After-Hospital Care (Transition Care)
Transition Care provides time-limited, goal-oriented and therapy-focused packages of services to older people after a hospital stay.
These packages include low intensity therapy—such as physiotherapy and occupational therapy—social work and nursing support or personal care. Transition Care is designed to improve older peoples’ independence and confidence after a hospital stay.
It allows your loved one to return home rather than prematurely enter residential care.
Transition care helps older people after a hospital stay complete their restorative process and optimize their functional capacity, while assisting them and their family or carer to make long-term arrangements.
You can only access transition care from hospital.
Transition care - Transition care provides short-term care that seeks to optimize the functioning and independence of older people after a hospital stay. Transition care is goal-oriented, time-limited and therapy-focused. It provides older people with a package of services that includes low intensity therapy such as 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.
Transition care facilitates a continuum of care for older people who have completed their hospital episode, including acute and sub-acute care (e.g. rehabilitation, geriatric evaluation and management), and who need more time and support to make a decision on their long term aged care options.
Transition care is time-limited, goal-oriented and therapy-focused packages of services to eligible older people after a hospital stay. The services are based on what's best for you and your situation, and how to help you become as independent as you can be after you have been in hospital. Provides services and contact with services that will be supporting older people who, after a hospital stay still need considerable support to recover; there may be a need to assessments by the Hospital Social Worker and Aged Care Assessment Team (ACAT) to identify care needs and appropriate supports to be provided for up to 12 weeks; there will be an expectation that you will contribute towards the cost of the services, however you will not be denied care because you are unable to afford it.
While providers set their own fees in consultation with you, the government sets maximum amounts. Currently, the maximum amount you may be asked to pay is:
Transition Care Programme
Maximum Daily Fee Rate
TCP delivered in a Home or Community Setting $10.63 per day
TCP delivered in a Residential Care Setting $51.63 per day
Schedule of Fees and Charges for Residential and Home Care: From 20 March 2020
This page provides the latest updates to aged care fees and charges.
[i] Residents in designated remote areas may be asked to pay an additional $1.06 per day.
Transition Care Programme
Page last updated: 22 January 2020
Transition Care provides time-limited, goal-oriented and therapy-focused packages of services to older people after a hospital stay.
These packages include low intensity therapy—such as physiotherapy and occupational therapy—social work and nursing support or personal care.
Transition Care is designed to improve a client’s independence and functioning in order to delay their entry into residential aged care.
Transition Care service delivery is managed by the state and territory governments. Within the framework of the programme, state and territory governments determine the model of service delivery that best respond to local service and individual care recipient needs. All state and territory governments have partnership arrangements with non-government organisations for the provision of Transition Care.
Key facts on transition care
At 30 June 2019, there were a total of 4,100 operational transition care places nationally.
Eligibility and transition care extension
The Transition Care Programme supports older people who would otherwise be eligible for residential care. To enter transition care clients must have been assessed as eligible by an Aged Care Assessment Team (ACAT) while they are an in-patient of a hospital. Clients can only enter transition care directly after discharge from hospital.
Transition Care provides short-term care of up to 12 weeks, care is able to be delivered in a hospital, residential or home setting.
Transition Care recipients can have their episode extended by a maximum of 42 days (an additional six weeks) to ensure that their further transition care needs are met. In such cases, an assessment for an extension, specifying the duration of the extension, may be made by an ACAT based on information provided by the Transition care service provider, and other sources as appropriate. The application for the extension must be completed within the initial 12-week episode of transition care.
A Transition Care episode can only be extended by up to 42 days. The transition care service provider, in consultation with the hospital geriatric rehabilitation service where necessary, must complete Part 1 of the Transition Care Extension form and forward it to the ACAT for assessment. Based on the information provided by the service provider, and other sources such as the care recipient and relevant health professionals as appropriate, the ACAT will assess whether or not an extension is required and complete Part 2 of this form.
Funding for the Transition Care Programme
The Transition Care Programme was established in 2004–05 as a jointly funded initiative between the Australian Government and state and territory governments. The Australian Government provides the Flexible Care Subsidy for the Transition Care Programme.
