Flexible care locations are legislated by the Aged Care Act Services include nursing and medical support, personal care, physiotherapy and case management.
TCP services The TCP provides: nursing support personal care physiotherapy and other allied health disciplines medical support case management. Length of support A TCP is time-limited. However, the most common scenarios are as follows: Usually people stay on the program for six to eight weeks and the limit is 12 weeks. Within this time, it is expected that people will have been assisted to access suitable longer-term care and support.
If further therapeutic benefit is possible, the program may request an extension from the Aged Care Assessment Service ACAS for a maximum period of 42 days or 6 weeks. A further extension cannot be requested for a person who has already received the maximum extension during a particular period of care.
Program costs The majority of the costs of the TCP are covered by the subsidy provided to Victorian health services by the Commonwealth and Victorian Governments. The maximum fees are calculated based on the basic single aged pension and are adjusted twice yearly 20 March and 20 September : community clients - Referrals to the TCP If a person is in hospital in an emergency department short stay unit, acute or subacute ward , they can self-refer to the TCP or have a referral made on their behalf by hospital staff.
TCP approach The TCP supports a person-centred and collaborative approach to achieve the best possible outcome for the person. Taking leave while in the TCP There is no leave provision while in the TCP unless a hospital admission is necessary and the stay is no longer than 24 hours.
Interstate people accessing the TCP The program commences upon discharge from hospital, is available nationally and not bound by geographical location. Overseas people accessing the TCP Older people from overseas can access TCP if they are recommended, following an Aged Care Assessment Service assessment, and if the program can support their care requirements while they are in Australia.
Young people accessing the TCP While the TCP guidelines refer to age based on the Commonwealth Government guidelines for planning purposes that is, older people aged 70 and above or Aboriginal and Torres Strait Islander people aged 50 and above , the Aged Care Act makes no reference to age. It is recommended that this be agreed upon before the TAC recipient is admitted to the program. In this topic. Subacute planning.
On this site. Ageing and aged care. Translated consumer information. More information. The strategies were dependent upon the systems-based barriers they encountered in either inpatient or community settings. Findings from the current study and from previous research emphasise that future implementation initiatives in transitional care must focus on supporting communication processes of discussion, questioning and patient engagement, between practitioners in all settings and programs, and with patients and informal carers.
However, this is complicated in the Australian context by recent changes in community-based aged care. In accordance with community expectations for greater consumer choice and control in their health and aged care, in the Australian federal government undertook substantial reforms in community aged care including investment in consumer-directed models of community-aged care [ 17 , 32 , 33 ]. Concurrently, discharged patients were required to self-refer for long-term aged care in the community, and some publicly funded models of community care including professional district nursing were de-funded [ 17 ].
This occurred without substantial funding increases for service navigation, professional nursing or allied health in general practice. Notwithstanding the many benefits of CDC for older adults and their informal carers, the shift to CDC has increased responsibility for older people and their informal carers in their own care, including transitional care [ 17 ]. Yet, findings from the current study indicate that most participant healthcare practitioners in the inpatient setting and in general practice assumed that follow-on professional support would be available to their patients following discharge.
Few participants were aware of the reforms and implementation of CDC and the associated increase in responsibility for patients and informal carers in transitional care or additional supports that they might require to negotiate and navigate their own care transition.
Participants in inpatient care and general practice did not explain any planned changes in assessment of older adults in relation to self-care abilities including those related to discharge, service navigation and care transition back to the community. Further research is warranted to determine how to best support healthcare professionals in assisting patients and informal carers to negotiate and navigate their transitional care.
This may include the development and implementation of tools and communication aids to support assessment of self-management in relation to chronic disease. New roles and models for healthcare practitioners may require development and evaluation in inpatient and community settings such as general practice to support service navigation for older adults and their informal carers experiencing care transitions. Because participants were purposively selected, it cannot be claimed that findings represent the experiences of all healthcare practitioners.
Data saturation would suggest the themes were frequent experiences among multidisciplinary and multi-site participants. The study included participants in in-patient acute medicine, rehabilitation, and community care programs. Application and transfer of findings to other programs, such as surgical services, cannot be claimed. However, our findings may have transferability to similar contexts of care elsewhere.
The findings from this Australian study have implications for transitional care. Healthcare practitioners use a range of discussion, questioning and patient engagement processes to communicate with each other and with patients and carers, and to coordinate transitional care. In Australia, communication skills are part of the educational preparation and continuing education of healthcare practitioners, however the degree to which this education is focussed on improving negotiation and navigation of care transitions for and with older adults is unclear.
