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

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