“…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”
Carinya of Bicton was the successful applicant to pilot transitional care for the South Metropolitan Health Service in 2004.
The pilot met all expected outcomes and developed a close relationship with the acute hospitals, State and Commonwealth Departments. The funding 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.
Transitional care is a multidisciplinary transitional 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.
Transitional 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 transitional 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:
The TCP has been funded by the State Health department under the direction of the Health Department since 2001. Frail aged people receive the appropriate care needed while they wait for placement in a residential care facility. Relatives should be actively seeking 1-3 preferred places in a residential aged care facility when they are aware of discharge planning at the acute hospital. The target time frame is up to 8 weeks.