We provide short-term support for older people after a hospital admission, who require more time to address their functional, physical, cognitive and psychosocial goals
TCP referrals must be started during the hospital admission. The Aged Care Assessment Service (ACAS) must also determine eligibility for TCP during the hospital admission. TCP can then commence on discharge from hospital.
The program aims to
· Support older people to recover from their often complex or long hospital stay
· Assist in further developing your skills in managing changes to your health or adjusting to a new baseline.
· Loan some types of equipment as required
· Increase independence for transition back to the community in your home
· Provide discharge planning support for accessing longer term supports in your home
· Can provide assistance to develop an Advance Care Directive or document your ‘Medical Treatment Decision Maker’ together with your GP
· Gives time in a supported bed-based setting to see if recovery is possible or assist in looking at alternative options if transition home cannot be safely achieved.
Up to 12 weeks of TCP
The program runs for up to twelve weeks and sometimes a short extension can be offered if appropriate. The 12 weeks is a combined maximum, for example, if 6 weeks is spent in bed-based TCP then another 6 weeks could be spent in home-based TCP.
Either Home Based or Bed Based, or perhaps a combination
The Transition Care Program at WDHS comprises seven allocated places. Four places are used as home-based places in your own home. The remaining three are bed-based places under TCP at either Grange Residential Care, Penshurst hospital or Coleraine hospital. It is not always possible to provide the bed based location preferred as places can only be offered as a vacancy becomes available.
Each person’s journey is individually catered for and designed with their input and consent.
The TCP Nurse Case Manager will visit clients each week, assess the client’s progress, care needs, and coordinate services as required. Our multidisciplinary team brings a broad range of skills to the program, enabling all areas of your transition care to be addressed.
Members of the TCP team may include (as individually required):
- TCP Coordinator/Case Manager
- Your Doctor
- Physiotherapist
- Occupational Therapist
- District Nursing Services (home based TCP only)
- Social worker
- Speech Therapist
- Continence Nurse Advisors
- Dietician
- Diabetes Educator
- Podiatrist
- Aged Care Coordinator
- Allied Health Assistants
- Meals on Wheels provided through WDHS
- Community Support Services (prev provided by local shire) – Home Care, Shopping Assistance, shower assistance
Geographical Area of Service
Home-based clients must reside within a 40km radius of Hamilton.
Family involvement
We encourage family members and caregivers to be involved in the transition process. To aid progress, the TCP coordinator or case manager may discuss the client’s goals and future planning with the family if the client consents. Education can be provided, if required, to assist ongoing care and safety of the client and their caregivers.
Client Fee
The cost of TCP is subsidised by the Commonwealth and Victorian governments, however there is a daily cost to the client for the program, which is adjusted twice a year in March and September.
The fee clients are asked to contribute are as follows;
- Home Based TCP = maximum equivalent of 17.5% of the single aged pension
- Bed Based TCP = maximum equivalent of 85% of the single aged pension
Contact
TCP Coordinator
Phone: (03) 555 18594
Please note: Referrals are assessed initially by TCP nurses for eligibility, and then an ACAS assessment must occur during the hospital admission before discharge.
Services:
Transition Care
Last modified:
Tuesday, 18 July, 2024
Links
Referral:
For patients to access the service they must have had an acute admission to hospital, prior to being accepted into the TCP. An Aged Care Assessment Service (ACAS) referral is required to ascertain a patient’s eligibility. Special consideration is given to younger patients who may be considered eligible for the program.
Referrals should be directed to the Care Coordinator. Any healthcare professional involved in the patients care can send a referral via TRAK community, direct phone call or email.
LOCATION
Hamilton House
Allied Health Centre
Tyres Street
Hamilton, Vic 3300
CONTACT US
03 55518352