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

Katherine Schultz, Leanne Carroll, Kristin Mainey, Elsa Dent

Research output: Contribution to journalArticlepeer-review

1 Citation (Scopus)


Background: 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. Aims: To identify service improvement opportunities in an Australian community TCP service. Methods: An in-depth retrospective study of 113 community TCP clients. Results: 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. Discussion: 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.

Original languageEnglish
Pages (from-to)1529-1532
Number of pages4
JournalAging clinical and experimental research
Issue number12
Publication statusPublished - 1 Dec 2018


  • Aged
  • Community Health Services/organization and administration
  • Efficiency
  • Organizational
  • Organizational Case Studies
  • Program evaluation


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