As hospital discharge pressures increase and wait times for aged care services continue to grow, a transition care program is becoming increasingly instrumental in helping older Australians recover, regain confidence and remain independent after a hospital stay.
A new white paper from Aged Care Research and Industry Innovation Australia (ARIIA) and Flinders University's Caring Futures Institute highlights the critical role of Australia's Transition Care Programme (TCP), while warning that workforce shortages, increasing complex care needs and gaps in care pathways are threatening its ability to deliver the best outcomes for older people.
The paper draws on insights from aged care providers, clinicians and sector leaders from across Australia who participated in a national workshop where they discussed how restorative transition care is being delivered following updated guidelines.
Transition care provides short term, goal focused support for older people leaving hospital, helping them rebuild strength, mobility and confidence so they can continue living independently and avoid unnecessary readmissions. As Australia's population ages and demand for services grows, stakeholders say the programme has never been more important.
Lead author, Dr Claire Gough, from Flinders' Caring Futures Institute says the sector strongly supports the principles behind the updated guidelines, but practical barriers are making implementation increasingly difficult.
"The message from stakeholders is clear. The guidelines reinforce what good restorative care looks like, but guidelines alone will not deliver outcomes," says Dr Gough, a physiotherapist and researcher who specialises in clinical rehabilitation.
"Older Australians are leaving hospital with increasingly complex needs and many services are struggling to access the workforce and resources required to support them effectively."
Workshop participants reported workforce shortages across allied health, nursing, pharmacy and primary care, creating challenges for providers in metropolitan, regional and remote communities alike. Some providers said they are unable to accept eligible clients because the necessary clinical expertise is simply not available.
The report also found that many older people face barriers beyond their health needs. Financial hardship, housing instability, long waits for support services, low health literacy and limited access to interpreters can all affect a person's ability to recover and maintain independence after discharge from hospital.
Joanna-lee Tan, Industry Manager at ARIIA says stronger connections between health and aged care services are needed to ensure recovery continues beyond the transition care period.
"Transition care cannot operate in isolation," says Ms Tan who is an Australian Physiotherapy Association (APA) Titled Gerontological Physiotherapist.
"When people finish the programme, they still need access to ongoing supports. Without stronger links between hospitals, primary care, community services and aged care, there is a real risk that people lose the progress they have worked hard to achieve."
The paper found that wait times for home support services and shortages in community based care are contributing to gaps in support following discharge from transition care programmes. Stakeholders warned that these gaps can undermine recovery and increase the risk of avoidable hospital readmissions.
Researchers also identified opportunities to improve outcomes through greater use of telehealth and technology, particularly in rural and remote areas. However, digital literacy, internet connectivity and clinician confidence remain barriers to wider adoption.
Dr Gough says investment in workforce capacity, system integration and better measures of restorative care outcomes will be essential to meeting the needs of Australia's ageing population.
"Every older Australian deserves the opportunity to recover well and maintain their independence after a hospital stay," she says.
"Our findings show that if we want transition care to fulfil its potential, we must invest in the workforce, strengthen connections across the system and ensure services are equipped to meet growing demand."
The ARIIA White paper, Restorative Care in Practice: Advancing the Transition Care Programme, by Gough, C, Donleavy, L, Tan, JL & George, S outlines practical recommendations to strengthen workforce capability, improve multidisciplinary care, support smoother transitions between services and help ensure older Australians can access the care they need, when they need it.
