At the BSR Club Breakfast Meeting on Friday 11 March 2022 Social Worker Karen Gosling talked with us about The Transition Care Program (TCP) and how it is administered on the Gold Coast, Queensland.

Transition Care Program (TCP)

The Transition Care Program (TCP) is a time limited  (up to 12 weeks) rehab-at-home program funded by both the federal and state governments, mainly Medicare. TCP provides goal orientated and therapy focused intervention to people over the age of 65 who require more time to complete their restorative process and optimise their functional capacity following hospitalisation for any reason. The person may have been in hospital for elective or emergency surgery, an accident, illness or stroke, or even just a few days of admission for investigation. But the referral must be received by TCP whilst the person is still in hospital – once they have discharged home it is too late to request admission to the program.

TCP was established in 2006 with the aim of preventing readmission to hospital or premature entry to an Aged Care Facility by the older person following a period of time in hospital. Research conducted prior to the program showed that people could manage in their own home and not have to readmit to hospital or nursing home, if they had support in the first 3 months following their hospital stay. Oldies do not bounce back as quickly as the younger ones following surgery or hospitalisation. However, given time and the right support (diet, exercise, wound care, emotional support, equipment, medication management, regular medical reviews, help with transport when they are not cleared for driving, involvement of family in discussions re care needs and future plans, arranging community services post-TCP, education about My Aged Care, Enduring Power of Attorney etc), people regain their ability, strength and stamina, and can often return to or be better than their PLOF (previous level of function).

The Program aims to support older people with individually tailored therapy by a multi-disciplinary team (Nurse, Physio, Occupational Therapist, dietitian, speech therapist, social worker, psychologist, pharmacist and allied health assistants), and activity of daily living assistance to enable them to further improve or maintain their physical, cognitive and psycho-social functioning. If the person needs personal assistance (eg showering) for a short while following a hip replacement or a stroke, for example, then this can be provided - TCP brokers to any one of the providers on the Gold Coast. If equipment is needed (higher medical chairs, wheelie walkers or toilet frames) whilst the person is on “hip precautions” following hip or knee surgery, when those joints cannot yet be bent at 90 degrees, then this too can be hired for as long as needed, and then returned to the medical equipment company.

The cost for services and equipment and attendance of the clinicians as often as needed, is included in the weekly fee of $77.50. However, if this cost causes financial stress then the person may apply for a full fee waiver.


Eligibility is determined by assessment abiding by the Aged Care Act (1997) and National Transition Care Guidelines. A current ACAT (Aged Care Assessment Team) approval is required for an older person to be admitted to Transition Care Program directly from hospital inpatient or the Hospital in the Home program. TCP accepts referrals from all public and private hospitals within the catchment area of the Gold Coast, including Tweed Hospital (and its rehab centre at Murwullimbah Hospital) as many of the patients reside on the Gold Coast. A delegate from ACAT visits the patient in hospital to discuss their needs and abilities, approving funding for TCP prior to the person returning home. Often ACAT will give approvals for a Home Care package, residential respite and even permanent care in an Aged Care Facility if these services may be required in the future. It saves another assessment later. An ACAT approval means approval for the government subsidised funding should the patient ever use the service, it does NOT mean the person is approved and therefore has to move into the Nursing Home!


As mentioned, TCP is a goal-oriented program. Early in the program, the client (name change from patient!) is encouraged to choose his or her own goals, and what they want to be doing by the end of TCP. Goals are many and varied, here are some examples:

Return to showering and dressing independently, be able to walk without any mobility aids indoors, be able to walk the length of my drive to collect the mail from the letterbox, return to driving, return to my social circle/previous activities (sewing group, U3A courses, woodwork, library, bus outings, pubs and clubs), return to playing golf, return to work!  

Prepare a light meal, manage my medication independently (this may be by use of a webster pack prepared by the local pharmacy), travel and attend my granddaughter’s wedding, get back to swimming in the sea (and yes, we have clinicians who don their swimmers and go into the sea or hydrotherapy pool with people who want this activity).

And several of my favourites:

  1. Return to volunteering at the hospital
  2. Walk along the sand at the beach holding my granddaughter’s hand (this meant managing uneven surfaces and not using the wheelie walker)
  3. Be able to yell at my husband (this from a lady who had reduced voice volume due to Parkinsons Disease and communication was an important part of her life and socialisation) and
  4. Get back to living on my houseboat on the Broadwater. This last goal was achieved by the man following a stroke and spending time at a mate’s place on land during TCP. In order for him to return safely to the houseboat, the physio and OT had to take him in his tinnie out to the houseboat to ensure he could transfer safely from tinnie to houseboat, tie up the tinnie, manoeuvre all the small spaces and slippery surfaces without falling, and the OT had to check height of chairs, toilet etc, and if grab rails were needed in the shower to ensure his ongoing safety living alone in his preferred place. The OT also assessed cognition and if the client could plan and organise his daily requirements and manage meals and medications. These impairments are common following a stroke.
Contact TCP at: Transition Care Program, Level 6, Southport Health Precinct, 16-30 High Street, Southport. Qld 4215  Telephone: 5687 9250

Download The Transition Care Program Brochure  >>