Transition Care Program

“…time-limited, goal-directed care for older people who need additional support to remain in, or return to, their own homes, and avoid premature or inappropriate entry to permanent residential aged care care or hospital”

About TCP

Carinya of Bicton was the successful applicant to pilot transitional care for the South Metropolitan Health Service in 2004.

Carinya has developed a close relationship with the acute hospitals, State and Commonwealth Departments. TCP is jointly funded by the Commonwealth and State Health Department. We have recently renewed our contract to continue to provide this service.

The initiative was designed to provide short term flexible care options for the frail, elderly at the interface of the acute/sub acute and residential aged care sector. The program is goal orientated therapy/treatment based programs with the aim to reduce inappropriate extended hospital lengths of stay and reduce premature admission to residential aged care. The clients are medically ready for discharge, but are assessed as having potential and motivation to maintain or improve their level of functioning. The target time frame is up to 12 weeks.

Transition care is a multidisciplinary service which aims to help patients following an acute episode requiring hospital admission to receive low intensive therapy and continuing nursing care to help improve their independence and confidence and hopefully return to their own home safety.

What Does it Involve?

Transition Care programs includes the ability to return home with an assessed care plan and continuing support from health professionals. Transition care can be provided for a period of up to 12 weeks, with the possibility to extend to 18 weeks if you are assessed as needing an extra period of therapeutic care. To be eligible for transition care, you must be an older person and an in-patient of a hospital and you must have completed your acute stage.

A flexible care program will be designed for the client to meet individual needs. The team will include:

  • GP
  • Nursing personnel
  • Allied health personnel
  • Social Workers
  • Carers

How do you access the program?

If a client requires residential care, relatives should be actively seeking 1-3 preferred places in a residential aged care facility. The target time frame is up to 8 weeks. In order to participate in the TCP, you will need to meet the following criteria:

  • An existing patient in an acute hospital
  • No longer requiring hospital care
  • Medically stable
  • Have an Aged Care Assessment Team Assessment approval for flexible care


  • 50 Residential Places – 10 of these are secure 

Your Investment

  • The fee is subject to the Commonwealth Government Guidelines
  • 17.5% of the basic pension if the care is delivered in your own home
  • 84% of the basic pension, if the care is delivered in the residential setting

All accommodation, comes with access to our spacious dining area, large activity areas, lounges with entertain centres and a piano area.

Western Australian Carers Charter

As a Carer, you have rights that have been set out by Western Australian legislation in the Carers Charter, you can find more information via the following pages:

The four principles of the Western Australian Carers Charter are:

  1. Carers must be treated with respect and dignity.
  2. The role of carers must be recognised by including carers in the assessment, planning, delivery and review of services that impact on them and the role of carers.
  3. The views and needs of carers must be taken into account along with the views, needs and best interests of people receiving care when decisions are made that impact on carers and the role of carers.
  4. Complaints made by carers in relation to services that impact on them and the role of carers must be given due attention and consideration.