Pressure on aged care systems puts spotlight on transition programs for older Australians
· Medical Xpressedited by Sadie Harley, reviewed by Andrew Zinin
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As hospital discharge pressures increase and wait times for elder care services continue to grow, a transition care program is becoming increasingly instrumental in helping older Australians recover, regain confidence and remain independent after a hospital stay.
A new white paper from Aged Care Research and Industry Innovation Australia (ARIIA) and Flinders University's Caring Futures Institute highlights the critical role of Australia's Transition Care Program (TCP), while warning that workforce shortages, increasingly complex care needs and gaps in care pathways are threatening its ability to deliver the best outcomes for older people.
The paper draws on insights from elder care providers, clinicians and sector leaders from across Australia who participated in a national workshop where they discussed how restorative transition care is being delivered following updated guidelines.
Transition care provides short-term, goal-focused support for older people leaving the hospital, helping them rebuild strength, mobility and confidence so they can continue living independently and avoid unnecessary readmissions. As Australia's population ages and demand for services grows, stakeholders say the program has never been more important.
Lead author Dr. Claire Gough, from Flinders' Caring Futures Institute, says the sector strongly supports the principles behind the updated guidelines, but practical barriers are making implementation increasingly difficult.
"The message from stakeholders is clear. The guidelines reinforce what good restorative care looks like, but guidelines alone will not deliver outcomes," says Gough, a physical therapist and researcher who specializes in clinical rehabilitation.
"Older Australians are leaving the hospital with increasingly complex needs and many services are struggling to access the workforce and resources required to support them effectively."
Workshop participants reported workforce shortages across allied health, nursing, pharmacy and primary care, creating challenges for providers in metropolitan, regional and remote communities alike. Some providers say they are unable to accept eligible clients because the necessary clinical expertise is simply not available.
The report also found that many older people face barriers beyond their health needs. Financial hardship, housing instability, long waits for support services, low health literacy and limited access to interpreters can all affect a person's ability to recover and maintain independence after discharge from the hospital.
Joanna-lee Tan, industry manager at ARIIA, says stronger connections between health and elder care services are needed to ensure recovery continues beyond the transition care period.
"Transition care cannot operate in isolation," says Tan, who is an Australian Physiotherapy Association (APA) titled gerontological physical therapist.
"When people finish the program, they still need access to ongoing support. Without stronger links between hospitals, primary care, community services and elder care, there is a real risk that people lose the progress they have worked hard to achieve."
The paper found that wait times for home support services and shortages in community-based care are contributing to gaps in support following discharge from transition care programs. Stakeholders warned that these gaps can undermine recovery and increase the risk of avoidable hospital readmissions.
Researchers also identified opportunities to improve outcomes through greater use of telehealth and technology, particularly in rural and remote areas. However, digital literacy, internet connectivity and clinician confidence remain barriers to wider adoption.
Gough says investment in workforce capacity, system integration and better measures of restorative care outcomes will be essential to meeting the needs of Australia's aging population.
"Every older Australian deserves the opportunity to recover well and maintain their independence after a hospital stay," she says.
"Our findings show that if we want transition care to fulfill its potential, we must invest in the workforce, strengthen connections across the system and ensure services are equipped to meet growing demand."
More information
Claire Gough et al, National Stakeholder Workshop: Restorative Care in Practice: Advancing the Transition Care Programme, Flinders University (2026). DOI: 10.25957/pmbv-cw92
Clinical categories
Geriatric palliative careHealthy agingAllied healthFamily medicine Provided by Flinders University Who's behind this story?
Sadie Harley
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Citation: Pressure on aged care systems puts spotlight on transition programs for older Australians (2026, October 5) retrieved 5 October 2026 from https://medicalxpress.com/news/2026-10-pressure-aged-spotlight-transition-older.html This document is subject to copyright. Apart from any fair dealing for the purpose of private study or research, no part may be reproduced without the written permission. The content is provided for information purposes only.