The Aged Care (Subsidy, Fees and Payments) Determination 2014 contains details on the amount of Flexible Care Subsidy for transition care.
Gold Coast Health
The Transition Care Team
Dietitian
If you experience a loss of weight (expected or unexpected), loss of appetite, find yourself lacking energy so that your ability to achieve your day-to-day activities is reduced, or feel you have inadequate nutrition from what you are eating, we have a dietitian available that can review your diet and give some practical advice, menu planning and shopping ideas that may help you improve your health. Our dietitian is also able to educate you on ideal nutritional management of conditions such as diabetes (whether it is a new diagnosis or you have had it for a while), constipation and many other medical conditions.
Nurse
Our Clinical Nurses can assist you with all health related tasks and issues such as incontinence, medications, pain management and wound care. They can educate you about your blood glucose levels, blood pressure, fluid restrictions, as well as general health education for heart disease, diabetes, lung disease, and many others. They may also liaise with your GP and specialist if needed, and provide continuous support and follow-up whilst with the Transition Care
Program.
Occupational Therapist
Our Occupational Therapists aim to maximize your independence and safety in and around your home and the community. They achieve this by assessing you in your environment, and may recommend suitable equipment or modifications for use that can help you achieve your day to day activities, social and leisure pursuits. They have a special interest in helping your daily activities to be as easy as possible, and facilitating return to the things you enjoyed prior to your hospitalisation. Occupational therapists can also assist people with memory strategies and help them to better organize and plan daily tasks.
Pharmacist
Our Pharmacist can review your medication on discharge from hospital, to ensure the safe use of your medicines. Their aim is to assist your medication management at home by supplying a medication profile, information on any newly-prescribed medication, advice on aids such as Webster packs, and to answer any questions about your prescriptions. The pharmacist will be able to liaise with your GP and/or Specialist to ensure you are taking the most suitable medicine, at the correct dose for your condition(s), in order to achieve the best outcomes for you.
Physiotherapist
Physiotherapists help to get you moving again after your hospital stay, and aim to help keep you moving through specific exercise, and
selection of walking aids if you need one. They can educate you on returning to daily activities and management of some types of your aches and pains. They can assess an facilitate your confident return to community activities (walking outside, hills, stairs, the beach, etc), and reduce your risk and fear of
falling. Physiotherapists can also help you if you have trouble breathing and difficulties clearing phlegm from your chest, and possibly reduce your chances of developing a chest infection.
Psychologist
Psychologists help individuals and their families manage and adjust to changes in their physical or emotional functioning, to help achieve a better quality of life. You may ask to talk to our psychologist if you notice you are feeling emotions such as frustration, agitation, hopelessness, or forgetfulness. Amongst other things they may also be able to help you if you find yourself feeling tearful, distractable, bored, sleeping poorly or lacking motivation to do things you would normally enjoy.
Social Worker and Welfare Officer
Our social worker and welfare officer are available to assist you and your family with planning what you will do once you are discharged from the Transition Care Program. They know of many services and options that are available in the community to help you manage long-term. They can provide practical support with Centrelink, Housing Queensland, or other complex paperwork, and assist you in accessing different support and financial services. They can also assist you in accessing various social and community groups and activities you may find beneficial, especially if you are feeling alone, isolated or sad following your hospital stay. They can also support those caring for you and help you to adjust to the changes you are experiencing.
Speech Pathologist
Speech Pathologists specialize in assessing and treating eating, swallowing and communication troubles that you may experience when you are at home or out-and-about. If you experience coughing or choking when eating or drinking, dribbling or drooling, notice your voice is not as loud as it once was, or have reduced confidence in social activities that involve talking or eating, our speech pathologist may be able to help.
Therapy Assistants
Therapy assistants work in conjunction with our clinical staff to assist in your recovery, and provide feedback to the health professionals regarding your progress. They assist with exercise programs, activities of daily living, support community access, and some transport as directed by therapy staff. They can deliver equipment and other supplies such as pads and supplements as prescribed.
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The Role of the Carer - YOU are Needed...
