From hospital to home: Peter and his care team

Peter and his care team

“ Transition is key...There shouldn't be a timeline. It should be very flexible so that you can do it according to what the person needs and what staffing needs.” 

- Peter’s community services supervisor

Who is Peter?

Residing in the heart of a Northern Ontario community, Peter has lived a life that defies the odds. Peter likes to do things a certain way and at his own pace, which gives him a sense of safety and security.  He enjoys drinking coffee, watching old Western movies, and spending time in his community. Not even the cold weather can keep him from taking his regular walks around the neighbourhood. Peter is an indigenous man in his seventies. He is able to make his own decisions and communicates both verbally and in writing when words fail to convey his thoughts. Diagnosed with a developmental disability and schizophrenia, Peter has faced a lot of adversity. Most recently, he spent nine years in the forensic unit of a mental health hospital, which is an inpatient mental health service for individuals involved with the legal system. 

What led to Peter’s hospitalization?

Peter’s life has been marked by a history of institutionalization, beginning with a criminal offence at the age of 15. From the age of 18 onward, he lived in the community on and off until a violent incident led to his return to a forensic mental health hospital where he remained for the next nine years. 

What were the challenges hindering Peter’s return to the community?

Peter’s journey back to the community was fraught with challenges, with one of the most significant being the lack of appropriate housing. However, the hurdles did not end there. Peter’s schizophrenia diagnosis added another layer of uncertainty, leading the staff at a potential new home to question their ability to provide the necessary support and ensure the safety of both staff and other residents. Peter’s forensic status and history of institutionalization also contributed to staff concerns. Added to these challenges, Peter’s family played a minimal role in his life, and his contact with the outside world had been limited during his stay in the forensic unit. The COVID-19 pandemic further complicated the transition process. 

 How did things change for the better for Peter?

Overcoming these challenges took time, hard work and collaboration between the hospital team and the staff at the supported group living residence but through their collective efforts, Peter was able to transition out of hospital successfully.

Peter’s team worked together to develop a comprehensive transition plan, which included details related to Peter’s likes and dislikes, funding considerations, medications, communication strategies, and a behaviour support plan. Importantly, the plan remained flexible, evolving throughout the transition process. Over a three-month period, staff members from both the forensic unit and Peter’s new home met regularly to develop the plan and prepare for the transition.  

Illustration of healthcare team discussing Peter's options.


“Before he came into the home, we had quite a few meetings with the hospital. We put in place things he needed. [The transition plan] evolved over time. It was a learning curve for everyone. You can put whatever on paper, but most of the learning occurs when you are with the person. We all evolved together.” 

- Supported group living residence staff

To help the supported group living residence staff understand Peter’s diagnosis, they received both in-person training and access to training videos. While the staff appreciated this effort, they felt that more comprehensive training would have been helpful, given their limited experience in supporting people with mental health concerns. To help the staff communicate with Peter, the hospital team also created a list of phrases and their meanings that were familiar to Peter.  Additionally, a behaviour analyst from the hospital worked closely with staff to collaboratively plan for the management of current and evolving behaviours and update Peter’s medication plan. 

The team also worked closely with Peter, making every effort to involve him in the planning process. Because of COVID restrictions, Peter was unable to visit his new home before the transition, but he was driven by the house and staff came out to warmly greet him. The behaviour analyst met with Peter multiple times to show him pictures of the staff and his new home. The behaviour analyst also created some visual aids and supported Peter to choose the décor for his room, including the paint colour, curtains, and furniture to ensure it was exactly how he wanted it. 

Throughout the transition period, Peter was invited to join the larger team planning meetings, though he wasn’t always interested in attending. In March 2021, Peter successfully moved into his new home.

Illustration of Peter moving into his new home.

How is Peter doing post-transition? 

Peter now lives in a supported group living residence with five other individuals. Though his housemates are younger, Peter has found a way to make it work by creating a space for himself where he feels at ease. He affectionately refers to it as “Peter’s restaurant," where his preferences take centre stage. He enjoys weekly excursions into the community, such as trips to the mall or neighbourhood walks, accompanied by a staff member.

