Transition Care Program 

What is Transition Care Program (TCP)?

The TCP is a short-term care of up to 12 weeks that is goal/treatment-based program provided for elderly people to help them get on their feet after hospital stay. 

Who is Eligible?

• Aboriginal Client or Torres Strait Islander 50+ of age residing in Geraldton
• Client admitted by either public or private hospital and ready to be discharged

Who can do a Referral?

Acceptable referral comes ONLY through the hospital via ACAT (Aged Care Assessment Team)

What Services TCP team can Provide?

• Nursing Care
• Home Care e.g. cleaning, personal hygiene, meal preparations
• Allied health maintenance therapies e.g. physiotherapist, counsellors, social worker, diabetes educator, dietician
• Facilitate social activities

What is the TCP Team’s Role?

• To provide safe and high quality culturally based care for Aboriginal or TorresStrait Islander people in the comfort of their homes post discharge from hospitals.
• To commence services within 48 hours after acceptance
• To care plan in collaboration with the client and signicant others e.g family
• To regularly review the care plan and direct towards the client’s goals
• To link clients with other support services required post discharge where possible

What is the Client’s Role?

• To sign the agreement of services to be provided
• To engage in the agreed care and services
• To raise any concerns and provide feedback
• To give a notice and reason for withdrawal from services at any given time