🩺 Introduction: Recovering with Dignity and Confidence
Leaving the hospital can bring both relief and uncertainty. For many older Australians, recovery doesn’t end at discharge — it continues at home, where the familiar environment offers comfort but also new challenges. You may need extra time, care, and support to regain strength and confidence before returning fully to independent living.
This is where Transition Care plays an essential role.
Funded by the Australian Government, the Transition Care Programme provides short-term care for older people after a hospital stay, helping them recover safely and maintain their independence for as long as possible.
For families in Melbourne and across Australia, understanding how transition care works — and how to find the right provider — can make all the difference.
🌿 What Is Transition Care?
The Transition Care Programme is designed to help older Australians recover after hospitalisation through short-term, goal-oriented care.
It offers up to 12 weeks of support (with a possible six-week extension) and focuses on rehabilitation, wellbeing, and helping people stay independent at home rather than entering permanent residential care too soon.
Care can be provided:
- In your own home
- In a residential aged care setting
- Or a combination of both
Each person’s program is tailored to their health needs, recovery goals, and preferences.
💡 Why Transition Care Matters
A hospital stay can temporarily affect strength, mobility, memory, or confidence. Transition care bridges the gap between hospital and home, ensuring that older people do not have to navigate recovery alone.
The program focuses on four key goals:
- Promote Recovery: Support physical and emotional healing after illness or surgery.
- Prevent Readmission: Reduce the likelihood of returning to hospital by ensuring safe recovery conditions.
- Restore Functionality: Help seniors rebuild strength, mobility, and confidence through therapy and personal care.
- Delay Residential Care: Enable older Australians to live independently at home for as long as possible.
It’s not just about medical recovery — it’s about restoring your sense of control and dignity after a major life event.
🏡 Types of Support Available
Transition care services are tailored to individual needs. Depending on your situation, your care plan might include one or more of the following:
- Nursing Support
Qualified nurses provide essential medical care such as:
- Wound management and dressing changes
- Medication support and monitoring
- Pain management
- Catheter and continence care
- Dementia care and oxygen therapy
- Personal Care Assistance
To help you manage daily living with comfort and dignity:
- Bathing, grooming, and personal hygiene
- Dressing and mobility assistance
- Support with meals and nutrition
- Assistance with continence and toileting
- Allied Health Services
Professional therapies to help you regain function and confidence:
- Physiotherapy for strength, mobility, and balance
- Occupational therapy to adapt your home environment and daily routines
- Podiatry for foot health and mobility support
- Dietetics to improve nutrition during recovery
- Speech pathology to assist with communication or swallowing difficulties
- Social and Emotional Support
Health professionals and social workers may provide:
- Counselling and mental health support
- Access to social and community engagement programs
- Cognitive and recreational activities
- Assistance for families exploring ongoing care options
Each care plan is built collaboratively between the hospital team, care providers, and you (or your family), ensuring your recovery goals are clearly defined and achievable.
👩⚕️ Who Is Eligible for Transition Care?
You may be eligible if you:
- Are 65 years or older (or 50+ if you are an Aboriginal or Torres Strait Islander person)
- Are currently in a public or private hospital and ready for discharge
- Have been assessed as likely to benefit from short-term, restorative care
Eligibility is determined through an aged care assessment — usually organised while you are still in hospital.
Once approved, you can choose to receive your care either in a facility or at home, depending on your needs and preferences.
🕐 How Long Does Transition Care Last?
Most people receive transition care for up to 12 weeks.
If more time is needed, a one-time extension of 42 days (6 weeks) can be requested through My Aged Care. This extension requires a reassessment and approval.
If you experience another hospital stay in the future, you can apply again for transition care — there is no lifetime limit on how many times you can receive it, as long as you remain eligible.
💬 When and How Care Begins
Timing is important.
Under the Transition Care Program:
- Care in a residential aged care facility must start within 24 hours after leaving hospital.
- Care at home must begin within 48 hours of discharge.
This ensures that support continues seamlessly from hospital to recovery, reducing risk of complications or relapse.
Hospital staff can arrange an assessment before your discharge, or you (or your family) can call My Aged Care at 1800 200 422 to begin the process.
💰 How Much Does Transition Care Cost?
The Australian Government subsidises most of the cost of transition care, but participants are expected to contribute a small daily fee.
According to the latest schedule from My Aged Care (2025):
- Residential transition care: Up to $65.55 per day
- Home-based transition care: Up to $13.49 per day
The exact amount you pay depends on your financial situation and your provider’s fee structure.
Importantly, no one can be refused care because they cannot afford to pay — financial hardship provisions are available.
🧭 How Transition Care Fits Within the Support at Home Program
From 1 November 2025, the Australian Government will introduce the Support at Home Program, which will replace Home Care Packages and streamline access to aged care services.
Transition Care will remain an essential part of this system — acting as the short-term, restorative bridge between hospital and long-term care planning.
In the new model:
- Transition Care will focus on helping people recover and return home safely.
- The Support at Home Program will provide longer-term, flexible in-home care options.
Together, these programs will ensure older Australians receive the right care, at the right time, in the right place.
🧩 How to Access Transition Care Step by Step
Step 1 — Talk to your hospital team
Let your nurse, social worker, or discharge planner know you may need short-term help after discharge. They can refer you for assessment.
Step 2 — Assessment by My Aged Care
A qualified assessor will evaluate your health, daily living needs, and recovery goals to determine eligibility for transition care.
Step 3 — Receive your approval
If eligible, you’ll receive a letter confirming your approval for the program. This outlines the type and duration of care you can access.
Step 4 — Choose your provider
You can select where and by whom your care will be delivered — at home or in a facility. This is where finding the right provider is crucial.
Step 5 — Begin your recovery journey
Once arrangements are in place, your care starts within 24–48 hours of leaving hospital, giving you immediate support in your transition back home.
❤️ The Emotional Side of Recovery
Recovering after hospitalisation can be overwhelming — not just physically, but emotionally.
Many older people worry about losing independence or becoming a burden on family. Transition care provides reassurance that recovery is possible and supported.
It also gives families valuable time to explore future care options without rushing decisions.
This “breathing space” helps older Australians regain confidence and make informed choices about their next steps.
🌈 How Care Finding Helps Families in Melbourne
Navigating aged care — from understanding eligibility to selecting providers — can feel confusing and time-consuming.
That’s where Support Services Connect Australia (SSCA) comes in.
With more than 25 years of experience in the Australian aged care sector, SSCA offers a free care finding service to help older Australians and their families make informed decisions.
Our care finding specialists can:
- Help you understand what transition care and ongoing support options are available
- Match you with trusted, government-approved providers near your location
- Ensure your preferences, goals, and budget are respected throughout the process
We simplify the complex aged care system so you can focus on what matters most — your recovery, comfort, and peace of mind.
✨ Conclusion: A Bridge to Independence
Transition care is not just a healthcare service — it’s a second chance at independence.
For many older Australians, it provides the vital support needed to regain strength, confidence, and connection after hospitalisation.
Whether you’re a senior preparing to return home or a family member seeking reassurance, understanding how this program works — and how to find the right care — is the first step toward a smoother recovery journey.
With guidance from SSCA’s free care finding service, families in Melbourne can access the care and confidence they need to move forward safely and independently.