Transition Care Program

The Transition Care Program (TCP) provides short-term care for older people after a hospital stay, tailored to individual goals. We are here to work with you to transition home with or without supports, or into the residential care facility that meets your needs.

TCP may be delivered in one of two settings: 

  • Bed-based, situated at St George's Hospital, or 
  • Home-based, usually in the cites of Yarra, Boroondara and southern Darebin.  

Clients receive case management, allied health and other supports as needed. 

Team members 

  • Case Managers 
  • Geriatricians (bed-based only) 
  • General Practitioners (bed-based only) 
  • Nurses 
  • Physiotherapists 
  • Occupational Therapists 
  • Other Allied Health disciplines can be accessed as required 

Service delivery 

  • Program duration can be up to 12 weeks; not everyone needs this long 
  •  Clients receive multi-disciplinary input including nursing, Allied Health, who will work with your own General Practitioner for clients receiving care at home. 
  • In our bed-based service, we also have visiting General Practitioners and Geriatrician support. 

Eligibility criteria 

  • Clients must be an admitted inpatient at either a Public or Private hospital at the time of referral 
  • Clients referred for TCP first need to undergo an Aged Care Assessment, which is organised by the hospital. 
  • Our home-based service supports residents living in the City of Yarra, City of Boroondara or City of Darebin; other TCP providers deliver care outside of these areas.. 

Referral process 

Internal SVHM referrals are to made via the Electronic Patient Journey Board 

External referrals can be made via fax to North East Metro- St Vincent’s ACAS on 9231 8588 for the approval. 

A completed referral form is required from internal and external Public and Private hospitals. Please contact the service via phone or email to request a copy of our current referral form.  

Contact details  

St Vincent’s TCP  
Office hours: Monday to Friday 8.00am – 4.30pm 
Phone: 9231 8573 
Email: TransitionCareReferralsSVHM@svha.org.au