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Do I need transition care?

If you end up in hospital for a time due to a health problem and are soon to be released back to your home, you may want to engage the Transition Care Program which can assist you in transitioning back into everyday life.

Last updated: December 8th 2022
The Transition Care Program helps to regain independence after a hospital stay. (Source: Shutterstock)

The Transition Care Program helps to regain independence after a hospital stay. (Source: Shutterstock)

Key points:

  • Transition care aims to delay an older persons need for longer term care options
  • The program lasts for up to 12 weeks with an opportunity to extend a further six weeks if necessary
  • Transition care provides a range of nursing care, personal care and low intensity therapy services

The Transition Care Program provides short term support and assistance for older people after completing any necessary acute and sub-acute care in a hospital.

It aims to help in improving an individual’s independence and confidence, especially if you are still feeling a bit fragile from being in hospital.

It’s a wish of the Australian Government to support older people in remaining at home for longer and feeling safe in that decision. Transition care can delay an older person’s need for longer term care or moving into an aged care facility.

The program provides goal oriented, time limited and therapy focused care for older people at the end of a hospital stay. The care you receive will be tailored around your personal needs.

It can be delivered in an individual’s own home, out in community, in a ‘live in’ setting which must be a home-like, non-hospital environment with space available for therapy, or a mix of all of these locations.

To be eligible for transition care, an older person must be an inpatient of a hospital and have been assessed by the Aged Care Assessment Team (ACAT), or Aged Care Assessment Service (ACAS) if you live in Victoria.

Transition care can be provided for a period of up to 12 weeks, with a possibility to extend to 18 weeks if assessed as requiring an extra period of therapeutic care. Seven weeks is the expected average.


Transition care provides a package of services which include a range of low intensity therapy services, nursing support and/or personal care services.

Low intensity therapy services may include:

  • Physiotherapy
  • Occupational therapy
  • Dietetics
  • Speech therapy
  • Podiatry
  • Counselling
  • Social work
  • Social activities

Nursing support is provided by a registered nurse, including:

  • Pain management
  • Wound care
  • Catheter care
  • Dementia support
  • Oxygen therapy
  • Medication assistance and management
  • On-call access to nursing services

Personal care services may include:

  • Assistance with showering and dressing
  • Eating and eating aids
  • Managing incontinence
  • Transport to appointments
  • Mobility and communication
  • Dressing or assistance in using dressing aids

You can access transition care after seeing an assessor for a face to face assessment while you are in hospital.

If you want to organise this assessment, you can either ask the hospital staff to arrange it for you or contact My Aged Care on 1800 200 422 to enquire about it further.

The assessment will confirm you are a patient in a hospital and have been told you are ready to leave soon, and will determine if transition care would benefit you for a short period of time.

Once your eligibility for the program has been established, you can organise transition care from a provider.

That provider should be able to support you in heading back home after your hospital stay, this includes if you end up entering an aged care facility or exiting a facility.


An approved provider may charge a contribution fee to the cost of your care.

If you are receiving care in a ‘live in’ setting, such as a residential aged care facility, the maximum fee is 85% of the basic daily rate of a single pension, or $56.87 per day. (20 September 2022 rates).

If you receive this care while at home, the maximum fee is 17.5% of the basic daily rate of single pension, or $11.55 per day. (20 September 2022 rates).

Access to transition care is decided on a needs basis, not on an individual’s ability to pay fees.

You cannot receive transition care if you are currently receiving respite care or short-term restorative care, however, you can still access the program if you are receiving a Home Care Package, Commonwealth Home Support Programme services or are living in an aged care home.

Talk to your hospital social worker or discharge planner to find out more details about the Transition Care Program.

When you leave hospital after a brief stay, do you believe the transition care program would have you more at ease while back at home? Tell us in the comments below.

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