Intensive Community Transitional Services

Intense Community Transitional Services delivers Community Transitional Services on a shorter term, more intensive basis to in individuals in their home or community.  These services are delivered to individuals who are transitioning from hospital to home or long term care, and/or who require intensive services in order to increase their ability to live as independently as possible in their home environment. Services are available across the South West (Elgin, Oxford, London/Middlesex, Huron, Perth, Grey and Bruce Counties) and are offered for up to six months.

Intensive Community Transitional Services Criteria:  

• Potential to improve through the rehabilitation process and commitment to participate
• Have identified rehabilitation goals that can be met within six months
• Tolerance for support sessions lasting at least 60 minutes
• Family/caregiver commitment to participate where applicable
• Medically stable
• Requires more intensive supports than are offered through our Community Transitional Services for a shorter period of time in order to build skills and/or transition successfully
• Minimum 18 years of age, no upper age limit

Discharge Criteria:

• Achievement of rehabilitation goals as identified in the Individualized Service Plan
• Six 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