The Transition Care Program (TCP) is a joint Australian Government and State funded program. Established in 2005, this national program was developed to assist older people regain physical and psychosocial functioning after a hospital stay. TCP services are delivered across Australia through the State and Territory Departments of Health as the Approved Providers under the Aged Care Act 1997. In NSW, the TCP is referred to as the Transitional Aged Care Program (TACP) to distinguish it from other health programs.

The TACP provides short-term restorative care to optimize the functioning and independence of older people and Aboriginal and Torres Strait Islanders (ATSI) over 50 years of age, after a hospital stay. It is goal-oriented, time limited, therapy focused and for a maximum of 12 weeks. It provides older people and ATSI people with a package of services that includes nursing support, personal care, domestic assistance and low intensity therapy from physiotherapy, occupational therapy, social work and speech pathology. It seeks to give the older person the opportunity to continue to improve after a hospital stay rather than to enter residential care prematurely.

TACP facilitates continuity of care across the health and aged care sectors for older people who have completed their hospital care (acute, sub-acute, rehabilitation) and who need more time to recover and decide on their long term care options.

The TACP in Northern Sydney Local Health District (NSLHD) has 88 community places named TRANSPAC NS, and a 20 place residential component namely the Northern Sydney Transition Care Unit (NSTCU).

NSLHD provides TACP services in partnership with contracted service providers for care services and an affiliated organisation for the therapy services.

Current service providers for TRANSPAC NS are: Anglican Retirement Villages, Baptistcare, Hammondcare, and Kincare.

Current service provider for NSTCU is UnitingCare Ageing and the NSTCU is located at Wesley Gardens 2B Morgan Rd Belrose NSW.

The Royal Rehab Community Based Rehabilitation Service provides the therapy services to both TRANSPAC NS and NSTCU.



The patient:

  • Is a public or private hospital in-patient, or is receiving acute or subacute care under a hospital-in-the-home or equivalent program where the patient is classified as an in-patient;
  • Has completed his/her episode of acute and/or subacute care, is medically stable and ready for discharge at the time of assessment;
    Wishes to enter Transition Care;
  • Would otherwise be eligible for at least low level residential care;
  • Would have the capacity to benefit from a package of services that includes, at least, low intensity therapy and nursing support or personal care; and
  • Would have the capacity to benefit from goal-oriented, time-limited and therapy-focussed care necessary to:
  • Complete their restorative process
  • Optimise their functional capacity; and
  • Assist in making long-term arrangements for their care
  • Is suitable for medical management by a General Practitioner (GP)
  • Has been assessed and approved by the Aged care Assessment Team as eligible for Transition Care and has a current Aged Care Client Record (ACCR) for Transition Care
  • For TRANSPAC NS and NSTCU the usual place of residence is within the local government areas of Hornsby, Ku-ring-gai, Mosman, North Sydney, Lane Cove, Willoughby, Ryde, Hunters Hill, Pittwater, Manly or Warringah.
  • Is ready for discharge and is able to be "discharged from hospital directly to the Transitional Aged Care Program".


Referrals are made to the NS TACP Clinical Coordinator and either faxed to (02)  8877 5112 or scanned and emailed to [email protected] and must include:
  • REFERRAL to TACP form including diagnoses, hospital admission date, expected discharge date and indicating care and therapy goals
  • Aged Care Client Record (ACCR) approved for Transition Care
  • Modified Barthel Index (MBI) Additional information can include physiotherapy and occupational therapy discharge reports, results of cognitive assessment screening or tests.

Urgent cases

Transitional Aged Care Program does not provide urgent care but health professionals can ring the NS TACP Clinical Coordinator on 02 8877 5167 to discuss an urgent referral.

Other Information

Transition Care Program is provided nationally and in NSW every Local Health District has an allocated number of TACP packages. Referrals can be made from any public or private hospital.

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