Since Peter’s move into his new home, he has been able to accomplish things that didn't seem possible during his hospital stay. He is communicating both verbally and in writing much more than he did in the hospital and now navigates the community without relying on his wheelchair.

Illustration of Peter's visit to the mall.

The initial phase of the transition was challenging as everyone adjusted, but with patience, flexibility and an adaptable plan, the process became smoother over time. In the first few months following Peter’s transition to the home, staff were able to call the forensic unit nurses 24/7 to address any of their questions or concerns, which was tremendously helpful. Peter also has a robust support network for his mental and physical health, including a family doctor, as well as ongoing support from the behaviour analyst, the nurse and the psychiatrist from the forensic unit. To alleviate concerns about bringing Peter back to the hospital for ongoing care, his psychiatrist comes to the home for Peter’s appointments and has been amazed by Peter’s progress. Peter’s successful transition is a testament to the dedicated and supportive team surrounding him, as well as his own resilience, empowering him to thrive in his new home.

“ We were not just “dropping him off” but providing support after the transition.” 

- Developmental service provider

What key components helped with Peter’s hospital-to-community transition?

Some key elements helped Peter transition out of the hospital. These key ingredients align with the ten core components identified in the report “Supporting alternate level of care (ALC) patients with a dual diagnosis to transition from hospital to home: Practice guidance.” 

Component 1 - Ongoing information sharing: Throughout the transition process and continuing post-transition, the hospital staff (including nurses, social worker, behaviour analyst, and psychiatrist) maintained regular communication with the supported group living residence staff. This ensured that any questions about how to best support Peter’s needs were promptly addressed. The behaviour analyst checked in regularly with staff to help modify and update strategies as needed to address changing behaviours, which helped both staff and Peter feel heard and supported.

Component 3 - Patient and family involvement in transition planning: The transition team worked hard to include Peter as much as possible in the planning process. While he wasn’t always interested in joining team meetings, he actively worked with the social worker and the behaviour analyst to design and furnish his room and make sure everything was just how he liked it. Unfortunately, Peter’s family was not involved.

Component 4 - Patient, family and community provider education, training and support: Before Peter’s transition to his new home, the hospital nurses, social worker and behaviour analyst provided training to the supported group living residence staff to support a smooth transition. This included both in-person training and access to training videos aimed at educating staff about Peter’s diagnosis. After Peter moved into his new home, staff continued to have access to the hospital team to address questions and help modify the plan to address changing behaviours.

Component 5 - Transition and Community Support Plan: Peter’s team worked together to develop an extensive transition plan, which included details related to Peter’s preferences, funding considerations, communication strategies, and his medical and behavioural support needs. Importantly, the plan was flexible, incorporated visuals, remained adaptable, and evolved throughout the transition process to meet Peter’s changing needs.

Component 6 - Graduated, overlapping and coordinated transitions: The residence staff and the hospital team worked closely together to support Peter’s transition. Before Peter moved into his new home, he met with the staff over videoconferencing, viewed pictures of his new home, accompanied by a social script, and had a virtual tour.  Peter even had a chance to drive by and wave to his new staff. After Peter’s move into his new home, staff from the developmental service agency had 24/7 access to the hospital nurses if they had any concerns. They also had full-time access to the behaviour analyst, who works in both the hospital and community and is a resource that is still available to them. 

Component 7 - Medication review and support: Peter’s medications continue to be managed by the hospital psychiatrist. As part of  unique arrangement to accommodate Peter’s needs, the psychiatrist providing home visits. The behaviour analyst also tracks Peter’s PRN (as needed medication) use and updates his plan as needed.

Component 8 - Coordinated follow-up medical and clinical care: Peter’s physical and mental health are well supported by a multidisciplinary team including a family doctor, dentist, behaviour analyst, psychiatrist, transitional nurse, and outpatient nurse.

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