How to Become a Transitional Care Nurse

The Transition Care Program (TCP) aims to minimise the number of older people experiencing inappropriate, extended lengths of stay in hospital or being prematurely admitted to residential care.

By offering case management, low-intensity therapy and personal support, TCP enables older people to have more time in a non-hospital environment to complete their restorative process. They can also finalise and access their long-term care arrangements.

Funding

The TCP is a joint Commonwealth and state/territory government funded program.

Target group

The target group for transition care services includes:

• older people in hospital who require more time to improve their physical, cognitive and psychosocial functioning to enable them to live independently
• older people in hospital for whom the focus is on optimising their functioning while assisting them and their families/carers to make appropriate long-term care arrangements.

TCP services

The TCP provides:

• nursing support
• personal care
• physiotherapy and other allied health disciplines
• medical support
• case management.

A complete list of the specified care and services for TCP can be found in the TCP information and client agreement.

All TCP care recipients work with their case manager and care team to establish their goals and develop their plan of care. It is expected that this plan will be regularly reviewed and updated as their care needs change.

Referrals to the TCP

If a person is in hospital (in an emergency department short stay unit, acute or subacute ward), they can self-refer to the TCP or have a referral made on their behalf by hospital staff.

The referral may be made to the TCP associated with the hospital or to one that provides services in the area where the person lives, or intends to live following hospitalisation.

The Aged Care Assessment Service (ACAS) will determine the person’s initial eligibility. Once satisfied, a member from the transition care team will meet with the person to discuss the program in more depth.

If the person wishes to go ahead, goals will be agreed on and these will inform the care plan. A client agreement will also be signed by the person (or their representative) and a TCP staff member.

Legislation governing the TCP

The flexible care locations used in the Transition Care Program are legislated by the Aged Care Act 1997 and the Aged Care Principles made under the Act.

Additionally, the Transition Care Program guidelines 2022 govern the provision and operation of the program.

Where TCP is delivered

TCP can be provided in a residential location, such as an aged care facility or in an older person’s home. Some people may move between locations as their care needs change.

When a person is assessed, the program determines where their care needs can best be met and what services they require.

Length of support

A TCP is time-limited. The amount of time required will depend on an individual’s situation. However, the most common scenarios are as follows:

• Usually people stay on the program for four to six weeks and the limit is 12 weeks. Within this time, it is expected that people will have been assisted to access suitable longer-term care and support.
• If further therapeutic benefit is possible, the program may request an extension from the Aged Care Assessment Service (ACAS) for a maximum period of 42 days (or 6 weeks). A further extension cannot be requested for a person who has already received the maximum extension during a particular period of care.

Program costs

The majority of the costs of the TCP are covered by the subsidy provided to Victorian health services by the Commonwealth and Victorian Governments. However, the Commonwealth Government also requires a daily care fee contribution from people who are able to pay.

The maximum fees are calculated based on the basic single aged pension and are adjusted twice yearly (20 March and 20 September):

• community clients - 17.5 per cent which equates to a daily rate
• residential clients - 85 per cent which equates to a daily rate.

Any financial concerns impacting on a person’s capacity to pay the contribution fee should be discussed with the person’s case manager.

TCP approach

The TCP supports a person-centred and collaborative approach to achieve the best possible outcome for the person. This means involving them in discussions, planning and decision-making.

In a case where the person is unable to participate in discussions and express preferences, a representative will act on their behalf.

Taking leave while in the TCP

• From 1 July 2021 the government introduced a provision to allow people receiving services from transition care to take up to 7 days leave, in total, from their transition care episode. The leave can be used for hospital or social reasons and can be taken as single days or longer.
• If there is an interruption to the TCP episode of care for more than 7 days, the transition care episode must end. To recommence TCP care, the person will require a valid Aged Care Assessment Service approval and must commence a new transition care episode directly after another hospital stay.

Interstate people accessing the TCP

The program commences upon discharge from hospital, is available nationally and not bound by geographical location.

This means that a person visiting Victoria and requiring the TCP following a hospital admission can either be referred to a service closer to their usual place of residence or supported by a Victorian service if remaining in this state.

It is unlikely that a Victorian service would support a person returning interstate because face-to-face contact could prove a challenge. Hence, the opportunity exists to refer to a service provider closer to where the person resides.

Overseas people accessing the TCP

Older people from overseas can access TCP if they are recommended, following an Aged Care Assessment Service assessment, and if the program can support their care requirements while they are in Australia.

If they are not permanent residents, they will not have Medicare or subsidised pharmaceutical entitlements and will therefore be responsible for any out-of-pocket expenses.

People from countries with reciprocal health care agreements with Australia may be eligible for Medicare. These countries include Belgium, Finland, Italy, Malta, the Netherlands, New Zealand, Norway, the Republic of Ireland, Slovenia, Sweden and the United Kingdom.

