Improving outcomes post-hospitalisation

The Southern Cross Care (WA) Transitional Care Program (TCP) is a short-term 12-week service designed to improve client outcomes post-hospitalisation, by reducing hospital readmissions and enhancing quality of life through accelerated recovery.

The primary goal of the TCP program is to facilitate a successful transition from the hospital to home, focusing on optimising functional independence and delaying the need for long-term care.

TCP utilises a variety of strategies and healthcare professionals, including nurses, therapists, and home-based care services, to help clients regain as much independence as possible. This may include personalised care plans, therapy support, nursing care and equipment for mobility support tailored to the specific needs of the individual. Each plan is goal-oriented and focuses on each client’s aims and goals, which are used to maintain or improve mobility.

To qualify for our TCP program, clients must be referred to the program by a hospital social worker following an acute episode requiring hospitalisation. Clients will also need an ACAT assessment and are required to attend their first appointment within four weeks of referral.

Supporting transition with allied health services

Our TCP can provide up to seven hours of allied health service support per week for clients living in Fremantle, coastal or surrounding areas. The first week may be more intensive, and then clients can transition to the Southern Plus Health and Wellness Centre, which features a gym and hydrotherapy pool.

For clients who need extra assistance after completing the program, there are potential options for an additional six weeks of care or 18 weeks in total.

TCP primarily aims to support individuals who require additional assistance following a hospital stay. This includes those who may not have a stable support network at home and those who need extra time and care to recover in a non-hospital environment.

Meet Derryle

Meet Derryle, our first client in our new Transitional Care Program which supports clients to transition back into the home after hospitalisation.

83 year old Derryle has lived in her home for 70 years. Her husband originally built the house, so it is important to her to stay in her home for as long as possible.

After staying in hospital for 40 days following a fall, our Transitional Care Program team have transitioned Derryle safely back into her home.

Derryle is receiving Personal Care daily, Physiotherapy twice daily five days a week and clinical care twice weekly. She also receives Home Chef meals and Occupational Therapy services.

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.


Home Care

Learn about the home care services supporting the Transitional Care Program

Learn more

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