Transition Care Program

What is the Transition Care Program?

Our Transition Care Program helps you safely recover after a hospital stay.

The program gently aids your recovery with short-term, personalised therapy based on your needs and goals. Support happens at your pace, with a focus on helping you rebuild confidence and functional independence for everyday living.

You will be supported by a caring team who get to know you. This includes nurses, allied health professionals such as occupational therapists and physiotherapists, and a dedicated group of multi-skilled support workers.

Talk to us

How does it work?

Ask for an assessment

Let the hospital staff know you’d like transition care and ask them to arrange an assessment for you. You can access the Transition Care Program even if you have a Support at Home Package or Commonwealth Home Support Program in place.

Get approved

Someone from our team will come and visit you in hospital for the assessment. Once approved, we will plan your discharge in partnership with hospital social workers to help ensure a smooth process and reduce the risk of readmission.

Receive care and recover

You will receive care from a multidisciplinary team who get to know you and your goals.

Care can be delivered for up to 12 weeks and is tailored to your needs.

Meet Derryle

After 40 days in hospital following a fall, Derryle has returned home safely with support from our Transition Care Team.

Through the program, Derryle received daily personal care, physiotherapy five days a week, and clinical care twice a week to help rebuild strength, confidence, and independence.

Derryle thrived with the program and is now settled in at home, feeling much more like herself again.

All staff are very friendly and have helped me. I want to stay at home for as long as possible and they have been very good. I want to say thank you to them.

Derryle

Looking after you

Your program coordinator and multidisciplinary team take time to understand what matters most to you. They help you set meaningful goals and take steady steps towards them, whether that is moving more easily, feeling stronger, or simply getting back to the routines you enjoy. Every step focuses on your physical and mental wellbeing, so you can feel comfortable and confident again.

Transition care may include:

Allied health support such as physiotherapy, occupational therapy, therapy support, speech pathology, and dietetics
Nursing care
Support services including daily living assistance, domestic support, and social support
Transport to medical appointments
Essential short-term equipment to keep you safe such as walkers

Every recovery journey is different, and you may have a few questions along the way. Here are some answers to common questions about our Transition Care Program.

Frequently asked questions

I already have a Support at Home package or Commonwealth Home Support Program in place. Am I still eligible?

Yes, you can access the Transition Care Program even if you have one of these programs in place. Our team will make sure none of your services are duplicated so you can maximise all your support.

How much does the Transition Care Program cost?

We will never surprise you with hidden costs and will always discuss our fees in consultation with you. Majority of the cost is covered by the government, but depending on your circumstances you may be required to contribute a co-payment of 17.5% of the single age pension. You can find accurate pricing from My Aged Care.

Support is available to those facing financial difficulties.

See pricing from My Aged Care

Can I arrange the required assessment myself?

Yes. If you prefer to, you or someone you trust can call My Aged Care on 1800 200 422 and they will explain the process.

What if I need support for more than 12 weeks?

In some cases, you may be able to extend your services for an additional six weeks (42 days), but this will require another assessment.

If you need to access the Transition Care Program again, even in the same year, there is no limit on the number of times you can apply. If eligible, you will be approved to receive transition care services again.

Where will I be transitioned to?

Your transition care journey depends on your needs. You may return home after hospital, move into residential aged care, or start at home and transition into a facility over time. If your needs change during the 12-week program, we adjust your care to suit you. Our focus is always to help you remain at home, as long as it is safe.

Take the next step in your recovery

You do not have to recover on your own. Speak to your hospital team about arranging a transition care assessment with Southern Cross Care WA.

You can also explore our Home Care services to see how we can further support your transition.

Home Care