on the assessed level of need, transition care will offer eligible people several or all of the following:

• Medical is provided by GPs and geriatrician consultancy
• Social work and case management
• Nursing support at home and in residential care setting
• Low intensity therapy or rehabilitation (physiotherapy, occupational therapy, speech pathology, dietetics)
• Personal care, home care, respite and meal delivery.

Intake
The TCP intake co-ordinator will respond to all referrals to assess the patient for suitability for TCP or restorative care and allocate the setting according to the person’s individual needs.

Fax referral to Bendigo Health Referral Centre on 1300 733 589 or 5454 7099