Transition Care is a short term program to provide support and active management for older patients at the completion of an acute hospital admission, who still require more time and support in a non-hospital environment to complete their restorative processes, optimize their functional capacity and finalise and access their long term care arrangements.

The program runs for twelve weeks with the option of a six week extension. Transition Care is a goal-based program. The Transition Care Program at WDHS comprises seven beds. Four beds are used as home or community-based beds and the remaining three are bed based admissions for the program. The beds are funded by the Department of Health and Ageing but there is a daily cost to the client for the program which is reviewed bi-annually.

The Transition Care Program is committed to providing the best possible outcomes for all patients admitted to the program. The program aims to achieve the maximum level of re-integration into the community by admitting patients at the right time; effectively assessing needs, implementing a structured care plan and discharge from the program being a smooth, seamless transition with an appropriate service plan in place.

The Program aims to:

  • increase participation in your own care
  • increase independence for transition back to the community
  • assist you to further develop your skills in managing these changes
  • provide support for you and your family in managing your transition to independence

Clients in the program will be accepting of services provided and participate in a goal focused program.  They will be looked after by a team of health professionals including doctors, nurses and therapists.  The team members hold regular meetings to discuss the progress of each client.

The Team

The Transition Care Coordinator is responsible for the day to day running of this service. A Case Manager is appointed to each client on the program.  The case manager will arrange all care required as well as assess client’s progress and needs weekly whilst on the program.

Our multi-disciplinary team brings their broad range of skills to the program, enabling all areas of your transition care to be effectively addressed.  Members may include:

  • Your Doctor
  • TCP care Coordinator
  • Case Manger
  • Physiotherapist
  • Occupational Therapist
  • Social Worker
  • Speech Pathologist
  • Continence Service
  • Dietitian
  • Diabetes Educator
  • Podiatrist
  • Aged Care Placement Coordinator
  • Allied Health Assistant
  • Shire or Council Services
  • District Nursing Service
  • Planned Activity Group

Geographical Area of service

Home-based clients must reside within a 40 km radius of Hamilton. Bed-based clients will be accommodated at The Grange, Coleraine Hospital, Penshurst Hospital or Hamilton Base depending on availability of a bed.

Family Involvement

We encourage family members and care givers to be involved in the transition process. To aid progress the case manager may discuss the client’s goals and future planning with the family if the client consents. Education is provided if required to assist in ongoing care and safety of the client and their care givers. This ensures a smooth and continuous service.

Transition Care Program

Care Coordinator

Phone:  (03) 5551 8594

Opening Hours

The Transition Care Co-ordinator can be contacted during business hours (8.00am – 4.30pm.) Monday to Friday, excluding public holidays


 Last updated: 24 June, 2016


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.


Hamilton House
Allied Health Centre
Tyres Street
Hamilton, Vic 3300


03 55518352

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