Northern Health’s Transition Care Program (TCP) provides care coordination and low-level therapy for clients that have had a recent hospital admission, for up to 12 weeks.

Based at Bundoora Centre, the program allows clients to continue their recovery while appropriate long-term care arrangements are finalised; this may be a return to the community, with or without community services, including Home Care Packages or permanent residential aged care.

There are two arms to the TCP – Home-Based (HB) and Bed-Based (BB).

The Home-Based Program is offered in the client’s own home. The Bed-Based program is located within Baptcare, Wattle Grove in Lalor.

Whilst on the program, the client will receive care coordination, brokered home support services (HB only), medical support and low-level therapy based upon the specific needs and goals of the client. Care Coordination is provided by the TCP care coordinators and medical support is provided collaboratively by the client’s GP and the TCP Geriatrician.

During the pandemic, the team faced many challenges including remote working and facilitating virtual care to clients who were reluctant to receive in-home care services. But, despite all the hurdles, TCP staff were praised by their clients for their perseverance and dedication to the service.

Edgar Menchavez, TCP Care Coordinator, commenced with the TCP in 2019 and has received outstanding feedback on a number of occasions from the many patients he has worked with, and their families, outlining his compassion, empathy, dedication and knowledge of community supports.

“Working with TCP can be a challenge. It is a constantly changing environment; we all have to adapt and respond to the changes appropriately. Nevertheless, I consider this job a privilege. I love working with older adults and our wonderful team,” he said.

This year, the team is looking forward to the implementation of the Electronic Medical Record (EMR) which will support open communication to the inpatient teams, increasing awareness of clients receiving community services via Northern Health.

“The Transition Services Team is one of the most flexible, dynamic and adaptable groups I have had the pleasure to lead,” said Matthew Wood, Transition Services Manager.

Pictured: L – R back row: Elza Alice Joseph, Vanessa Hodge, Najeebuddin Mohammed, Sharyn Green, Sally-Anne McFawn, Mathew Wood, Elizabeth Pentland, Sharyn Stockdale, Sara Faccini., Jill Rachel, Rachel Raucci.

Front Row: Yin Min Aye, Jenny Christof, Edgar Menchavez, Kirk Ombina.