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Community Care

Aged Care Assessment Services (ACAS)
Aged Care Assessment Services (ACAS) is a team who assist older people and their carers to identify care that will best meet their needs when they are not able to manage at home without assistance. ACAS provides a comprehensive assessment of care needs and information on suitable care options including Community Care Services, Community Aged Care Packages or Residential Aged Care services. They help to arrange access or referral to appropriate care needs. Bendigo ACAS provides services for the Loddon Mallee region, except the Mildura area. An appointment is required to access this service.

Catchment: (Local Government areas where this service is available)
Buloke, Campaspe, Central Goldfields, Gannawarra, Greater Bendigo, Loddon, Macedon Ranges, Mount Alexander and Swan Hill.

Referral Process: Bendigo Health Referral Centre accepts referrals’ from inpatient services, hospital outpatient and ambulatory services, general practitioners, allied health and self referrals. The preferred referral method is via the SCTT form, although medical director summary templates from GP’s are also accepted.

Referral may be sent by post to:

Bendigo Health Referral Centre,
Bendigo Health
PO Box 126, Bendigo. Vic. 3552.

Fax: (03) 5454 7099 or 1300 733 589 toll free Phone: (03) 5454 7059 or 1300 733 581 toll free

Transition Care Program (TCP)
The Transition Care Program (TCP) provides short-term care to help with the functioning and independence of older people after a hospital stay. The program facilitates care for older people who have completed their hospital stay and need more time and support to make a decision on their long term aged care options. It provides older people with a package of services that includes low intensity therapy, eg physiotherapy and occupational therapy, as well as social work, nursing support or personal care. It seeks to enable older people to return home after a hospital stay rather than enter residential care prematurely.
TCP at Bendigo Health operates two programs:
Transition care: A Commonwealth and Victorian funded program for older people to allow more time for recuperation following a hospital stay and prevent premature admission to residential care. People must be admitted directly from hospital discharge.
Restorative care: a Victorian Department of Health funded program to assist with patient flow and reduce demand on hospitals. People may be admitted from hospital, the Emergency Department or the community.

TCP is a regional service with 32 places based in Bendigo and 50 places based in the region. TCP at Bendigo Health has two settings of care: 
At home for people able to return home to continue recovery and at Bentley's Aged Care with 24 hour nursing care for people who are unable to return home from hospital.

The TCP places based at the following health services are: 

  • Bendigo - 20 bed, 12 home based   
  • Echuca - Six bed, four home based, 5485 5916 
  • Swan Hill - Five bed and three home based, 5036 4568 
  • Maryborough - Two bed and two home based, 5461 0309 
  • Kyabram - Two bed and two home based, 5857 0256 
  • Castlemaine - Four bed and two home based, 5471 1589 
  • Kyneton - Two bed and two home based, 5422 9911 
  • Rochester and Elmore - Two bed and one home based, 5484 4301 
  • Inglewood - One bed and one home based, 5431 7000 
  • Kerang - Two bed and one home based, 5450 9218 
  • Boort - One bed and one home based, 5451 5200 
  • Cohuna - One bed and one home based, 5456 5300 
  • Heathcote - One bed and one home based, 5431 0900

Eligibility for TCP

  • At least 65 years of age or have an aged related illness 
  • Medically stable and ready for discharge 
  • At risk of, or eligible to enter low or high permanent residential care 
  • ACAS approval for admission to TCP. 
Bendigo Health TCP manages restorative care. People may be admitted to restorative care from hospital including the Emergency Department or from home. The aim of restorative care is to reduce demand on hospital beds by providing alternative accommodation and support services.

There is:

  • Seven bed based places for people of any age who are unable to return directly home from hospital or who are not managing at home and require alternative accommodation and additional support to minimise or avoid the risk of a hospital presentation. The bed based places are situated at Bentleys Aged Care 
  • Four home based places for people who require additional support and services at home following discharge from hospital and also to assist recuperation to minimise or remove the risk of a hospital presentation.

The TCP intake co-ordinator will respond to all referrals to assess the patient for suitability for TCP or restorative care and allocate the setting according to the person’s individual needs.

Fax referral to Bendigo Health Referral Centre on 1300 733 589 or 5454 7099

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