The care we provide ensures a seamless transition from acute care to the home or supported living environment, especially for individuals whose ability to self-care has been significantly compromised. This service also plays a vital role in relieving pressure on acute hospital beds, supporting the broader healthcare system.

Our 50-bed facility operates 24 hours a day, 7 days a week, with an average length of stay ranging from 14 to 42 days. Within this setting, our focus is to relieve suffering, enhance comfort, promote quality of life, and restore patients to their highest possible level of function.

All care and support are delivered in a calm, clean, and safe environment, where patients can rest and recover under the attentive care of a dedicated professional multidisciplinary team.

Criteria for Admission

Admission to our Transitional Care Facility is based on functional need rather than diagnosis, ensuring that care is directed to those who will benefit most from short-term, enhanced support. A referral form must be completed prior to admission, and patients are considered according to the following criteria:

• Age: Patients must be over 18 years of age.

• Health System Linkage: Patients must be registered at a state health facility and have a folder number.

• Medical Stability: Patients should be medically and mentally stable (including patients with stable dementia) but with compromised functional status.

• Discharge Planning: Complex discharge planning is required to enable safe return to home living.

• Functional Decline: Patients who have experienced a recent decline in functional status and need a short period of enhanced care.

• Rehabilitation/Recuperation: Individuals requiring short-term rehabilitation, recuperation, or respite care.

• Post-Hospitalisation: Patients needing continued care following an acute hospital admission.

• Rehabilitation Potential: Patients requiring rehabilitation with a fair to good prognosis.

• Palliative Needs: Patients in need of palliative care, including symptom and pain control.

• Wound Care: Patients with complex and/or chronic wounds requiring specialised care.

Exclusions

While our Transitional Care Facility provides a wide range of services, there are certain cases that fall outside the scope of care we are able to offer. To ensure patient safety and appropriate placement, we are unable to admit:

• Patients on ventilators.

• Patients presenting with medical emergencies.

• Patients who are pregnant.

• Patients arriving for admission outside of designated admission hours.

• Patients with active TB who have not yet completed at least 2 weeks of therapy (excluding XDR and MDR cases).

• Patients with highly infectious diseases.

• Patients experiencing acute psychosis.

• Patients requiring intravenous therapy.

• Patients still in need of specialised laboratory investigations.

These exclusions are in place to protect both patients and staff, and to ensure that individuals receive care in the most suitable healthcare setting for their needs.

Requirements by Referrer

To ensure a smooth admission process and continuity of care, the following requirements must be met by the referring healthcare professional:

• A completed standard referral form for admission to the Transitional Care Facility.

• An appropriately detailed and comprehensive care transfer plan or discharge summary.

• The patient must arrive for admission between 08h00 and 20h00 on the day of admission.

• The referrer must provide all prescribed medication for the first 28 days.

• Specialist-initiated or re-boarded medication must be supplied after the initial 28 days.

• Assistive devices required by the patient should be provided. If not yet available, they must be delivered once issued.

• The referrer must supply all specialist surgical requirements for wound dressing or other care (e.g., stoma care, dressing packs).

• Transport to the facility remains the responsibility of the patient and family.

• Admissions are accepted 7 days per week.

These requirements help us ensure that every patient is safely and effectively supported during their stay, with care that is continuous, well-coordinated, and responsive to their needs.

Referrals

Patients are referred to the Transitional Care Facility through the following pathways:

• Referral sources include State Hospitals, Community Health Centres, and Community-Based Services.

• A completed referral form is required prior to assessment and admission.

• All relevant sections of the referral form must be completed; guidance can be obtained from the Transitional Care Facility team if there is any uncertainty.

• Patients must bring their own prescribed medication from home when admitted, which will be returned with them upon discharge.

• Transport arrangements to and from the facility remain the responsibility of the patient and family.

This process ensures that patients are admitted safely, with the necessary information and resources in place to support seamless care transitions.

Contact Details:

Tel:  021 948 0340/0786

Transitional Care Facility Referrals forms should be submitted to: imcreferrals@tygerberghospice.org

Visiting hours are from: 15h00 – 16h00 and 19h00 – 20h00 daily

Physical Address:
Grounds of Karl Bremer Hospital
Unit M7 & M8
c/o Mike Pienaar Boulevard & Frans Conradie Drive
Bellville
7530