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A new white paper from ARIIA and Flinders University’s Caring Futures Institute says workforce shortages, complex needs and weak links between services are making it harder to deliver restorative transition care to older Australians after hospital stays. Stakeholders support updated program guidelines but say staffing, resources and ongoing community support are needed to help people maintain recovery and independence.
A new white paper from Aged Care Research and Industry Innovation Australia and Flinders University’s Caring Futures Institute says staffing shortages and gaps in follow-up services are challenging Australia’s Transition Care Program, which supports older people after hospital discharge. The findings matter as pressure on hospitals and growing waits for aged care services raise the stakes for helping people recover and continue living independently.
The paper draws on a national workshop involving aged care providers, clinicians and sector leaders. Participants discussed how restorative transition care is being delivered following updated guidelines. The program provides short-term, goal-focused support to help older people rebuild strength, mobility and confidence after leaving hospital.
Workshop participants reported shortages across allied health, nursing, pharmacy and primary care in metropolitan, regional and remote communities. The paper says some providers cannot accept eligible clients because they lack the clinical expertise needed to support them. Lead author Dr. Claire Gough said stakeholders supported the principles in the updated guidelines, but practical constraints were limiting delivery.
The report also identifies barriers that can affect recovery beyond clinical care, including financial hardship, housing instability, long waits for support, low health literacy and limited access to interpreters. It says waits for home support and shortages in community services can leave people without assistance when transition care ends, potentially undermining recovery and increasing the risk of avoidable readmission.
Care Gaps After Hospital Discharge
Transition care is intended to bridge the period between a hospital stay and a return to independent living or ongoing support. If people cannot access the program, or lose support after it ends, progress in strength and mobility may be harder to maintain. The report’s findings point to pressure across the wider care pathway, not only within the transition program itself.
For older people and their families, the practical issue is whether suitable help is available at the point it is needed. The workshop findings suggest that staff availability, local service capacity and continuity of care can shape access and recovery. The paper does not quantify how many people are affected or measure the program’s outcomes nationally, so it does not establish the scale of those effects.
The report also points to possible roles for telehealth and technology, particularly for rural and remote communities. It cautions that digital literacy, internet access and clinician confidence are obstacles, meaning technology is not a substitute for adequate staffing or accessible in-person services.
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How Transition Care Is Designed
Australia’s Transition Care Program provides short-term support after a hospital stay, with a focus on helping older people regain function and remain independent. The white paper examines restorative care in practice following updated guidelines and brings together views from people working across aged care and health services.
The paper is a stakeholder report, not a national audit of service capacity or a trial comparing patient outcomes. Its findings reflect concerns raised at the workshop. The authors frame the program as increasingly important as the population ages and demand for services grows, while warning that guidelines alone cannot resolve shortages in the workforce and community support.
Gough, a physical therapist and rehabilitation researcher at Flinders’ Caring Futures Institute, and Joanna-lee Tan, an industry manager at ARIIA and titled gerontological physical therapist, emphasized that transition care depends on connections among hospitals, primary care, community services and aged care. The report was published by Flinders University in 2026.
“The guidelines reinforce what good restorative care looks like, but guidelines alone will not deliver outcomes.”
— Dr. Claire Gough, lead author and researcher at Flinders University’s Caring Futures Institute
Scale of Service Shortages
The paper does not provide national figures on unfilled positions, rejected referrals, wait times or readmissions, and it does not quantify how many older people are unable to access transition care. Its conclusions are based on workshop discussions rather than a national measurement of program performance.
It is also unclear from the report how quickly staffing and service gaps could be addressed, what funding would be required, or which changes would have the greatest effect. The report identifies telehealth as an opportunity but does not establish how much it could expand access or improve outcomes across different communities.
Calls for Workforce and Service Links
The paper’s authors call for investment in workforce capacity, stronger links across services and better ways to measure restorative care outcomes. These are recommendations; the source material does not announce a government funding decision, a new implementation timetable or a policy response.
Further developments to watch include whether health and aged care services respond to the identified workforce and follow-up gaps, and whether technology can be used where local access is limited. No specific next review date or formal program change is stated in the report.
Key Questions
What does Australia’s Transition Care Program do?
It provides short-term, goal-focused support for older people leaving hospital, helping them rebuild strength, mobility and confidence and continue living independently.
What problems did the white paper identify?
Workshop participants reported shortages across allied health, nursing, pharmacy and primary care, alongside waits for home support and gaps in community care after transition support ends.
Who produced the report?
The white paper was produced by Aged Care Research and Industry Innovation Australia and Flinders University’s Caring Futures Institute, drawing on a national workshop with sector participants.
Does the report announce new funding or policy changes?
No funding decision or formal policy change is announced in the source material. The authors call for workforce investment, better service connections and improved outcome measures.
Source: rss
