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A white paper from ARIIA and Flinders University says Australia’s Transition Care Program helps older people rebuild strength and independence after hospital stays, but growing care needs and workforce shortages are making delivery harder. Stakeholders also point to long waits for community support and weak links between services as risks to recovery.
A new white paper from Aged Care Research and Industry Innovation Australia (ARIIA) and Flinders University says workforce shortages, complex care needs and gaps in follow-up services are making it harder for Australia’s Transition Care Program (TCP) to support older people after hospital stays. The program provides short-term, goal-focused care to help people regain strength and confidence, with the aim of supporting independent living and avoiding unnecessary readmissions.
The paper draws on a national workshop involving aged care providers, clinicians and sector leaders who discussed restorative care under updated guidelines. Participants supported the guidelines’ principles, lead author Dr. Claire Gough said, but reported that services often lack the staff and resources to put them into practice. Older people are also leaving hospitals with increasingly complex needs, she said.
Workshop participants reported shortages across allied health, nursing, pharmacy and primary care, affecting metropolitan, regional and remote communities. Some providers said they could not accept eligible clients because the necessary clinical expertise was unavailable. The paper also identifies financial hardship, unstable housing, long waits for services, limited health literacy and lack of interpreter access as barriers that can affect recovery.
The report says that long waits for home support and community-based care can leave people without help after their TCP episode ends. Stakeholders warned that these gaps may undermine progress and raise the risk of avoidable hospital readmission. The authors identify telehealth and other technology as possible ways to improve access, particularly in rural and remote areas, while noting barriers that include internet access, digital literacy and clinicians’ confidence using the tools.
Keeping Recovery on Track
The report focuses on what happens after an older person leaves hospital: recovery often depends on care continuing across services, not just on support delivered during a short program. If a person cannot access home support or community care when their TCP episode ends, progress made during recovery may be harder to maintain. The paper presents this as a concern raised by workshop participants, rather than a measured estimate of readmissions caused by service gaps.
These pressures matter as Australia’s population ages and demand grows. The findings point to the practical demands on providers: enough trained staff to accept eligible clients, and reliable links between hospitals, primary care, community services and aged care. Without those connections, people may face a break in support at a time when they are rebuilding everyday abilities.
The paper also highlights that recovery is shaped by circumstances beyond clinical care. Housing instability, financial hardship and communication barriers can affect whether someone can follow a care plan or access services. Addressing these issues may require coordination across sectors, while the report says stronger workforce capacity and service integration are needed for the program to meet growing demand.
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How the Care Program Works
The TCP is a short-term, goal-focused service for older people leaving hospital. Its restorative approach aims to help participants rebuild strength, mobility and confidence so they can continue living independently. The white paper considers how this care is being delivered following updated guidelines; it does not report a new government policy or a change to program eligibility.
The findings come from a national stakeholder workshop and describe the experiences and concerns shared by providers, clinicians and sector leaders. The paper, titled National Stakeholder Workshop: Restorative Care in Practice: Advancing the Transition Care Programme, was published by Flinders University in 2026. The report was covered by Medical Xpress on October 5.
Joanna-lee Tan, an ARIIA industry manager and physiotherapist, said support needs to continue beyond the program. Her point reflects a central concern in the paper: people may still need help after a time-limited care episode, while waits and shortages in community services can limit what is available next.
“The guidelines reinforce what good restorative care looks like, but guidelines alone will not deliver outcomes.”
— Dr. Claire Gough, lead author and Flinders University researcher
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Scale of Service Gaps
The white paper reports stakeholder experiences and concerns; the supplied report does not give figures for the number of older people affected, the size of workforce shortages, or how long people wait for home support. It also does not quantify whether service gaps have led to higher readmission rates. The stated risk of avoidable readmission is a warning from stakeholders, not a measured outcome in the source material.
It is also unclear which regions or groups face the greatest barriers, how many eligible clients providers have been unable to accept, and what resources would be needed to address the reported shortages. The report identifies telehealth as an opportunity but does not provide an estimate of its likely reach or effect. Digital access and clinician confidence remain barriers, according to the paper.
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Building Links After Discharge
The paper’s authors call for investment in workforce capacity, stronger service connections and better measures of restorative care outcomes. The report does not set out a government response, funding commitment or implementation timetable. No specific next policy milestone is identified in the supplied source.
Providers and health services will need to address how people can move from hospital care through the TCP and into ongoing community support. The paper’s findings also leave questions for future evaluation: whether added workforce capacity improves access, whether service links reduce interruptions in care, and how outcomes can be measured across different communities.
community support for older adults
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Key Questions
What is Australia’s Transition Care Program?
It is a short-term, goal-focused program that supports older people after a hospital stay as they rebuild strength, mobility and confidence.
What problems does the new report identify?
Workshop participants cited staff shortages, complex care needs and gaps in follow-up support, including long waits for home and community services.
Does the report show that the program has increased hospital readmissions?
No. Stakeholders warned that gaps in support may raise the risk of avoidable readmissions, but the supplied report does not quantify readmissions or establish a measured increase.
What changes do the authors call for?
They call for investment in workforce capacity, stronger coordination across health and aged care services, and better measures of restorative care outcomes.
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