How transitional aged care helps keep older Aussies out of hospital

Older people admitted to hospital are at a greater risk of experiencing a decline in motor skills or cognition once they leave hospital – often leading them straight back there. Transitional aged care offers temporary care specialised in helping older people transition back into daily life after a hospital stay.

According to figures from the Australian Institute of Health and Welfare (AIHW), in 2022-23, 17 per of Australians were aged 65 and over, yet they accounted for 44 per cent of all hospitalisations.

Upon leaving hospital, many older people find adjusting to their daily routine again difficult. They may find it much harder to perform normal tasks than they did before, even if only temporarily.

But this makes the period immediately after leaving hospital a particularly vulnerable one for older people, and there’s a significant chance that without help they will end up back in hospital, either by aggravating the original problem, or creating a new one.

Enter the Transition Care Programme

The majority of older people going into hospital were leading full, independent lives before their health issue and would not consider themselves as someone who needs aged care.

But temporary support from the Transition Care Program (TCP) during this time can help ease the transition and help them regain their functional independence and avoid the need for longer term care and support services.

Starting transition care while the patient is still in hospital has also been linked to earlier patient discharges.

Recent analysis from the AIHW shows around three out of five people returned to the community after starting transition care in 2020–21, of those people almost nine in 10 reported improved functional independence and confidence after receiving transition care.

Fewer than one in seven people who returned to the community went on to enter permanent residential aged care by the end of the following year, highlighting the importance of targeted interventions after leaving hospital.

The AIHW says that aside from the benefits to the individual and their families, there is also a broader community benefit if such intervention delays or prevents a person’s entry into residential aged care or readmission to hospital.

What kind of support is available?

There are number of different support options available depending on the level of help the patient requires.

To determine that level, functional independence is measured by assessing the person on their ability to perform 10 kinds of daily activities: eating, bathing, getting dressed, personal hygiene, using the toilet, bladder control, bowel control, climbing stairs, walking (or wheelchair use for those using one) and moving between a chair and a bed.

The person’s skill at each task is given a score out of 100. Lower scores mean a person has less independence and more support is needed to complete self-care tasks. Higher scores mean a person has more independence, and less support is needed.

Once the level of care needed is assessed, that care can be delivered in a number of different ways, either at the patient’s home or in a healthcare setting.

Actual types of care delivered vary as much as the needs of the patients themselves, but often include personal assistance with everyday tasks such as bathing, showering, eating and dressing; nursing support for pain management, wound care and dementia support; and low intensity therapy services like physiotherapy, podiatry and even psychological counselling if it’s required.

Whether the patient receives their care at home or in a residential aged care facility depends on the level of support required, but the AIHW stats show the care location actually has a connection to overall patient outcomes.

The stats showed 54 per cent of people received transition care in the community, 34 per cent in a residential aged care facility and 12 per cent in some places.

Two in three of those who completed transition care in the community at least some of the time returned to normal life after transition care. In contrast, only one in five people who completed care in residential aged care returned to the community.

But that may be mostly due to the severity of the heath issues that sent them to hospital in the first place. The data also showed people completing transition care in residential aged care had lower functional independence at both the start and end of the program and half immediately entered permanent residential aged care after transition care ended.

Have you ever needed to use the Transition Care Programme? What other ways could we expand the care options available? Let us know in the comments section below.

Also read: Aged care complaints up 20 per cent over last year, data shows