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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.

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