Transition Care Program

My Dad was fortunate to return home from hospital on the Transition Care Program (TCP), twice.
The first time was after his Total Knee Replacement (TKR) in 2015 and the second time was after the ‘big stroke’ mid 2017.

Both of these times TCP was able to help us get Dad home sooner, as his recovery continued to be supported by a team of clinicians who came to my parent’s home.
Getting Dad home sooner was a priority as Dad was delirious during both of these hospital admissions and getting him home would promote the resolution of the delirium.

TCP provides time limited (up to 12 weeks), goal oriented restorative care for older people who are returning home from hospital.

Eligibility for accessing the TCP is determined by the Aged Care Assessment Team (ACAT) who will undertake an assessment in hospital to ascertain your goals upon discharge.

This is the catch…you must be assessed while in hospital and discharge home from hospital to be eligible for TCP.
You cannot go home and then try to be accepted onto TCP.

This is how acceptance onto TCP looks. 

An older person has a fall at home sustaining an injury, let’s just say a soft tissue injury and bruising of the arm.
There are some lacerations on the person’s arm too, as the person fell against the sharp edge of a coffee table.
The older person is taken to hospital and admitted as the arm is very painful and the doctors want to make sure there are no fractures.
The lacerations need dressing too.

After a few days in hospital the doctors are thinking about sending the older person home.
The physiotherapist and occupational therapist are a little hesitant as the older person is unable to shower themself without assistance due to the ongoing pain.
The older person wonders how they will manage to cook meals and get to the GP to have the dressings on their arm changed, as the arm is too painful to drive.

The team agrees to refer to TCP.

The ACAT attend the hospital and assess the older person, determining that the goals the person would like to achieve are showering independently, cooking, being able to clean the house and resume driving.

The ACAT approve the older person for eligibility for TCP.

Care planning.

The TCP team design a plan of care that delivers in home physio, occupational therapy, nursing and personal care to the older person.
The team also arrange for a personal alarm to be installed.

The older person goes home and the next day the team start attending the older person’s home to support the implementation of the care plan.
The physio prescribes exercises, the occupational therapist facilitates some modifications to the bathroom (rails) and some equipment to be delivered (an over toilet frame, shower chair and ramps at the front and back doors), the nurse changes the dressings and a carer is sourced to assist with showering and meal preparation.

Over the next 12 weeks the older person regains their confidence and feels stronger, enabling them to manage their activities of daily living independently again.
At this point, TCP concludes.

TCP is available to people discharging from both public and private hospitals.
It is available in any State or Territory in Australia.
I have even had clients who were interstate (Victoria) and we liaised with the hospital in Melbourne to have the patient assessed and approved for TCP, then we coordinated with our local TCP team to commence TCP on the person’s arrival back home in Queensland.

I tell all my clients about it.
If there is one thing I could ask you to remember if you or your ageing loved one is admitted to hospital and will be returning home, ask about going home on TCP.

It is an excellent program!