For many older people, a hospital stay can be accompanied by a decline in functioning. The Transition Care Program (TCP) provides short-term care to older Australians in this situation directly after discharge from hospital. The program aims to improve care recipients' level of independence and functioning and to delay entry to residential aged care. TCP can be delivered in the community (at home) or in a home-like live-in setting.

This report provides an overview of the activities of the program from 2005-06 to 2012-13. Its main focus is on full periods of care, including joined consecutive transition care episodes, so that the final outcomes of the care recipient's interaction with the program can be examined. Program outcomes reported include changes in functioning, discharge destinations, and entry to permanent residential aged care within 12 months of completing transition care. Selected characteristics of care recipients are also reported.

Between 2005 and 2013 the program assisted more than 87,000 people

The program began in 2005, and until 30 June 2013, it had delivered more than 108,000 transition care episodes, which comprised nearly 94,400 periods of care that were provided to a total of 87,142 people.

Three in four care recipients had improved functional status

For 4 out of 5 periods of care (81%), the recipients completed their planned care. For those recipients, around 3 in 4 (76%) left the program with an improved level of functioning. The functional state of around 1 in 6 care recipients stayed about the same.

More than half of the care recipients returned to live in the community

At the end of more than half of the periods of care (54%), care recipients returned to live in the community-18% without assistance from community-based aged care services, and 36% with assistance from community-based aged care services. About 1 in 5 (21%) entered residential aged care directly from transition care, and 2% of care recipients died while receiving care.

Indigenous care recipients were more likely to return to the community (58%) and less likely to enter residential aged care (14%) than non-Indigenous care recipients (54% and 21% respectively), but they were more likely to return to hospital (20% compared with 17%).

A higher proportion of people from non-English-speaking backgrounds were discharged to residential aged care (25% compared with 20% of Australian-born recipients), and a lower proportion returned to the community (51% compared with 55%). This is in contrast to the general patterns of admission to aged care, where use of residential aged care is lower among people from non-English-speaking backgrounds compared with Australian-born people, and use of aged care packages in the community is generally higher.

Two-thirds of care recipients living in the community did not enter residential aged care within 12 months

About 98% of care recipients were living in the community when they were admitted to hospital; 66% of these had not entered residential aged care 12 months after discharge from their first period of transition care. At 30 June 2013, 53% had not entered residential aged care at all over the life of the program.