The Transition Care Program's (TCP) purpose is to minimise the number of older people experiencing inappropriate, extended lengths of stay in hospital or being prematurely admitted into residential aged care. TCP provides short- term care that seeks to foster independence in older people, after a hospital stay and is a goal-orientated, time-limited and therapy-focused program. 

What do we do?

TCP Care Coordinators work in collaboration with clients and family/ care providers to determine client- focused goals, develop a personalised care plan and an individualised package of services, which can include: 

  • Accommodation in a supported aged care facility or services at home
  • Case Management
  • Nursing
  • Low intensity therapy – such as Occupational Therapy and Physiotherapy
  • Social Work support
  • Personal care (bathing or showering)
  • Domestic home care (cleaning)
  • Meal assistance (shopping, meal preparation)
  • Support for appointments (may include transport)
  • Some equipment needs
  • In Home Respite &
  • Social Activities

TCP can be offered in a person's home (home-based) or in a residential setting (bed-based) and enables older people to have more time in a non-hospital environment to complete their restorative process or finalise and access their long-term care arrangements.

This is a time-limited program with clients usually on the program for 6 to 8 weeks ( with an upper limit of 12 weeks) depending on requirements. 

Who do we care for?

The target group for TCP includes:

  • older people for whom further improvements to their physical, cognitive and psychosocial functioning are achievable, along with an improved capacity enabling them to live independently.
  • older people for whom the focus is on optimising their functioning, while assisting them and their families/carers to make appropriate long-term care arrangements.

How can you access this service?

If a person is in hospital (emergency department, short stay unit, acute or subacute ward) they can self-refer to TCP or have a referral made on their behalf by hospital staff.

The Aged Care Assessment Service (ACAS) will determine initial eligibility and then a member from the TCP team will meet with the person to discuss the program in more depth.

If the person wishes to go ahead with the program, the TCP Information and Client Agreement document will be signed, individualised client goals will be agreed on and a care plan will be developed.

Commonly asked questions

Is there a cost?

Costs for TCP are covered through a subsidy provided by the Commonwealth and Victorian Governments. However, the Commonwealth Government also requires a daily care fee contribution from people who are able to pay.

The maximum fees are calculated based on the basic single aged pension and are adjusted twice yearly (20 March and 20 September):

  • Home Based clients - 17.5% of the current single aged pension
  • Bed Based clients – 85% of the current single aged pension

Any financial concerns impacting on a person’s capacity to pay the contribution fee should be discussed with the person’s case manager.

Additionally, the cost of medical services, such as pathology, radiology and pharmacy (prescription) medicines is not included as part of TCP and you will be required to pay for these separately. If you are at your safety net level, please let your care coordinator know.

Transition Care Program


102 Ascot Street South
Ballarat VIC 3350

Opening Hours

Monday to Friday 8.30 am - 5 pm (office is closed weekends and public holidays)

Transitional Care is offered across six health services within the Grampians region:

Ballarat Health Services 03 5320 3851
Hepburn Health 03 5321 6544
Wimmera Healthcare Group 03 5381 9294
Stawell Regional Health 03 5358 8604
Ballan District Health and Care 03 5366 7920
Beaufort and Skipton Health Service 03 5349 1665


03 5320 3663


TCP Bed-Based Facility


Morgan Street
Sebastopol VIC 3352


03 5335 0501

Have something to tell us? We welcome all feedback from patients, family members or carers. Tell us more.