Identification of service improvement opportunities in an Australian community transition care program


Transition care programs (TCPs) are designed to optimise functional recovery and independence in older adults post-hospitalisation. These programs are under high demand, and understanding inefficiencies in patient flow are a key step towards service improvement.


To identify service improvement opportunities in an Australian community TCP service.


An in-depth retrospective study of 113 community TCP clients.


TCP occupancy was high (94%) and client functional level improved across the program. Inefficiencies experienced included: admission delays to the program; low completion rates (61%) predominantly due to re-hospitalisation; variable response times by Allied Health services (5–20 days); and discharge delays—the latter attributed to waiting for services such as Home Care Packages through Non-Government Organisations.


This study identified several opportunities for service improvement in a community TCP service. Health practitioners should be regularly provided with up-to-date information on efficiency of TCP services.

Aging Clinical and Experimental Research (2018) 30 (12): 1529