Community Transitional Services

Community Transitional Services (CTS) delivers one-to-one transitional support, rehabilitation and service coordination to individuals in their home or community.  Services are flexible and focus on skills training, improving quality of life and making connections with other service providers and community resources.  Services are available across the South West (Elgin, Oxford, London/Middlesex, Huron, Perth, Grey and Bruce Counties) and are offered for up to 12 months.

Community Transitional Services Criteria:

  • Potential to improve through the rehabilitation process
  • Have commitment to participate and identified rehabilitation goals that can be met within 12 months
  • Tolerance for support sessions lasting at least 60 minutes
  • Family/caregiver commitment to participate where applicable
  • Medically stable
  • Minimum 18 years of age, exceptions can be made on a case by case basis for individuals between 16-18 years, no upper age limit

Discharge Criteria:

  • Achievement of rehabilitation goals as identified in the Individualized Service Plan
  • 12 months in service (maximum length of stay in program)
  • Low levels of participation (ongoing service planning and referrals arranged as needed)
  • Repeated breach of service conditions as outlined in the Service Agreement
  • Significant change in medical condition
  • Unanticipated change in functional status where higher levels of support are required, exceeding available program staffing resources

Exclusion Criteria:

  • High level of risk of harm to others if no safe method of providing service can be identified

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