How effective are programs at managing transition from hospital to home? A case study of the Australian transition care program

The Australian Transition Care Program was established at the interface of the acute and aged care sectors with particular emphasis on transitions between acute and community care. The program is intended to enable a significant proportion of care recipients to return home, rather than prematurely enter residential aged care, optimize their functional capacity, and reduce inappropriate extended lengths of hospital stay for older people. Broadly, the model is configured and targeted in accordance with programs reported in the international literature to be effective. Early evaluations suggest good acceptance of the program by hospitals, patients and staff. Ultimately, however, the program's place in the array of post-acute services should be determined by its demonstrated efficacy relative to other services which cater for similar patient groups.Currently there is a lack of robust evaluation to provide convincing evidence of efficacy, either from a patient outcome or cost reduction perspective. As the program expands and matures, there will be opportunity to scrutinise the systematic effects, with lessons for both Australian and international policy makers and clinical leaders.Internationally, short hospital lengths of stay and a high demand for post-acute care have led to new models of care for older people that offer coordinated discharge, ongoing support and often a focus on functional restoration. Transition Care is a term that encompasses such services and is defined as a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different levels of care and among a diverse range of providers, services and settings [1,2].Reform programs which enhance clinical integration and continuity of care include innovative models for integrated service delivery and care [3,4]; establishment of new "cross-border" roles for care coordinators to improve transitions across healthcare settings [1,5]; and case managers such as co