Transition Service

The Transition Service aims to support adults with disabilities who wish to move towards a more independent, community-based lifestyle. The service adopts a person-centred approach, working collaboratively with the persons with disabilities, their family, support networks, and relevant professionals to develop the skills, confidence, and support required for successful community living.

Through structured interventions, practical skill development, assessments, and coordinated support planning, the team aims to facilitate safe, sustainable, and meaningful transitions from institutionalised and dependent living arrangements to greater autonomy and participation within the community.

The Transition Team provides services to adults with disabilities who demonstrate a wish and potential to progress towards greater independence.

Individuals may be considered eligible when they:

• Have an intellectual, physical, sensory, or psychosocial disability that impacts their daily functioning.
• Require structured support and intervention to develop independent living skills.
• Are interested in exploring alternative living arrangements, community living, or increased autonomy.

• Can benefit from a time-bound, goal-oriented transition programme aimed at increasing independence and reducing reliance on formal supports.
• Are able to engage, with appropriate support, in the assessment and intervention process.

Eligibility is determined on an individual basis following a comprehensive assessment of the person’s needs, goals, support requirements, risks, and capacity to benefit from transition-focused interventions.

Eligible individuals are also placed on a prioritisation list, with priority determined according to factors such as the date of referral, the individual’s needs and circumstances, the availability of suitable placements, and the proposed transition pathway.

Referrals to the Transition Services may be submitted by other Aġenzija Sapport services, multidisciplinary professionals or other authorised stakeholders.

The Agency’s Intake Team receives and processes all intake requests by prospective service users, families, and other professionals who ask for any service within the Agency. All intakes are meticulously assessed by the Intake professionals, who will identify which service/s the individual can benefit from depending on the needs, interests and wishes of the individual.

Following this assessment, the team will liaise accordingly with the professionals from the departments of the services identified and carry out follow-up action plans. In case where the need of Transition Services is being noticed, the Intake Team will liaise with the Social Work Team for further assessments. If the Social Worker, from his/her professional assessment, concludes that the family and/or individual falls under the Transition Services’ eligibility criteria, the case will then be discussed with Transition Team professionals.

Upon receipt of a referral, the team conducts an initial screening process to determine suitability for the service and to identify immediate support needs.

A comprehensive assessment is undertaken, which may include:

• Review of the individual’s current circumstances, support arrangements, and living environment.

• Assessment of daily living and self-care skills, community participation, and social functioning, including overnight trials.

• Consideration of health, behavioural, communication, financial, and safeguarding needs.

• Identification of personal goals, aspirations, strengths, and areas for development. Consultation with the individual, family, support staff, and relevant professionals.

Following the assessment, an individualised transition plan is developed, setting out agreed goals, interventions, required supports, timelines, and outcome measures. Progress is monitored regularly, with interventions adapted as needed to ensure that the individual’s needs, preferences, and changing circumstances remain central throughout the transition process.