Transition Care Program(TCP)

Pennwood Transition Care Program (TCP) will help you with the recovery process after a stay in the hospital so that you can get back to your normal lifestyle.

Pennwood Transition Care Program (TCP)

The Transition Care Program (TCP) is a collaborative initiative that is jointly funded by the Australian Government and SA Health. Pennwood Aged care Services works with the Central Adelaide Local Health Network (CALHN) to deliver the program at Pennwood Village. We have 20 beds allocated to TCP and a caring team of multidisciplinary staff dedicated to helping older people regain as much independence as possible.

The primary aim of TCP is to improve functional capacity to enable people to return home with or without support or en ter residential aged care at a lower level of care and support than would have otherwise been possible. The program aims to minimise the number of older people experiencing inappropriate, extended lengths of stay in hospital or being prematurely admitted to residential care.

It provides a package of services that includes low intensive therapy such as:

 

  • Care coordination
  • Nursing
  • Personal care assistance
  • Social activities
  • Art therapy
  • Breakfast group
  • Physiotherapy, occupational therapy and speech therapy
  • Social work
  • Continence aids
  • Equipment
  • Other services as required

 

TCP is for a period of up to 12 weeks (or less, depending on progress).

TCP can be delivered as part residential care (where people stay at Pennwood Village to receive care) and part care at home (community TCP). When a client is ready to go home, we conduct a home assessment and work with the client and their family to ensure they have everything they need at home to live safely and independently.

CALHN will arrange support at home while the client is still part of the TCP. If continued support is needed after 12 weeks (ie a home care package), Pennwood Aged Care Services can deliver the package.

 

Services

Goals

TCP is a short term, restorative, goal directed program. We work with clients to develop goals. These goals reflect what they would like to achieve before returning home. The aim of goal setting is to increase motivation, identify strengths and weaknesses, give a consistent aim for all team members, foster a sense of achievement and monitor progress.

Referrals

All TCP referrals come through Commonwealth Department of Health’s My Aged Care program and the South Australian hospital system.

To contact CALHN’s TCP department:

CALHN TCP BrochureDownload here

Find out more about our Transition Care Program