In addition to being the “silent care coordinators,” unpaid family caregivers directly provide most long-term services and supports needed by persons with chronic illnesses and functional limitations, as well as much direct nursing care.
Carers know the strengths and weaknesses of patients and caregivers in chronic care management; accompany patients to physician visits and serve as facilitators of patient physician communication; are “walking medical records” in emergencies and provide care continuity across settings.
Carers manage behavioral problems; spot early warning signs of symptom changes and medication errors and interactions; are gatekeepers who help decide when and which clinician to call, and when to seek emergency care.
Carers identify patient needs for community-based services as well as medical equipment and assistive devices/technology; are advocates for patients with physicians and other health professionals, and in hospitals and rehabilitation facilities, with home health agencies, and in nursing homes. They monitor costs and deal with insurance claims and denials, and help to express patient goals and preferences for care.
With many thanks for their insights into the Actual Role of Caregivers in the ongoing health and care of the person they care for.
excerpt on page10. "Family Caregiving and Transitional Care: A Critical Review" Mary Jo Gibson, Kathleen A. Kelly, and Alan K. Kaplan October 2012.
https://www.caregiver.org/sites/caregiver.org/files/pdfs/FamCGing_TransCare_CritRvw_FINAL10.31.2012.pdf
and for a more detailed explanation in the form of a table: Look specifically at page 14.
https://www.legislation.gov.au/Details/F2018C00695
Part 4—Amount of flexible care subsidy—care provided as short‑term restorative care
106A Purpose of this Part
For section 52‑1 of the Act, this Part sets out a method for working out the amount of flexible care subsidy for a day for a care recipient who is being provided with short‑term restorative care (as defined by section 106A of the Subsidy Principles 2014) through a flexible care service.
106B Amount of flexible care subsidy
(1) The amount of flexible care subsidy for a day for a care recipient is the sum of:
(a) the basic subsidy amount for the day for the care recipient; and
(b) the dementia and veterans’ supplement equivalent amount for the day for the care recipient.
Basic subsidy amount
(2) For paragraph (1)(a), the basic subsidy amount for the day for the care recipient is $201.78.
Dementia and veterans’ supplement equivalent amount
(3) For paragraph (1)(b), the dementia and veterans’ supplement equivalent amount for the day for the care recipient is $4.05.
If you are already living in an aged care home and you are paying the maximum basic daily fee, you cannot be asked to pay the same amount to your transition care service provider.
Therapy services
Low intensity therapy to help you recover sooner and safer:
- physiotherapy
- occupational therapy
- podiatry
- dietetics
- speech pathology
- counselling services
- social work, connecting you to wider community support
- social activities such as lifestyle, cognitive, and general exercise programs.
Nursing support
Clinical care carried out by a registered nurse:
- pain management
- wound care
- oxygen therapy
- medication assistance
- dementia support
- catheter care
- on-call access to specialised nursing services.
Personal care
Personal assistance with everyday tasks:
- bathing, showering, personal hygiene and grooming
- maintaining continence or managing incontinence
- eating and eating aids
- dressing, undressing, and using dressing aids
- moving, walking, wheelchair use, and using devices and appliances designed to aid mobility
- communication, including addressing difficulties arising from special conditions, such as dementia.
- counselling services
- social work, connecting you to wider community support
- social activities such as lifestyle, cognitive, and general exercise programs.
Short-term care - Transition Care
https://www.myagedcare.gov.au/short-term-care/transition-care
This program MUST be arranged whilst you are still in the hospital.
Please note Specialist rehabilitation and aged care teams that will respond to patients when they first come into the Gold Coast University Hospital and Robina Hospital, as early as in the Emergency Department.
You will see a vast difference in the way YOU receive care and the ability of the Team to help you return HOME earlier, or receive the care YOU need in your own home.
Third public hospital for Gold Coast:
Gold Coast Health is leasing the former Gold Coast Surgical Hospital at Varsity Lakes to deliver more efficient public elective surgery to the community - YOU.
Renamed Varsity Lakes Day Hospital welcomed its first surgical patients on 1 November 2017. Across six operating theatres, the Gold Coast Health team expects to perform 15,000 routine surgeries each year at Varsity Lakes including gastroenterology, gynaecology, orthopaedics, plastics and ophthalmology. This includes an additional 3000 endoscopies every year.
