Open Access Debate

How effective are programs at managing transition from hospital to home? A case study of the Australian transition care program

Leonard C Gray1, Nancye M Peel1*, Maria Crotty2, Susan E Kurrle3, Lynne C Giles24 and Ian D Cameron5

Author Affiliations

1 Centre for Research in Geriatric Medicine, The University of Queensland, Level 2, Building 33, Princess Alexandra Hospital, Woolloongabba, Queensland 4102, Australia

2 Department of Rehabilitation & Aged Care, Flinders University, Repatriation General Hospital, Daw Park, South Australia 5041, Australia

3 Rehabilitation and Aged Care Service, Hornsby Ku-ring-gai Hospital, Hornsby NSW 2077, Australia

4 Discipline of Public Health, The University of Adelaide, South Australia 5005, Australia

5 Rehabilitation Studies Unit, Sydney Medical School, University of Sydney, PO Box 6, Ryde NSW 2112, Australia

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BMC Geriatrics 2012, 12:6  doi:10.1186/1471-2318-12-6

Published: 14 March 2012



An increasing demand for acute care services due in part to rising proportions of older people and increasing rates of chronic diseases has led to new models of post-acute care for older people that offer coordinated discharge, ongoing support and often a focus on functional restoration. Overall, review of the literature suggests there is considerable uncertainty around the effectiveness and resource implications of the various model configurations and delivery approaches. In this paper, we review the current evidence on the efficacy of such programs, using the Australian Transition Care Program as a case study.


The Australian Transition Care Program was established at the interface of the acute and aged care sectors with particular emphasis on transitions between acute and community care. The program is intended to enable a significant proportion of care recipients to return home, rather than prematurely enter residential aged care, optimize their functional capacity, and reduce inappropriate extended lengths of hospital stay for older people. Broadly, the model is configured and targeted in accordance with programs reported in the international literature to be effective. Early evaluations suggest good acceptance of the program by hospitals, patients and staff. Ultimately, however, the program's place in the array of post-acute services should be determined by its demonstrated efficacy relative to other services which cater for similar patient groups.


Currently there is a lack of robust evaluation to provide convincing evidence of efficacy, either from a patient outcome or cost reduction perspective. As the program expands and matures, there will be opportunity to scrutinise the systematic effects, with lessons for both Australian and international policy makers and clinical leaders.