Transitional Care

About Transitional Care

Transitional care encompasses a broad range of service to promote the safe and timely passage of individuals between levels of care and across care and support settings.
We work closely with every individual to develop a transition plan which includes:

  • Establishing effective communication plans that give every individual choice and enable them to be involved in decision making.
  • Ensure every plan is person centred through taking in to account individual culture and values in order to keep the individual at the centre of everything we do
  • Effective transfer of information upon admission and as part of multi-agency processes
  • Ensuring each individual has access to essential services
  • A single point person who co-ordinates the transitional planning and ensures continuity of care
  • Promote meaningful and pro-active family or advocate involvement
  • Promote and develop each individual’s confidence in themselves and their abilities.

A Case Study

My name is Peter and in 2004 I suffered a brain acquired injury which left me with very poor short term memory and a hearing impairment. I had lost all my daily living skills and had severe short term memory loss; I couldn’t remember conversations or events 5 minutes ago. I found life confusing and tiring.

I moved into Woodville, a small residential care home in New Outlook in 2004 straight from hospital. Through a process of assessment and person centred planning, staff worked with me to develop strategies and tools to enable me to regain my skills and abilities and understand how I could manage my memory loss. They worked in partnership with other agencies to support all my needs and help me to identify what I wanted from my care service. My main aim was to be able to live independently again and so my carers helped met to pursue this goal one step at a time.

Eventually, through their support and training, I was able to learn and remember the route to the post office, to the library, to my local shops and, most importantly, to the local pub! It has been a long process but with their help and consistency, I finally moved into my own flat this year! Because I remained with New Outlook as my landlord, the staff were able to provide a really detailed handover of what works for me and as such I now receive flexible support to help me to manage on a day to day basis – little reminders such as my shopping list and any appointments are really important to me. I have really gained in confidence and made new friends, though I still keep in touch with my carers at Woodville.

I am looking to get a dog to keep me fit and share my bachelor pad! Life is really good and I didn’t think this would be possible back in 2004!”

For further information, please contact customer services on 0121 602 6511