The new day hospital will also increase valuable bed space and reduce the length of stay for patients waiting for surgery at Gold Coast University and Robina hospitals...
healthwaves+ Your local health news December 2017 / Januray 2018. p.3.
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Gold Coast Transition Care Program
Transition Care Program - Gold Coast
Community Aged Care Packages
Transition Care Program - Gold Coast Provides a package of services (up to 12 weeks) for older people currently in hospital and ready for discharge. Clients are assessed by the ACAT prior to discharge. Services can include allied health, nursing, personal care, domestic assistance, food services, case management.
Zurich House
8 - 10 Karp Crt
Suburb: BUNDALL
State: QLD
Postcode: 4217
Tel. (07) 5570 8579
Fees
An approved provider may charge a contribution fee to the cost of your care.
The maximum fee is 85% of the basic daily rate of a single pension for care delivered in a ‘live in’ setting, or 17.5% of the basic daily rate of single pension for care provided at home.
Access to transition care is decided on a needs basis, not on an individual’s ability to pay fees.
Talk to your hospital social worker or discharge planner to find out more details about the Transition Care Program.
Hospital and assessment information for care plan development:
For those people approved as eligible for transition care, the hospital geriatric rehabilitation service and the ACAT assessment are key information sources for the development of a care plan to guide the physical and cognitive therapy services delivered through transition care. It is important that the ACAT attaches a copy of all relevant assessment documentation to the copy of the Aged Care Client Record given to the service provider.
Entry to transition care:
A care recipient can only enter transition care directly upon discharge from hospital in order to derive maximum benefit from a time-limited episode of low intensity therapeutic interventions. An ACAT approval to enter transition care is valid on the date the ACAT delegate signs the approval, and then for four weeks (28 calendar days) after the date of signing (see also section 3.4.4 Approval for transition care).
Older people who are receiving care under a hospital-in-the-home or equivalent programme cannot commence their transition care episode while they are still classified as an in-patient of the hospital. Older people who are discharged from hospital and have returned to their usual place of residence before commencing the programme are no longer eligible to enter the programme.
Duration of care:
The average duration of a transition care is 7.5 weeks. Flexible care subsidy will be paid for all recipients up to a maximum of 12 weeks. Where an extension has been granted, up to a further six weeks flexible care subsidy will be paid (see also section 3.5.7 Extensions). To ensure that the limited resources benefit as many older people as possible, there should not be an assumption that the programme is a ‘twelve-week programme’ for every care recipient. Care is provided based on each care recipient’s care needs. While some care recipients may require the maximum 12 weeks of care and an extension of up to six weeks, the majority of care recipients do not require the maximum period of care. Additionally, where residential and home care based services are both provided as forms of transitional care during one episode of care, there must not be a gap between these services.
Your Service provider manages the day-to-day operations of a transition care service.
Transition Care service delivery is managed by the state and territory governments. Within the framework of the programme, state and territory governments determine the model of service delivery that best respond to local service and individual care recipient needs. All state and territory governments have partnership arrangements with non-government organisations for the provision of Transition Care.
Transition Care recipients can have their episode extended by a maximum of 42 days (an additional six weeks) to ensure that their further transition care needs are met. In such cases, an assessment for an extension, specifying the duration of the extension, may be made by an ACAT based on information provided by the Transition care service provider, and other sources as appropriate. The application for the extension must be completed within the initial 12-week episode of transition care.
A Transition Care episode can only be extended by up to 42 days. The transition care service provider, in consultation with the hospital geriatric rehabilitation service where necessary, must complete Part 1 of the Transition Care Extension form and forward it to the ACAT for assessment. Based on the information provided by the service provider, and other sources such as the care recipient and relevant health professionals as appropriate, the ACAT will assess whether or not an extension is required and complete Part 2 of this form.
13 February 2019
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Integrated care:
Gold Coast Integrated Care (GCIC) is changing the way patients with chronic conditions are treated on the Gold Coast. The complex program incorporates a multidisciplinary team, from specialist care to allied health and community-based services, across a number of sites supporting patients and their GP's.
