Short-term support after hospital — and how to ask for it before discharge
Transition Care provides up to 12 weeks of short-term support after a hospital stay — time to recover and to make longer-term care decisions without pressure. It must be arranged before discharge. Once the person leaves hospital, this option closes.
In short: Ask the hospital social worker today: "Is this person eligible for the Transition Care Programme?" It provides nursing, allied health, and personal care for up to 12 weeks at a low daily fee. It can be delivered at home or in a facility. Most people miss it because nobody tells them to ask.
By Steve Hadfield, AgedCareActionPlan.au · Last updated: 25 April 2026
⚠
This must be arranged before discharge. Once the person leaves hospital, the Transition Care window closes permanently. It cannot be arranged retrospectively. Ask the social worker today — do not wait.
What does Transition Care actually provide?
Transition Care is a short-term, goal-focused program designed to maximise independence after a hospital stay. It is funded by the Australian Government and delivered by approved providers.
🏥
Nursing support
Wound care, medication management, post-operative care, monitoring recovery
🦾
Allied health
Physiotherapy, occupational therapy, speech pathology — focused on regaining function
🧑
Personal care
Showering, dressing, mobility assistance — during the recovery period
🏠
Home or facility
Delivered at home with visits, or in a dedicated Transition Care place or residential facility
📅
Up to 12 weeks
Extendable to 18 weeks in exceptional circumstances with approval
💰
Low daily fee
Set at 17.5% of the single basic Age Pension per day — approximately $11–12/day at current pension rates. No means test required.
What to say to the hospital social worker
Use these exact words. The more specific you are, the faster the process moves.
Script 1 — asking if eligible
"I'd like to ask about the Transition Care Programme. Is this person eligible? I understand it needs to be arranged before discharge — can you tell me the process and how quickly we can get this started?"
Script 2 — if discharge is being rushed
"This person hasn't been assessed for Transition Care yet and I'm concerned discharge is being planned before a safe support arrangement is in place. I'd like this to be assessed before any discharge date is confirmed. Can we arrange a social worker meeting today?"
Script 3 — if they say Transition Care isn't available
"Can you tell me specifically why Transition Care isn't available — is it an eligibility issue, a capacity issue, or something else? And what are the alternatives to bridge the gap between hospital and longer-term care?"
What should you use Transition Care time for?
The 12 weeks is not just recovery time — it's decision time. Use it to:
✓Complete a Home Care Package application through My Aged Care if one hasn't been done — wait times can be long and starting early matters
✓Research residential care facilities if that's the likely longer-term outcome — visit facilities while in Transition Care — notn Transition Care, not under discharge pressure
✓Get a financial assessment through Services Australia to understand what residential care would cost
✓Work with the allied health team on realistic goals — their assessment of the likely functional recovery informs longer-term planning
✓Review home modifications needed for a safe return home — the OT can assess the home and recommend changes
Common questions about Transition Care
Who is eligible for Transition Care?▼
How long does Transition Care last?▼
What does Transition Care cost?▼
Can Transition Care be delivered at home?▼
What if the hospital doesn't mention Transition Care?▼
What happens after Transition Care ends?▼
Who to contact about Transition Care
Hospital social worker or discharge planner
Your first contact — they arrange the referral. Ask at the nurses' station.
Hospital switchboard
My Aged Care
General information about Transition Care eligibility and finding a provider
1800 200 422
OPAN — Older Persons Advocacy Network
Free advocacy if discharge is being rushed without a Transition Care assessment