Most participants were unaware of pending changes related to the implementation of a CDC program in community-based aged care. Findings from the study highlight the need for health practitioners to adapt their care coordination and communication practice to an evolving care context of stronger expectations that older adults and their informal carers will take greater responsibility for their own care in the community.
In care transition contexts shaped by multidisciplinary teams, sub-acute care and consumer-directed care, health practitioners should focus on supporting older adults and their informal caregivers to navigate their own care transitions.
We gratefully acknowledge all participants in this study and the support of Eastern Health, RDNS, Baptcare and participating general practices. Ronald Uittenbroek PhD. Journal of the American Geriatrics Society , ; 52 5 : — Multidisciplinary team interventions to optimise health outcomes for older people in acute care settings: A systematic review.
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Geriatric Medicine Clinic. Continence Clinic. Pain Clinic for Older People. Gastroenterology Our Team. Referral Information. MC1 and CL conducted data analysis. MC1 drafted, reviewed, and edited the manuscript. All authors read, edited, and approved the final manuscript. Correspondence to Monica Cations. The linkage and construction of the input data used in this study was performed by the Australian Institute of Health and Welfare.
MC1 has been employed in the last five years to assist with data collection for drug trials funded by Janssen and Merck. MC2 receives funding from Novartis for trials of hip fracture involving treatments for sarcopenia. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Consort diagram. Cumulative incidence of entering permanent residential aged care within six months of discharge from Transition Care Program.
Table S1. Table S2. Results of univariate analyses for all outcomes. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.
Reprints and Permissions. Cations, M. Factors associated with success in transition care services among older people in Australia. BMC Geriatr 20, Download citation. Received : 16 June Accepted : 17 November Published : 23 November Anyone you share the following link with will be able to read this content:. Sorry, a shareable link is not currently available for this article.
Provided by the Springer Nature SharedIt content-sharing initiative. Skip to main content. Search all BMC articles Search. Download PDF. Abstract Background The Australian Transition Care Program TCP is a national intermediate care service aiming to optimise functional independence and delay entry to permanent care for older people leaving hospital. Method We conducted a descriptive cohort study of all older Australians accessing TCP for the first time between and Results Functional independence improved from entry to discharge for 46, Conclusions More than half of TCP users are discharged to home and remain at home after 6 months.
Background Supporting older people to transition between health and aged care services is a global challenge [ 1 ]. Methods Design and participants We conducted a descriptive cohort study using data from the Registry of Senior Australians ROSA cohort of all older Australians who accessed government-subsidised aged care services from [ 15 , 16 ].
Variables of interest Potential factors associated with TCP outcomes included variables found to affect the success of TCP in previous reports [ 7 ] plus additional variables considered by the authors as important for rehabilitation. Analysis All results were stratified by TCP setting residential, community, or both , given the known clinical and demographic differences between these groups [ 7 ].
Table 1 Demographic and clinical features of individuals at their first TCP episode to Full size table. Table 3 Results of multinominal regression analysis assessing factors associated with improved and worsening Modified Barthel Index scores from entry to exit of first TCP episode, adjusted for stat Full size table. Table 4 Results of binomial logistic regression modelling assessing factors associated with discharge from first TCP episode to community, adjusted for state Full size table.
Table 5 Results of Fine-Gray subdistribution hazard regression models assessing factors associated with entry to PRAC within six months of discharge from first TCP episode, accounting for competing risk for death and adjusted for state Full size table. Discussion Thirty-eight per cent of Australians who accessed TCP from to recorded improved functional independence from entry to discharge from the program, while the remainder recorded no change or worsened.
Strengths and limitations This is the first ever national evaluation of the full Australian TCP program that accounts for the heterogeneity of individuals accessing these services. Availability of data and materials The datasets used and analysed during the current study are available upon application to the ROSA team.
References 1. Article Google Scholar 2. Article Google Scholar 4. Article Google Scholar 5. Google Scholar 7. Google Scholar 8. Article Google Scholar 9. Article Google Scholar PubMed Google Scholar Article Google Scholar Download references. Inacio Authors Monica Cations View author publications.
View author publications. Consent for publication Not applicable. Competing interests MC1 has been employed in the last five years to assist with data collection for drug trials funded by Janssen and Merck.
Supplementary Information. Additional file 1: Fig. About this article. Cite this article Cations, M. Copy to clipboard. Contact us Submission enquiries: bmcgeriatrics biomedcentral.
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