For further information, see ‘Reciprocal Health Care Agreements’ on the Commonwealth Department of Health website.

People receiving Commonwealth funded residential services can access TCP if assessed by the Aged Care Assessment Service (ACAS) as eligible while in hospital, and if the program can provide the required support.

A leave provision exists for such people, enabling access to TCP while their bed is held during their absence. The provider must be informed of this intention because there are funding implications for such services where the stay exceeds four weeks (or 28 days).

A resident of an aged care facility may need to continue fee payment while absent, which will impact on their capacity to pay TCP fees. This will then result in the need to waive the TPC fees.

While it is possible for TCP to support the person in their existing facility, this may not be a sustainable option due to existing health service contractual arrangements. As such, a person requiring bed-based care provision may be asked to move to a location the health service is using to provide transition care.

Please note: A TCP home-based place cannot be used to support a person wishing to return to their residential aged care facility.

Home Care Package recipients accessing the TCP

People receiving Commonwealth funded home care packages can access TCP if assessed by the ACAS as eligible while in hospital and if the program can provide the required support.

A leave provision exists for such clients enabling access to TCP while their package is held during their period of absence. However, the provider must be informed of this intention because there are funding implications for such services where the stay exceeds four weeks (or 28 days).

The program must provide the required services to a home care package recipient and not simply top up the existing care plan because the person will be on leave from the package.

Please note: Home care package recipients cannot be charged fees from their provider for the period during which they receive the transition care.

A resident of a Supported Residential Service (SRS) can access TCP if assessed as suitable while in hospital. The person can be supported as a home-based client because an SRS is not a Commonwealth funded aged care service.

The only exception would be where TCP had a contract with an SRS for the purposes of providing a bed-based service.

It is therefore possible for an SRS recipient to be referred for a home care package because the SRS is considered their home. However, negotiation must take place between providers when accepting the client to ensure services are not duplicated.

Please note: The client contribution fee may need to be waived because they will be paying a fee to the SRS to secure their bed while supported in TCP and no leave provision is possible.

Young people accessing the TCP

As a last response, a younger person with an approved NDIS plan, including supports to explore age-appropriate housing and supports, many be able to access services through TCP. The younger person (and/or their representative) are referred to the My Aged Care contact centre so they are registered within the MyAgedCare system and then the My Aged Care contact centre will refer the younger person to:

The NDIA (for NDIS participants) or

AFA (for non-NDIS participants, or individuals who are yet to test their NDIS eligibility).

Source: Principles and guidelines for a younger persons access to commonwealth funded aged care services

Transport Accident Commission clients accessing the TCP

Compensable clients of the Transport Accident Commission (TAC) can access the TCP as long as they satisfy the eligibility criteria.

It is important to note that some clients may have age-related conditions that will not be covered by their TAC claim because they are not related to the injury sustained. As such, TCP can support such clients where deemed appropriate, but will need to ensure they are not providing a service that should be delivered by TAC and that potential TCP clients are not disadvantaged.

A close working relationship and agreement with TAC will ensure clarity of roles, expectations and goals for the TCP.

Any contact with TAC will only be possible following the prospective client’s consent.

People waiting for the outcome of their TAC application can still access the TCP as long as they satisfy the eligibility criteria and the provider can deliver a service that adequately addresses their care needs.

Once their application outcome is known, they will work with TAC to address their care requirements.

TAC recipients paying for the TCP

A transition care service can request that TAC cover the subsidy normally provided by the Commonwealth and State Governments for the purposes of transition care. This includes the client contribution fee, as would be the case if such a patient were in hospital.

It is recommended that this be agreed upon before the TAC recipient is admitted to the program.

Worksafe Victoria recipients accessing the TCP

Similar to the case of a compensable TAC client, a Worksafe Victoria recipient can access the TCP as long as they are assessed as suitable during their hospital admission.

Once again, the TCP can request that Worksafe Victoria cover the subsidy normally provided by the Commonwealth and State Governments for the purposes of transition care. This includes the client contribution fee, as would be the case if the person were in hospital.

It is recommended that this be agreed upon before the Worksafe Victoria recipient is admitted to the program.

Department of Veterans’ Affairs recipients accessing the TCP

A Department of Veterans’ Affairs recipient can access the TCP if assessed in hospital as being suitable.

The Department of Veterans’ Affairs advises that recipients (with the exception of prisoners of war) are expected to pay the client contribution fee.

The transition care service provider will work closely with the Department of Veterans’ Affairs to ensure the care requirements of the veteran are adequately addressed.

The Department of Health & Human Services has developed an information booklet for consumers that provides important information about the TCP and explains what people can expect when they are receiving care. It explains people's rights and responsibilities and the obligations of the Transition Care service. This booklet is also a formal agreement between the consumer and their Transition Care service provider as required by the Aged Care Act 1997. The English language version of the booklet is available for download from this page, and is also available in a number of community languages .