Navigating Transition Care Programs (TCP)

The transition care program

Today I spoke with Zoe Lance, RN, about the transition care program, otherwise known as "TCP". TCP can be conceptualised as a half-way house between acute care and being able to manage safely at home. The gateway to TCP is the aged care assessment, without which a TCP referral cannot be accepted. Referrals are usually received from acute hospital settings or from geriatric evaluation and management (GEM) services.

There are broadly two streams of TCP, a residential stream and a community stream. The determination of which stream a patient enters depends on the initial TCP assessment of function. For instance, patients who are unable to weight bear would not be deemed as suitable for community TCP but would be directed to residential TCP.

Residential TCP can provide 24 hours per day nursing and care support for patients in a residential care setting. Factors that suggest that a Patient would be deemed as fit for community TCP would include that fact that the patient would be weight bearing.

Services that can be provided for community TCP patients include visits by district nurses, the provision of personal care and the provision of services such as meals on wheels.

All TCP programs have stated goals of care. These are the functional goals that the patient would be expected to manage at the end of a twelve-week program. These can include being able to manage all activities of daily living (such as dressing bathing showering toileting and feeding) and managing medication safely.

Whilst both these services are heavily subsidised patients are expected to contribute approximately $10.85 for community-based TCP services and $52.71 for residential TCP services. The patient's contribution to residential TCP services is similar to that payable for residential respite services.