The transition of care between hospital and home is a key point in health care delivery where adverse events and disruptions to continuous and comprehensive care often occur. Poor transitions of care impact on patient safety, the quality and experience of care and the overall performance of the ACT’s health system.

The primary objective of this innovative Pilot is to ‘improve patient focused transitions of care between hospital and primary health care and community settings’.

Service Delivery Model

Following consultation with key stakeholders CHN has developed a Transitions of Care Service Delivery Model which adopts an evidence-based system level response to the challenges faced by patients when transitioning from the hospital to home setting. This pilot project commenced in April 2017 and is expected to conclude in June 2018.   

A copy of the service delivery model is available here.

The Transition of Care Pilot is currently being delivered in collaboration with the Division of Medicine and the Emergency Department at the Canberra Hospital. Key components include:

  • target patient enrolment – aimed at patients with complex and chronic conditions and considered at risk of hospital readmission
  • transition coordination support from the hospital to home setting individuals to sustain continuity of care through (re)connecting with general practice and PHC services, outpatient, community health and care services 
  • patient education and self-management support
  • a small pool of flexible funds to facilitate access to health and community based services on a gap filling basis.


A formative evaluation will be conducted by a research organisation to be appointed by Capital Health Network.


The Transition of Care team consists of:

  • Transition of Care Coordinator: Naomi Edison
  • Transition of Care Coordinator: Julie McMahon

Referral Form

Please click here to download a Referral Form for Transistions of Care.

Further information

For further information, please contact us at toc [at]