What is the Transition Care Program?

Transition Care Program

About the program

The Transition Care Program (TCP) is designed to help older people recuperate after a hospital stay to help you regain functional independence confidence. You can access TCP even if you have a Home Care Package (HCP) or Commonwealth Home Support Program (CHSP) services in place.

Orthopedic Doctor and Senior Patient with Walker at Nursing Home

Lasting up to 12 weeks, the program is funded to provide a range of tailored supports and can include:

  • Personal care.
  • Nursing support.
  • Allied health care: occupational therapy, physiotherapy, dietetics, podiatry, social activities and social work.
  • Case management.

These services can take place in your home, or a residential respite facility whilst any aids and equipment are being arranged for you to safely return home. A transition care coordinator will be appointed to help you set goals to get the best possible outcome.

What happens to my HCP during the program?

Although your Home Care Package will be 'on hold', you will keep accumulating your full subsidy (including any supplements) for the first 28 days.

Is there a cost for TCP?

Yes, there are some costs to receive TCP which will be discussed with you at the time of your assessment in hospital.

During a hospital stay, if you've been assessed as eligible for the Transition Care Program, it's important to inform your case manager so they can continue to support you while you receive the necessary care. They will also ensure you continue to accumulate your HCP funding so it is available to you when the program ends.

home visit care nurse

Why TCP is important?

This Transition Care Program assists people stay in their homes for longer. Avoiding the need for longer-term care, and delays seniors Australians moving into an Aged Care Home for as long as possible. The TCP helps senior Australians get back on their feet after a hospital stay.

Am I eligible for TCP?

To be eligible for the Transition Care Program, a person must undergo an ACAT assessment. Home Care Package recipients have already undergone this assessment. They may be eligible if it is an older person and:

  • Have been told they are ready to leave the hospital.
  • a patient in a hospital (public or private) including people receiving hospital services in-home.
  • the person would benefit from receiving TCP services for a short period of time.

A person may also be eligible if the person is to receive care or support services in their own home, they will have 48 hours from their date of discharge from hospital, to enter care.

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Contact Trilogy Care today on 1300 459 190 or info@trilogycare.com.au for information on alternative care solutions while receiving Home Care Package funding.

5 Questions to ask your Home Care provider

5 Questions to ask your Home Care Provider

When entering the aged care system, there is a large amount of information to understand while navigating this structure. This information is important for seniors to be aware of, so they can receive the best care suited for them. Recognising the difference between a Home Care Package (HCP), Nursing Home, and Retirement Home or the difference between self-managed and fully managed Home Care Packages is vital when considering what kind of support you require to stay healthy, independent, safe and connected to the community. Choosing the right Home Care Package provider is essential for personalised care and support.

Choosing Wisely Australia ® has created a handy checklist for healthcare consumers to ask their doctors or healthcare provider to make sure they end up with the right amount of support.

Do I really need this test, treatment or procedure?

Tests may help you and your doctor or other health provider determine the problem. Treatments, such as medicines, and procedures may help to treat it. Consider what the outcomes could be, if treatment is not received right away, and how this will affect your support group.

What are the risks?

Will there be side effects to the test or treatment? what are the chances of getting results that are not accurate? Could that lead to more testing, additional treatments or another procedure? By understanding the risks of a treatment or procedure, you are better educated of the potential outcomes, and can make an informed decision.

Are there simpler, safer options?

Are there alternative options to treatment that could work? Lifestyle changes, such as eating healthier foods or exercising more, can be safe and effective options. Exploring all your options, can assist you in discovering effective solutions to your care needs. Always consult with a medical professional before coming to a conclusion.

What happens if I don't do anything?

Ask if your condition might get worse – or better – if you do not have the test, treatment or procedure right away. Reassess your lifestyle, current care needs and potential future support, and if they can be covered by your HCP funds. Consult with your carers, friends or family on their experience’s.

What are the costs?

Costs can be financial, emotional or a cost of your time. Where there is a cost to the community, is the cost reasonable or is there a cheaper alternative? How long will I need to recover? Will my health continue to deteriorate after this procedure? Can I do anything to recover effectively? Consider if Home Care Package funds can be used for to assist you after you have received the procedure.

Remember to keep in touch with your care manager when your health or care needs change or as new health conditions are diagnosed. This will help ensure your care plan can be updated to reflect your needs. Trilogy Care’s team is dedicated to working with your reassess your care needs regularly so that you are always receiving the right amount of support. Look for a Home Care provider that values transparency, offering clear communication and honest guidance throughout the care journey. By partnering with a dedicated Home Care provider, seniors can access a wide range of services designed to enhance their quality of life and promote overall well-being.

Contact Trilogy Care on 1300 459 190, to speak with your Care Manager, email care@trilogycare.

 

What is a care plan?

A woman helps an elderly lady review a document at home, highlighting home care planning.

Understanding Care Plans

Upon committing to a self-managed Home Care Package (HCP) provider, such as Trilogy Care. You will be required to attend a Care Plan Meeting, which will assess your lifestyle, care needs, goals, and the services you would like to receive from the Home Care Package Program.  

Care Plans are a necessary and important part of receiving a Home Care Package. The Care Plan meeting is to assess your needs and goals so that you are able to receive services under the Home Care Package program. It also ensures what is included/wanted is acceptable under the Home Care Package guidelines and aligns with the program.  

For example, you may say your goal is to stay healthy and therefore need your medication paid for – this does not align with the scope of the program and therefore cannot be included in your services. Learn more about Home Care Packages Inclusions & Exclusions. 

Care Plans

Care Plans begin with a range of comprehensive assessments that assist in building a clear picture of each consumer as an individual. By completing the assessments, your care needs will be matched with suitable services. Your assessments, goals, care plan and budget are all inter-connected, and they guide the way your package funds are allocated every month.

1.Home Care Package providers are to provide care recipients a written Care Plan before home care services begin, or within 14 days of their Trilogy commencement date. 

2. As your provider, we work in partnership with you to develop and agree on the care plan goals and actions, so that you are satisfied with the care you are receiving. 

3. Your ACAT assessment and Provider care assessments are the joint foundations for your care plan development. It does not matter how long ago your ACAT assessment occurred – this assessment is how you were approved for the HCP program. 

4. Your goals, needs and preferences should be reflected in your care plan – and because everyone is different, it is individually tailored to your specific needs. 

5. Trilogy Care evaluates Care Plans for new consumers as required and when changes need to be made. Additionally, a formal annual review happens every year to assess changes in care needs. Check-in calls are completed quarterly to ensure oversight of care and services. 

6. Your package level and budget is matched to your care needs and is meant to be fully utilised to meet those assessed needs. Unless you need to accumulate funds for something specific, there is usually no need to save funds. 

7. Your plan should include your goals, and the actions and services in place to help you meet those goals. 

8. It should include all the informal care and supports you receive to help you meet your goals, even if the package does not directly pay for them. Including the help your family, friends, and others provide you. 

9. Relevant parts of your plan should be shared with people who will be helping you to meet your goals, such as support workers, nurses, or other relevant parties. 

10. When new supports or services are recommended for you, so you are remaining healthy, Trilogy Care is flexible in changing and updating the document. All package spending is aligned with the care plan. 

What you can do

You can keep your care plan up-to-date by ensuring your support workers, care managers, family and friends are aware of any changes, and by participating in the necessary updates when new services and supports are recommended or required.  

Keeping in contact with Trilogy Care by speaking with your care manager to discuss your care plan, goals, and to make sure your package budget is being fully utilised to meet your assessed care needs.