Meet the social workers supporting TCP customers through life’s biggest decisions

What is Transition Care Program?

TCP is a federally funded program for people aged 65 and over, or 50 and over for Aboriginal and Torres Strait Islander people, who have been assessed in hospital and need more time and support before their next chapter can begin. For up to 12 weeks, at Juniper a multidisciplinary team works with each customer toward their individual goals that will help them be safe after the program, whether that be their own home or a residential aged care home.

“It’s referred to as slow stream rehab,” Megan said. “Customers receive lots of attention and access to nursing, occupational therapy, physiotherapy and social work.”

Social workers sit alongside the clinical team, but their focus is on supporting customers through a different type of recovery. While nurses, occupational therapists and physiotherapists work together to restore a customer’s health and function, social workers focus on the life surrounding it. Not every customer will need their input, but for those who do, the support tends to take two main forms.

The emotional side of the role

Central to the social work approach is what Kesh calls the biopsychosocial model, considering not just a customer’s medical needs but their emotional and social circumstances too.

“We don’t solely depend on the medical. We consider the medical input, but there is that whole psychosocial component of an individual,” Kesh said.

This often means advocating for a customer’s right to make their own choices and helping the broader team understand who that person is beyond their care needs.

For some customers, the goal of going home becomes less realistic as the weeks progress. Helping families come to terms with that is one of the most difficult parts of the role.

“Couples who have been married for 60, 70 years, and you’re separating them. It’s not natural. It’s emotional distress. Everything takes time,” Kesh said.

Navigating the path to residential care

When going home is no longer an option, the social work team helps customers and families understand what permanent residential care looks like and supports them through every step of getting there.

“Quite often when people get to us, we can’t help them to recover enough to go home,” Megan said. “And so then we have to sit with the family, explain why we don’t believe going home is possible anymore, and really ramp up trying to find them a residential care placement.”

Kesh explains the process starts with a family meeting and a clear understanding of what matters most to the customer, such as location, affordability and proximity to loved ones.

“We start by identifying locations, understanding finances and affordability. I advise families to speak with the financial information services officer at Services Australia, because that’s a free service to help navigate finances, and it’s very important,” he said.

Kesh knows how quickly that complexity can overwhelm a family and sees navigating it as one of the most important things his team does.

“It’s really difficult for an older person to navigate this system by themselves. Going to Services Australia and not knowing what to say, they’re going to send you back and forth,” he said.

Through it all, Kesh remains hopeful about the outcomes.

“Things do work out. Things 100% work out. It always does work out. But it takes time.”

Why these roles matter in WA

At a time when hospitals are under pressure, TCP gives older people the time and space they need to recover safely outside an acute environment.

“If you’re an older person recovering from a health event, hospitals can be really dangerous,” Megan said. “What we want to do is move people out of hospital as quickly as we can.”

For Kesh, the social work role within TCP is about something bigger than discharge planning. It’s about giving people agency at a moment when they might feel they have very little.

“Transition Care gives someone the opportunity to improve and to take charge of their life. If they go home and it doesn’t work out, that’s okay. We work on what they need and try again. We don’t write someone off after one visit to the hospital.”

“Knowing that it is challenging for people to go through this by themselves, that’s what keeps me coming back. Just giving a family a couple of forms to fill in, you reduce so much of the stress for them. You see the smile on their face. Sometimes that’s all it takes, just having someone in your corner.”