Easing your
transition home
from hospital


CareTransition supports you during your recovery after hospital.

We’re focused on making your recovery smooth and safe so you can stay out of hospital

CareTransition is for patients who are at risk of having to return to hospital after discharge.

Support for a smooth recovery

Your CareTransition Coach provides comprehensive follow-up support to help you manage your recovery. They will help you identify and work towards goals, manage your medicines, and understand what warning signs could mean your condition is getting worse—and what to do if they occur. They’ll also help connect you back to your GP and other health professionals.

Support services include:

  • a home visit by your CareTransition Coach to help you set health goals and develop an action plan
  • ongoing phone support from your coach during the 30 days after you leave hospital
  • an information pack to help you track your health conditions, medications and appointments.

Program duration

The CareTransition program runs
for 30 days, focusing on the critical post-discharge period.

How we help: Geoff’s story

Geoff is 89 and enrolled in CareTransition after having a carcinoma removed from his left eye.

“I feel like I have my life back again. Since leaving hospital I no longer feel drowsy all the time.”

Geoff had been feeling “like a zombie”, drowsy and not himself. He had been going blank and pale as though he was “disappearing from his body.” These episodes occurred every day, stopping him from his daily activities.

Even before his surgery Geoff had been struggling—he was taking more than 20 different medicines, and had concerns that they might be causing negative side effects.

Support included:

Hospital Care Transition Icon
  • A home medication review
Medical Helper Care Transition Icon
  • Support and coaching during his recovery.


With his CareTransition coach’s encouragement, Geoff booked appointments with his GP and specialist to discuss the medicines he was taking. His specialist adjusted the medications, which had an immediate positive effect on his wellbeing. He now understands what each medicine does, and monitors his blood pressure at home every day. He feels like himself again and is back to his usual daily activities.

Patient’s name and photo have been changed for privacy purposes.

If you would like to know more about CareTransition, call 1300 729 684.

Evidence that
CareTransition works

CareTransition is based on a rigorously evaluated program that supports patients to take an active role in their care.


The program (Care Transitions Intervention) has been evaluated in two randomised controlled trials with about 850 people. Participants were significantly less likely to be readmitted to hospital, not just during the program itself, but in the five months afterward as well.1,2

The program has since been implemented by over 900 organisations. Other studies have shown that people who participated in the program were less likely to return to hospital within 30 days, 60-days and one year later.3,4

Other studies have also shown that support during the transition period5 and programs that improve medication management are effective at reducing hospitalisation.6

References: 1. Coleman EA, et al. The Care Transitions Intervention: Results of a Randomised Controlled Trial. Archives of Internal Medicine, 2006, vol. 166, pp. 1822–1828. 2. Parry C, et al. Further Application of the Care Transitions Intervention: Results of a Randomised Controlled Trial Conducted in a Fee-For-Service Setting. Home Health Care Services Quarterly, 2009, vol. 28, pp. 84–99. 3. Care Transition. Evidence and Adoption. Available online: www.caretransitions.org/documents/Evidence_and_Adoptions_2.pdf last accessed: 4 Nov 2015. 4. Fenfang Li, et al. The Kauai Care Transition Program at Kauai Veterans Memorial Hospital. Hospital Discharge Planning Grant Final Evaluation Report, Report to the twenty-eighth legislature state of Hawaii, 2013. 5. Scott IA. Public hospital bed crisis: too few or too misused?, 2010, Aust. Health Review 34, 317–324. 6. Brown, R.S., et al. Six Features Of Medicare Coordinated Care Demonstration Programs That Cut Hospital Admissions Of High-Risk Patients. Health Affairs, 2012. 31(6): p. 1156–66.