Transitional Aged Care Model of Care
Transitional Aged Care is a program to address the needs of older people who, in the absence of the program, would require residential aged care.
It is a time-limited (12 weeks) period of support and low intensity therapy in a residential or community setting. It provides older people who have been assessed by an Aged Care Assessment Team (ACAT) as eligible for admission to residential aged care with an opportunity to optimise their functional capacity and determine their appropriate long-term care requirements.
Key to the model is the provision of a goal-oriented therapy program which aims to help patients achieve their goals in their own home environment or a home-like environment. Support is provided for activities in which the patient is not fully independent. Services are tailored according to each individual patient's requirements and are adjusted as the patient's function improves.
- To allow time for older people to complete their recovery and optimise their functional capacity in a non-hospital environment.
- To allow the older person, their carer(s) and families to make th emost appropriate choice about their long-term care needs.
- To reduce inappropriate extended hospital lengths of stay and minimise premature admission to residential aged care.
Older people who:
- are in the process of making a decision about their long-term care options after a stay in hospital (older people who have already decided to enter residential aged care are not eligible).
- at the completion of their acute/subacute hospital episode, have the capacity to benefit from a period of low-intensity therapy and who have been assessed by the ACAT team as eligible for at least low-level residential aged care.
- NSW Transitional Aged Care Program Guidelines
The NSW TACP Guidelines provide practical guidance to NSW TACP Service providers in meeting the national legislative and policy requirements for service delivery. The Guidelines are designed to complement and make reference to the national Transition Care Program 2011 Guidelines wherever relevant, rather than duplicating the information they provide.
- Making Change Model of Care
A detailed methodology to implement change in healthcare.
References to support the Transitional Aged Care Model
- Australian Bureau of Statistics, 2005. Population Projections Australia 2004 - 2101, Catalogue No.3222.0.
- Australian Government Department of Health and Ageing, 2005. Transition care program: program guidelines. Australian Government, Canberra.
- Australian Institute of Health and Welfare, 2002. Australian hospital statistics 2000-01. AIHW cat. No. HSE20.
- Australian Institute of Health and Welfare, 2006. Australian hospital statistics 2004-05. AIHW cat. No. HSE41 Australian Institute of Health and Welfare, Canberra.
- Carr, J.H. and Shepherd, R.B. 1987. 'A motor relearning program for stroke'. 2nd edition. Oxford: Heinemann Medical.
- Creditor, M.C., 1993. Hazards of hospitalisation of the elderly. Annals of Internal Medicine, 118: 219-223.
- Howe, A.L. 2002. Informing policy and service development at the interfaces between acute and aged care. Australian Health Review, 25(6): 54-63.
- Hirsch, C.H., Sommers, L., Olsen, A., Mullen, L. and Winograd, C.H., 1990. 'The natural history of functional morbidity in hospitalised older patients'. Journal of the American Geriatric Society, 38(12): 1296-1303.
- Kroemer, D.J., Bloor, G. and Fieberg, J. 2004. Acute transition alliance: rehabilitation at the acute/aged care interface. Australian Health Review, 28(3): 266-274.
- NSW Health, 2004. Framework for integrated support and management of older people in the NSW Health System. NSW Department of Health, North Sydney.
- Williams, A., 2004. Patients with co-morbidities: perceptions of acute care services, Journal of Advanced Nursing, 46(1):13-22.
Integrated Care Branch
NSW Ministry of Health
Phone: 02 9391 9390