Community Transition Services
Supporting People’s Move from
Hospital to Home
About Us
Every week, our teams support people with multiple needs in complex situations who are ready to return home. People should feel supported to choose their own pathways back into the community after months or years spent in hospitals or assessment and treatment units.
Our focus of support:
Learning Disabilities Support
Mental Health Support
Autism Support
Buccal Midazolam
Complex Care
Epilepsy Support
Makaton
Eating Disorders Support
Supported Living
What’s next after the hospital?
Upon discharge, we work with care providers to offer ongoing support, proactively identify potential challenges, and minimise hospital readmission risk. Our teams remain in close communication with the person and their care providers until they are stable and ready to move to long-term support with a confident provider.
Why CTS Matters?
It matters because far too frequently, people leaving hospital have experienced significant trauma, and have challenges reintegrating into community living. CTS is a piece of the puzzle that works to overcome those barriers.
Here is how our Community Transition Service changes that.
Recently, our CTS team supported a transition home for someone, after 18 months in hospital, within just 6 weeks of stepping in. The result? A stable transition, and over £1.5M in costs saved. You can read more about it here.
CAN WE HELP YOU NEXT?
LETS GO
HOME
Our Responsibilities
- Human-rights-based & trauma-informed practices
- Create personalised care and Positive Behaviour Support plans
- Assessing personal needs with a multidisciplinary team
- Build trust through familiar, consistent support
- Preparing and adapting homes for safety and learning skills
- Using clear, creative communication tools
- Providing phased transition and post-discharge support
Our Specialists
- Community Psychiatric Nurses
- Registered Mental Health Nurses
- Experienced Support Workers
- Positive Behaviour Support
- Occupational Therapy
- Multimedia and Communication Specialists
PROACT-SCIPr-UK® Accredited
Training care teams to deliver proactive, therapeutic support by using practical innovative strategies and reducing reliance on restrictive practices.”
How do we care for our team’s well-being and safety when incidents happen?
Here you can read more.
Proven Transition Framework
Hospital Setting
Create a team to match person’s unique needs and characteristics
In-Reach
Work together with the person as a part of their specialist support team.
Help to find suitable community support where people can thrive.
Transition
Ensure a smooth transition to a new home and provide all necessary support.
Work in partnership with the new provider to ensure the right match for each person.
Discharge
Gradually withdraw our support team.
Provide assistance and support to the person and the new provider until we ensure that the transition is safe and well established.
We work in partnership with Integrated Care Boards, local authorities, and other care providers for effective discharge support.
Outcomes
The care professionals we work with know there is a better way with us.
Lisa had spent almost three decades in a hospital – thirty long years where the idea of returning home might have seemed unimaginable. Yet today, that is her reality. We knew this was possible, and with the right human-centric support, she now lives in her own home, making choices and decisions that fit her needs.
Here is why.
The care professionals we work with know there is a better way with us.
Before Discharge
- Holistic assessment by PBS specialists, nurses & therapists.
- Lisa co-created her Positive Behaviour Support plan.
- An animated social story showed her new home, travel, and moving day.
During Discharge
- Phased move strategy with gradual changes.
- Familiar team supported her throughout the process.
- Clear video and photos explained every step of the journey.
After Discharge
- Began exploring her home, garden, and neighbourhood.
- Behaviours of concern dropped from up to 48 incidents a month to just 8.
- Living more independently with trusted ongoing support.
Read our transition journeys
Zayn
Zayn’s Journey to Independence Through Consistent, Person-Centred Support
Ryan
Trust, Resilience and the Right Support: Ryan’s Transition to Community Life
Luke
Luke’s Care Journey
Lisa
Reshaping Life After 30 Years in a Hospital
Ј
Transforming lives: J’s Transition From Hospital to Home
Download Case Studies
Our Team
Sacha Frost
Regional Manager
I’ve worked in healthcare since I was 16 and, with over eight years at the company, I’m passionate about supporting others, driving growth, and making a positive impact while balancing family life and staying active
Jenny McGuire
Senior Care Co-ordinator
With 3 years in healthcare, I enjoy creating tailored care packages with the right team, supporting our internal team, and being the main point of contact for clinicians, with the most rewarding part of my role being smooth, successful transitions from hospital to home.
Hannah White
Care Coordinator
With nearly 5 years experience as a support worker and care coordinator, I love building strong relationships, visiting the individuals we support, and seeing the positive impact our care has on their lives.
Kierra Walker
Care Co-Ordinator
Since starting my healthcare career at 17, my commitment to person-centred care and making a difference in people’s lives has remained at the heart of my work.
Prevent Delays. Ensure Support.
We take it from here.
Our dedicated transition team ensures the care is continued without interruption and re-admission risk.
Contact Us or Make a Referral and See the Difference
Bristol Office Details
Working Time
24/7
Telephone
0345 894 2264
contactus@nurselinehealthcare.com
Location
2510 Aztec WestBristol BS32 4AQ