GCIC has established partnerships with 14 GP clinics and community-based healthcare providers to facilitate a seamless continuum of care to patients with chronic conditions such as heart disease, chronic obstructive pulmonary disease, kidney disease and diabetes.
These care types builds on the success of the existing transition care programme that assists older people to return home after a hospital stay. These new places allow additional flexibility in how care is accessed and delivered.
Transition Care Program
Service Description
Transition Care provides short term care that seeks to optimize the functioning and independence of older people after a hospital stay. Transition Care is goal orientated, time limited and therapy focused. It provides older people with a package of services that includes low intensity therapy such as physiotherapy and occupational therapy, case management as well as social work, nursing support or personal care. Transition care can be offered in a person's home (community based) or in a residential setting (bed based).
The Program facilitates a continuum of care for older people who have completed their hospital episode, including acute and sub acute care (eg rehabilitation, geriatric evaluation and management), and who need more time and support to make a decision on their long term aged care options.
It seeks to enable older people to return home after a hospital stay rather than enter residential care prematurely.
Eligibility
To be eligible for Transition Care, the person must be an admitted patient of a public or private hospital and assessed in hospital by an Aged Care Assessment Service (ACAT).
Fees
A client contribution set by the Commonwealth Government is required for the Transition Care Program.
While providers set their own fees in consultation with you, the government sets maximum amounts. Currently, the maximum amount you may be asked to pay is:
Transition Care Programme
Maximum Daily Fee Rate
TCP delivered in a Home or Community Setting $10.63 per day
TCP delivered in a Residential Care Setting $51.63 per day
Schedule of Fees and Charges for Residential and Home Care: From 20 March 2020
This page provides the latest updates to aged care fees and charges.
[i] Residents in designated remote areas may be asked to pay an additional $1.06 per day.
NOTE: The Transition Care Program is to be rolled into the overall aged care provision ratio and will make up two places in the ratio of 125 places. This is estimated to provide 6,000 places by 2021.
Transition care provides short-term care that is:
- focused on your individual goals
- focused on particular therapies
- for a short time only
Transition care focuses on your individual goals and therapies with the aim of helping you to return to your usual state of independence.
The maximum duration is 12 weeks. This may be extended to 18 weeks if you are assessed as needing more help during the program. The average duration of care is seven weeks.
To be eligible an older person must be an in-patient of a hospital and have completed their acute and any necessary sub-acute care (e.g.
rehabilitation). While still in hospital, tell the nurse that you need to be assessed by an Aged Care Assessment Team (ACAT or ACAS in Victoria) as someone eligible for transition care.
You must enter the program Directly upon discharge from hospital.
Transition Care provides a package of services that is tailored to the needs of the client and may include a range of low intensity therapy and nursing support or personal care.
- Examples of low intensity therapy services may include;
- nursing support for clinical care such as wound care
- physiotherapy (exercise, mobility, strength and balance);
- occupational therapy;
- dietetics; (nutrition assessment, food and nutrition advice, dietary changes);
- podiatry (foot care);
- speech therapy;
- personal care
- counselling; and access to a social worker.
Examples of personal care services may include assistance with:
- showering,
- eating,
- managing continence,
- transport to appointments,
- moving,
- walking, and
- communication.
Transition care is provided in the older person’s home or a ‘live-in’ setting. ‘Live in’ setting refers to facility based accommodation with a more home-like, less institutional feel and with space available for therapy. This setting can be part of an existing aged care home or health facility, for example a separate wing of a
hospital.
Costs for care services vary depending on your circumstances and the kind of help you need. If you can afford to, you will be expected to contribute to the cost of your transition care by paying a basic daily fee. However, you will always have access to the services you need, regardless of your financial situation. You will never be denied a serviced because you can't afford it.
Phone 1800 500 853 (Aged Care Information Line)
The Transition Care Program to be rolled into the overall aged care provision ratio and will make up two places in the ratio of 125 places. This is estimated to provide 6,000 places by 2021.
23 March 2020