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Transition Care Program

Transition Care Program services can be provided either in your own home or in a bed based service at:
The Beaufort Hospital located just off the Western Highway on Havelock Street, Beaufort or The Skipton Hospital located in Blake Street, Skipton.

The Transition Care Program (TCP) provides care services for a short term period for older people who have been in hospital. By offering low level therapy and support it allows people to be discharged safely and continue their recovery out of the hospital system, while appropriate long term care is arranged.

What services can the TCP provide?

A case manager will assist you in managing your care. They will meet with you and your family / carer to discuss, plan and manage your care. In consultation, the case manager will develop a care plan that meets your needs. Services that may be included are:

  • Physiotherapy
  • Occupational Therapy
  • Counselling
  • Nursing
  • Personal care
  • Home Care Services

Who should I talk to if I want more information about the TCP?

You can ask either the nursing or allied health staff looking after you on the ward for more information about the program. They will ensure somebody who knows about the program can provide you with more information.

The Transition Care Program is NOT a long term care arrangement.

What will Happen Next?

If you are medically stable and agree to participate and a place is available, the hospital will contact the TCP and our TCP Team along with the Aged Care Assessment Service (ACAS) will visit you.

Our TCP Team and the Aged Care Assessment Service (ACAS) will assess your needs, discuss with you and your family/carer a plan of care and determine if the program is appropriate for you.

If you are agreeable, we will arrange for you to be discharged/transferred as soon as you are medically stable and your GP has been notified. The period of time that you will need to be on the program will be discussed with you at admission and through your time on the program to discharge. Your rights and responsibilities will be discussed with you and your family/carer by the TCP case manager.

Potential TCP recipients should be aware that access to the program is dependent upon:

  • A person being admitted to an acute or subacute care hospital (public or private)
  • A person being assessed and approved as eligible for the Transition Care Program by Aged Care Assessment Service (ACAS) while in hospital
  • A person transferring directly to the Transition Care Program from an acute or subacute care hospital
  • Availability of a vacant Transition Care Program place at Beaufort and Skipton Health Service

How do I access the Service?

An older person in hospital may self-refer for assessment, or may be referred by any member of the multidisciplinary team caring for the older person in hospital, or by their carer or family member.

Transition Care Program at Beaufort and Skipton Health Service can accept Transition Care Program recipients from any hospital in Victoria.

Transition Care Program is available in the community; this includes Streatham, Linton, Snake Valley, Waubra, Lexton, Raglan, Buangor and districts.

Your home location will be assessed when you enquire regarding a community TCP placement.

If you do not have an existing relationship with a GP at Beaufort or Skipton Medical Practice, you will need to accept the nominated GP for your TCP admission for the bed based placements.


Yes, you will have to pay the normal daily care fee for aged care client services. Details and payments will be discussed and agreed to before you commence the program. Alternative arrangements can be investigated in cases of financial need.

Beaufort: 03 5349 1665
Skipton: 03 5349 1665


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