Bringing People Home
J’s Tailored Transition from Hospital to Community
J is a vibrant young man who loves spending time outside and engaging in activities that bring him joy. J is also autistic and lives with a learning disability. His journey has been shaped by significant challenges, particularly during times when he lacked the freedom to make choices about how and where he spent his days. J’s story highlights the impact of holistic and integrated support in transitioning from hospital to community care, where his preferences and independence are truly honoured.
J’s Story
J was living independently with 2:1 support before his well-being declined and a crisis occurred, leading to hospitalisation. Due to a shortage of local inpatient beds, J was placed in a unit far from his family, only receiving social work visits every six weeks. Despite identifying a new community support provider, ongoing housing issues caused a delayed discharge, preventing J from leaving the unit for 18 months.
During this period, J’s communication challenges and behaviours of concern intensified, requiring 24/7 4:1 support. His support workers were nearing burnout, and a medium secure unit was considered, which would have further isolated J from his family and increased costs. On the recommendation of a social care colleague, LD Network’s Community Transition Services (CTS) was proposed as an alternative and holistic solution.
The Holistic Approach
The goal was to assist J in transitioning from the hospital to a home-like environment while helping him improve his overall well-being and reducing behaviours of concern. The process began with a person-centred approach and a commitment to understanding J’s unique personality, needs, preferences and strengths.
The CTS team included an internal multidisciplinary team of Positive Behaviour Support (PBS) Specialists, Speech and Language Therapists, Community Psychiatric Nurses, and other care professionals. They worked collaboratively to evaluate J’s needs and develop a comprehensive support plan. They listened to J’s needs and collected extensive input from his existing team and family to ensure a smooth transition.
A phased transition strategy was implemented, and a team of support workers with the right traits, experiences and skills were selected to support J. Over a period of four months, they established a strong bond with J, addressing key challenges that contributed to his behaviours of concern. For example, by effectively communicating with J, they realised he was experiencing dental issues, which were contributing to his behaviours of concern.
Meanwhile, the new provider recruited a team based on the insights provided by LD Network, and suitable housing was arranged. The team implemented a gradual handover to maintain continuity and stability for J. They also provided essential training to the new provider’s team to ensure they were well-prepared to meet J’s needs.
The Impact of Person-Centred Care
With the right support, J transitioned from the hospital to a home-like environment in the community, regaining a sense of hope and belonging. His behaviours of concern significantly decreased, and he is now a happier person with more control over his day-to-day life. His journey emphasises the value of compassionate care, collaboration, and person-centred support in achieving positive outcomes and fostering a brighter future.
Positive Outcomes
Improved Coping Mechanisms: Addressing J’s needs effectively led to a significant decrease in behaviours of concern.
Strengthened Support System: The new provider was thoroughly prepared, facilitating a smooth transition and ongoing support.
Cost Savings: The phased transition not only benefited J but also generated significant cost savings for the healthcare system.
Bringing People Closer to Home
LD Network is committed to providing a safe and effective transition from hospital to community support for autistic people, people living with a learning disability and mental health needs.
Our community transition services focus on supporting people to develop the confidence, skills, and independence needed to lead fulfilling lives at home and within the community. We are committed to guiding healthcare providers to ensure they can continue offering support as long as necessary. Our objective is to avoid hospital readmission by addressing unexpected challenges and situations with effectiveness and empathy.
