The Transition Care Program (TCP) is a national program aimed to offer post-acute care to older patients at the conclusion of a hospital episode. It is goal oriented and time limited, offering a package of services including low intensity rehabilitation, to assist older patients to transition from hospital to the community. Goal-setting enhances both the process and outcome of clinical care and is a core practice in rehabilitation.

A program of work under this theme is to classify goals as stated by TCP clients using the International Classification of Function and Disability (ICF) framework and to examine factors associated with goal attainment for TCP clients. Other programs of research in TCP are to monitor the level of physical activities for TCP clients using accelerometry and to investigate the association between attainment of mobility goals and changes in physical activity level throughout the TCP episode.

This work is led by Dr Salih Salih and Dr Nancye Peel.

Following a multisite observational study in TCP to develop a suite of process and outcome orientated Quality Indicators (QIs) applicable to older persons in transition from acute care to the community, a program of work is being undertaken by an Advanced Trainee in Geriatric Medicine to explore the relationship between process and outcome QIs as tools to reflect the quality of health services provided to the frail aged in TCP. 

This work is led by Professor Len Gray and Dr Nancye Peel.