Written by Dr.Graham Ferguson Date: 05 August 2025
Transition Care: A program to transition clinically stable patients, who still need formal care, out of WA's Acute Care Hospitals via short-term residential care.
WA’s Transition Care Program provides a pathway to provide care to people who are clinically stable but still need care. The program allows people to transition from acute care hospitals to short-term residential care facilities. Here they spend up to 12 weeks (or longer) recovering and rehabilitating to a level that allows them to either return home or to move to a longer-term care facility.
The program helps to:
- Reduce the uncertainty (inferred pressure) on a person and their family to leave the hospital environment once they are clinically stable.
- Provide a short-term accommodation service with clinical care and rehabilitation services.
- Provide information about future options and support people to decide on the next steps.
- Reduce the pressure on hospitals and allow them focus on acute, clinically unstable patients – opening up more capacity for such patients.
The Lived Experience Team has engaged with Transition Care (TC) patients and their families to uncover the lived experience of the program. These experiences reveal the most important steps in the process, people’s evaluation of those steps and the program overall, and the impact of the service. Participants discuss the following key steps:
a. Deciding to leave hospital and enter Transition Care
TC residents tell us that the option to leave the hospital environment was welcome. Acute care is described as “good when you need it but is not really a comfortable long term environment.” Participants talked about stress and perceived pressure as they balance wanting to go home (and staff wanting the bed) with lack of options and being unsure about future care needs. Information was key to clarify expectations of the respite facility, the stay, treatment patterns and future options. Some people feel that they have no option “He had to go there because there was nowhere else for him to go.” Perhaps because plans change “We didn’t have a choice but to put him there, he was in hospital and there were no beds available at the facility he was meant to go to.” Sometimes the patient and the family member were not on the same page – not just with the decision but because the patient wanted to return home. “I am unhappy that my daughter has made these decisions for me.”
But many acknowledge that TC was a good (if pressured) decision “I was in an emergency situation. I needed the recovery time, the care and the rehabilitation.”
b. Transitioning from hospital to Transition Care
This transition relies on effective transfer of medical and QoL information (including doctor, pharmacy and nursing handover). There are also communication issues – keeping the consumer and their loved ones informed of the transition, timing and requirements. Many consumers experienced limited communication about the non-medical needs of the consumer “he arrived and they had no idea what he liked” and some experienced medical communication issues e.g. “Meds were not adequately organised so that they could be administered on the day of transfer.” However, most people thought that this was made up by the staff at the facility “they took the time to get to know dad to see what he liked, he was there for about 3 months.”
Some participants commented on the key role of the Social Worker in developing and updating an action plan to support decision, transition and subsequent plan for recovery.
c. The experience of Transition Care
Most consumers thought that the facility, care and staff were well suited to deliver care for a substantial recovery period. Progress within the timeframe was important because “I wouldn’t want to stay forever.” Consumers note that there is a clinical (rehab), regimented approach in TC that is not necessarily comfortable but does encourage residents to engage in their own care. The processes were discussed as suitable for people who need “rest, rehab, and engagement with others.” People also noted that TC provides time to explore and prepare for next steps.
“When I came, I couldn’t walk. The physio’s were the difference – they got me walking again. My leg is still sore and my balance is only 90% but I didn’t think it would get better or that I would be able to walk again. It was some time in the process that I was just doing the exercises and not getting anywhere that suddenly I could pick my foot up. I can’t speak highly enough of them. It has been great and I could not be happier.”
However, some residents did not enjoy the regimented approach or the “endless classes”, preferring more flexibility and autonomy. Some people also called for more attention to engagement outside of the care process commenting on lack of “social activities”, “limited encouragement to socialise”, etc. Not everyone agreed:
“It helped him to get physically get stronger and learn to accept that he was no longer able to live independently. He was forced to interact with people, which he hates doing, but I think that was good for him because he had gone months without talking to people. He’s very introverted. After mum died and during covid he became very isolated. Being around people and good carers forced him to come out of his shell and use social skills he forgot he had.”
d. Preparing for next steps
Future planning and support to identify and pursue next steps is a crucial part of the TC program. This can be complex because predicting level of care required after rehab is difficult, people are emotionally attached to their previous home and scared of change, the options can’t really be experienced before the decision is made, and options are constrained by individual care needs, availability, finances, and the need to maintain connection to loved ones. Whilst people appreciate the time, care and assessment of medical needs that TC provides, they were less sure that it helped them to decide and find options for next steps: “It was hard to get a clear answer on timeframes and extent of his recovery which made gathering information on his next steps difficult.”
e. Transitioning to the next step
TC allowed most people to improve their health and their self-care practice in preparation for transitioning to the next step. For some, this is to return home “it gave my wife an opportunity to mix with people in the home which she didn’t get in the last place she was in or in hospital. It gave her a better transition from hospital to home.”
“He was not caring for himself before TC. Now that he’s been cared for, the difference is amazing. He looks and sounds different – a lot of that is to do with [the provider]. He’s here with me now [interstate] and in a nursing home where I can keep an eye on him. The stay was a really good bridge for him to get better.”
The WA government provides this program and will continue to fund it (and/or the similar Pilot Respite Program) moving forward. However, there are opportunities to make the impact of the service clear and to streamline the experience of the service. The impact of this service seems to far outweigh the cost of provision but it would be good to explore and understand the areas of most impact and therefore how to improve impact overall.
Disclaimer
The information and insights presented in this article are provided for general informational purposes only. They reflect the views of the author(s) at the time of writing and should not be relied upon as professional or other expert advice. Readers are encouraged to seek independent, qualified assistance before making any decisions or taking action based on this material.
Enquire About Collaboration Opportunities
Email: unheardconsumer@curtin.edu.au
Phone: 92663875
Live Experience Lab (B402.416)
Curtin University, 208 Kent Street, Bentley, WA 6102