Jordan and his cousin Leo
“Everyone in his family is completely gone. He will say “don't leave me”. He believes if he acts a certain way he may be taken away, like he felt he was with his mother.”
- Residential supervisor
Who is Jordan?
Jordan, a 54-year-old man with a developmental disability, has experienced a life journey characterized by love, loss and unwavering support. Though he is not very talkative, he is an outgoing, social and nurturing individual. During his free time, Jordan enjoys doing yoga, playing baseball, and indulging in his favourite pastime - watching hockey on television. Jordan and his older brother Stephen, who also had a developmental disability, lived together with their mother until she passed away in August 2021. Unable to care for themselves after her death and with no safe living alternative, they ended up in the hospital where Jordan remained for over a year.
What led to Jordan’s hospitalization?
Jordan’s mother, who did her best to raise and support her sons, also lived with her own mental health challenges. The three of them lived a fairly isolated life in subsidized housing, with little involvement from other family members or support services. In early 2021, Jordan’s mother fell ill and was hospitalized for months, leaving the brothers to take care of themselves for the first time. Sadly, shortly after returning home, she passed away, leaving the brothers alone and bewildered. Social services became involved after a neighbour realized what had happened and emergency first responders were called. In August 2021, Jordan and Stephen were admitted to a hospital.
What were the challenges hindering Jordan’s return to the community?
The hospital psychologist’s assessment confirmed that the brothers had significant disabilities and were not capable of managing their own affairs. This assessment led to a referral for both brothers to their local DSO (Developmental Services Ontario, the central intake for developmental services) which confirmed the psychologist’s conclusions.
With nowhere else to go, the brothers were transferred to the hospital's reactivation centre, where people can stay when they no longer need acute care but there is no appropriate discharge option.
How did things change for the better for Jordan?
Once Leo became involved, one of the first things he did was reach out to a local developmental service provider to help find a home for Jordan and his brother. The developmental service provider, working closely with Leo and the hospital team, played a critical role in developing a transition plan and ultimately finding a home where the brothers could stay together, though it took some time to get there. While the hospital social worker tried their best to help, the agency’s in-depth understanding of the developmental sector proved pivotal.
From September 2021 to April 2022, the reactivation care center became the brothers’ new home. Though it was not the ideal environment, the reactivation center provided a sense of safety and the brothers had positive relationships with the staff. The nurse practitioner played a pivotal role in overseeing various aspects of his care and regularly communicated with Leo.
In April 2022, Jordan and his brother were able to move to an apartment with 24-hour supervision supported by the local developmental service provider. Sadly, just a week after moving in, Jordan’s brother was hospitalized for cardiac arrest and ultimately, passed away. In June 2022, Jordan moved into a supported three-bedroom apartment with two roommates and 24/7 support.
“The developmental service agency took us by the hand and led us through. Without them this would not have happened. They were able to guide us and streamline things. They would call and advocate for Jordan’s special needs. They were like the case planner, hospital social worker, all in one.” – Leo, Jordan’s cousin
How is Jordan doing post-transition?
Jordan has transitioned successfully to his new home. Despite the tremendous grief he has experienced with the losses of both his mother and his brother, he remains socially engaged and maintains a happy disposition. He enjoys socializing with his peers, attending developmentally appropriate and stimulating programs, and interacting with staff.
Recently, Jordan’s mental health deteriorated, which led to some distressed behaviours. Thankfully, his family doctor made sure he got the support he needed, which included a hospital visit, and he was able to return home quickly.
What key components helped with Jordan’s hospital-to-community transition?
Jordan's successful transition from hospital to community was facilitated by several crucial elements. These elements align with some of the 10 core components identified in the practice guidance document.
Component 1 - Ongoing information sharing: The developmental service agency social worker and team were diligent and took the lead in consistently providing ongoing communication and updates to Jordan and his cousin Leo. The nurse practitioner at the reactivation center maintained regular contact with Leo to keep him informed of Jordan’s condition.
Component 2 - Comprehensive assessment: Upon Jordan’s admission to the hospital, he received a developmentally-informed assessment. This comprehensive assessment paved the way for a referral to the DSO, which corroborated the psychologist's findings. Ideally, this assessment process is started upon admission, as it was in Jordan's case, so this information can inform a customized transition plan and help optimize the transition process.
Component 3 - Patient and family involvement in transition planning: Staff from the reactivation center and the developmental service provider worked closely with Jordan and his cousin Leo to find a home that best suited Jordan’s needs. They advocated on Jordan’s behalf in rejecting inappropriate offers like nursing homes to make sure they found a place that would best fit Jordan’s needs and his cultural values.
Component 6 - Graduated overlapping and coordinated transitions: The staff members from both the reactivation center and the developmental service provider went the extra mile to ensure that Jordan had a smooth transition into his new home. The staff who were going to be supporting Jordan in the community spent time with him while he was still in the hospital so they could get to know each other and help Jordan feel more comfortable after he moved home. Additionally, staff from the reactivation center went with Jordan to help him move into his new home and provide some familiarity during the transition.
Component 8 - Coordinated follow-up medical and clinical care: Now that Jordan is in the community, he continues to get the health care that he needs. The developmental service provider takes Jordan to all his medical appointments and he receives ongoing support from a home care nurse.
Component 9 - Appropriate and timely housing and community support: Though it took some time, Jordan ultimately was able to get a placement in a home that meets his needs. He is surrounded by a community that not only respects his cultural values, but also offers attentive staff who provide unwavering support.
Component 10 - Sufficient and flexible funding: Emergency funding secured by the developmental service provider allowed Jordan and his brother to move to a fully supported living arrangement with 24/7 supervision while awaiting access to a more permanent, funded residential opportunity.