A complementary transition care program enhancing the hospital discharge process, so you can stay at home and manage your own recovery.

CareTransition is designed to make your transition from hospital to home a smooth one, reducing the risk of an unplanned readmission. This program provides you with a tailored plan to complement and enhance the discharge process, in order to give you a better understanding of your condition and to help you manage recovery at home.


What is CareTransition?

CareTransition has been designed for people who are most at risk of an avoidable readmission after discharge to hospital. It includes a comprehensive hospital discharge plus follow-up support to help you take an active role in your care and improve your long-term health outcomes.

The program is based on evidence that transitional care programs that provide at-home support significantly reduce the likelihood of at-risk patients being readmitted to hospital.


How does CareTransition help?

When you’ve been in hospital, the transition home can be a confusing time. CareTransition takes the guesswork out of your home recovery by providing you with the support you need to comfortably and confidently manage your recovery at home.

Your care coordinator will liaise with your doctor to help identify your needs so you can recover well at home. You’ll also receive support and help with things such as managing medication, preparing for the first visit with your doctor, or even talking to specialists. In short, you can rest assured that you’ll receive all the assistance you need during this vulnerable time.


How does CareTransition work?

CareTransition is a 30-day program that begins when you’re discharged from hospital. Your care coordinator will visit you at home to set your personal health goals, assessing your medical needs to help you through this transition period.

You’ll also receive ongoing phone call support to check how things are going, and you’ll be able to ask all the questions you need. Support also includes an information pack to track your health, medications and any follow-up medical appointments.

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I always felt that there was a lot of support from the care coordinators and the Customer Care Consultants, with really good customer service.

VIC participant

Case study

How we help people like Geoff

Geoff is 89 and recovering after having a carcinoma removed from his left eye. He lives alone in a two-storey house.

Lately, Geoff has described feeling “like a zombie”, drowsy and not himself. He’s been going blank and pale. These episodes have occurred every day, stopping him from his daily activities. They’ve been so severe that passers-by had called an ambulance on more than one occasion. Geoff was referred to CareTransition after his eye surgery, and he told his care coordinator he was particularly concerned his medication regime could be contributing to his poor quality of life. He’d been taking more than 20 medications, including five different blood pressure medications, which he took together at breakfast at around 7am.

Support included:

  • Geoff’s care coordinator working with his GP to arrange a home medication review
  • arranging follow up post-hospital admission with his GP
  • arranging an appointment with his cardiologist due to concerns he was over-medicated.

As a result, Geoff says: “I feel like I have my life back again. Since leaving hospital I no longer feel drowsy all the time.”


How do I know if I’m eligible for the program?

Quite often when people are in hospital, they’re given a lot of information and instructions on what to do once they get home. This can sometimes be a bit overwhelming. This program goes through your discharge information with you ensuring you fully understand all discharge instructions. This will help you back to your normal routine and reduce the risk of needing to go back to hospital unnecessarily.

Why is this program being offered?

Rising rates of chronic health issues have put more strain on the Australian healthcare system and whilst GPs are managing this, work pressures and under-resourcing can make it difficult for clinicians to incorporate integrated management support into patient schedules.

CareComplete and the funding parties believe that investing in programs such as CareTransition will help alleviate some of these pressures from our healthcare system and empower individuals to know what they can do to help manage their health.

I’m already getting support services from another provider when I get home. Why would I need this program as well?

A CareTransition visit is not like a visit from another healthcare worker. This program doesn’t replace other services you may receive but offers you additional support in managing your own recovery. Other healthcare workers, such as a physiotherapist, often help you with one specific area of your recovery. However, a care coordinator may be able to offer support in different areas, such as answering questions about medication or preparing for follow-up appointments. Your care coordinator will be focussed on the goals that are most important to you.

How will I benefit?

Quite often when people are in hospital, they’re given a lot of information and many instructions on what to do once they get home. This can sometimes be a bit overwhelming. Your care coordinator will help you make a smooth transition from hospital to home, to reduce the risk of you having an unplanned readmission to hospital.

What’s involved if I participate?

Your care coordinator will go through your discharge information with you to ensure you fully understand all your medications and, if you have any changes to your medications, that you know what to do.

If you’ve been given other discharge instructions, they will go through them with you and will help you develop a plan so you can follow these instructions. They can also answer any questions you may have, and help you work out how to get back to your normal routine and activities.

What’s a care coordinator?

A care coordinator is an allied health professional such as a physiotherapist or occupational therapist. All CareTransition care coordinators hold current registration to practice with the Australian Health Practitioners Regulation Agency (AHPRA) or their relevant professional organisation. A care coordinator specialises in coordinating your care and assists you in identifying and achieving your health goals.

What’s a customer care consultant?

A customer care consultant provides administrative support for the CareComplete programs. Customer care consultant will also interact virtually with participants to check in on their progress and provide information when required.

I’ve already got good support in place. Why would I need this program?

The purpose of this program is to help improve your skills and knowledge of how to manage your health to prevent unnecessary readmissions to hospital. Your care coordinator will provide you with tools and support that promote knowledge and self-management of your health or conditions which can be very useful alongside family support.

Does this program cost me anything?

For eligible participants, the program itself is free to participate in.

However, if there are costs involved in any of the services recommended to you such as a dietitian appointment, physiotherapy appointment or other services that benefit you, your care coordinator will discuss your options with you. We will not enrol you into any program for any additional services if you do not agree to it.

Depending on your level and types of cover, some of these services may be claimable from your private health insurance. We recommend you contact your health fund if services are suggested to you and check your eligibility.

How is my privacy protected?

We are committed to protecting your privacy as part of your participation in the CareTransition program. We will handle your personal information in accordance with all applicable Commonwealth and state legislation, which governs use collection, disclosure, storage, access and disposal of personal information.

For detailed information about how we deal with your personal information, you can read our privacy policy