Residential Transitional Services
Residential Transitional Services (RTS) offers short-term community-based assessment and transitional rehabilitation in a structured 24/7 residential environment (London only), services focus on assessment, skills training, capacity building with the client, family and their support system; and a seamless transition from hospital to home, or long-term care. Services are offered for up to 6 months based on the individuals’ needs.
Residential Transitional Criteria:
- Potential to improve through the rehabilitation process and transition to an appropriate placement within 6 months
- Have identified rehabilitation goals and commitment to participate
- Accessible unit may be available. Depending upon available resources may need to transfer and complete ADLs independently.
- Tolerance for support sessions lasting at least 60 minutes
- Safe without direct supervision for at least 30 minutes at a time
- Ability and willingness to have a roommate
- Family/caregiver commitment to participate where applicable
- Have a confirmed discharge location
- Minimum 18 years of age, no upper age limit
Discharge Criteria:
- Achievement of rehabilitation goals as identified in the Individualized Service Plan
- 6 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
