Transition Care

We provide transition care on behalf of the Victorian State Government and Ballarat Health Service to eligible older people living in the Hepburn Shire at home or at Creswick Hospital, Daylesford Hospital or Trentham Hostel

The Transition Care Program provides short-term care and services for older people (or younger persons with aged related conditions) after an acute episode of care in a hospital. By offering low-level therapy and support it allows older people to continue their recovery out of hospital while appropriate long-term care is arranged. The maximum time you can stay on the program is 12 weeks, although in an exceptional circumstance you can be approved for an extension of up to another six weeks.

Transition care can either be provided in a bed-based care setting such as in a nursing home or in your own home. Where you receive care will depend on the type of care you need. Some people may receive care in more than one care setting (but not at the same time, for example, commence in bed based and then move to home based or vice versa) during their time on the program.

At Hepburn Health, you can receive transition care in your own home in the Hepburn Shire or at Creswick Hospital, Daylesford Hospital or Trentham Hostel. It will depend upon the level of care you require during your stay.

What is provided by transition care?

The type of care you receive will depend on what you need and what setting you receive transition care.

Services include:

  • case management;
  • nursing and personal care;
  • domestic home care, such as cleaning services;
  • meal assistance;
  • help with bathing and showering;
  • organisation of appointments (including transport);
  • social activities or diversional therapy;
  • low-level therapy as provided by allied health staff such as a physiotherapist or occupational therapist;
  • continence aids;
  • assessment for equipment by a physiotherapist or occupational therapist and
  • in-home

What does case manager do?

When you commence transition care you will be allocated a case manager. This person will help you and your carer or family from the time you start on the program to when you finish. Your case manager will help you set goals for what you want to achieve.

Your case manager will:

  • conduct the initial and ongoing assessment of your care needs
  • coordinate and monitor your care plan with you
  • liaise with service providers to keep them informed of changes required in your care plan
  • ensure you have the opportunity to participate in decisions affecting your care
  • provide information and education
  • act as an advocate or supporter on your behalf if needed
  • provide emotional support to you and your carer and
  • develop a discharge plan with you to make sure the support and services you need are in place when you are discharged.

Eligibility & Cost

To receive transition care you will need to be assessed and approved by the Aged Care Assessment Service (ACAS) while you are in hospital. Someone will organise this for you.

Transition care is a jointly funded aged care service of the Victorian State Government and the Commonwealth Government established under the Aged Care Act 1997. Funding covers most of the cost of the program; however you are also asked to pay a fee to contribute to the cost of your care. Transition care is not covered by private health insurance.

The maximum fee is determined by the Government and is calculated as follows:

  • Home-based clients – daily rate of 17.5% of current single aged pension
  • Bed-based clients – daily rate of 85% of current single aged

If you are unable to pay the fee, please discuss this with your case manager. If applying for a fee reduction you may be asked to show proof of your income and financial situation. Fees can be reviewed and discussed with your case manager at any time.

Integrated Community Aged Care Office
18 Hospital St Daylesford   
Phone: 5321 6596
Fax: 5321 6584
Email: agedcare@hhs.vic.gov.au

Hepburn Health is accredited by the Quality Innovation Program Rainbow Tick certification for inclusive practices that respect the wishes of LGBTI individuals.