Why Transitions Can Be Difficult for People with Complex Needs
When a person relies on familiar routines, people and surroundings, a transition can remove several sources of reassurance at once, such as a changing environment, communicating with unfamiliar healthcare professionals and staff, and the need to adjust to new expectations. They may miss people, or activities that were already set up to help them feel settled may be gone.
Everything that once made life more manageable is on the brink of change, and people don’t feel safe anymore. A change may therefore disrupt an existing way of coping, particularly when information is unclear, or plans change unexpectedly. These experiences vary between people with complex care needs, autistic people, people with a learning disability, or people who need challenging behaviour support.
Common Sources of Distress During a Transition
Distress during a transition can begin before the change happens and continue after it is complete. For a person who relies on predictable routines or needs support to communicate, clear guidance and information can reduce uncertainty during this period and make the change easier to manage. Several changes can happen within what others see as one transition, and moving from one setting to another can be a vulnerable time. Moving home, for example, may mean adjusting to different sounds and lighting, unfamiliar support workers, a new bedroom and changes to meals or family visits. Teams should focus on identifying concerns early so support can follow the person across settings and preserve continuity.
The possible contributors to distress are:
- Uncertainty
- Disrupted routines
- Sensory changes
- Communication barriers
- Changes in relationships
- Reduced choice or control
- Physical or emotional discomfort
- Inconsistent support
Core PBS Principles That Support Safer Transitions
Positive Behaviour Support (PBS) is a framework intended to support safer transitions and improve quality of life, not simply reduce challenging behaviour. It is commonly used for individuals with learning disabilities and supports people to build new skills. This begins with finding out what helps them feel comfortable, how they communicate and which relationships and routines matter to them. PBS was developed in the 1980s to reduce punishment use, and its values underpin person-centred planning.
Why PBS Should Begin Before the Transition
PBS should begin before a transition so teams can determine what support should be in place before the move and shape the change from the outset around what helps a person feel safe. Time spent with the person and those who know them well helps incoming teams learn how they communicate, which routines matter and what may cause distress, so their input can be included in a more refined PBS plan. This knowledge can inform the new environment, daily support and introductions to unfamiliar people, as part of a person-centred approach. Creating a timeline with milestones helps teams implement preparation in manageable stages.
Early preparation also gives teams an opportunity to put proactive support in place and put priority on the person’s mental health, such as making information accessible, adapting surroundings, supporting communication and agreeing how to recognise and respond to early signs of distress, alongside education for staff and families and practical resources to support implementation. A shared PBS plan helps everyone understand what to do and provides a basis for reviewing support as the person experiences the change. The plan should follow relevant guidance and be reviewed to remain effective. The aim is for the person to enter the next stage with support already built around them, with room to adjust as they settle.
Involving the Person in Their Own Transition
Involving the person in their own transition means giving them active engagement from the beginning, so they can choose what matters most while options are still open. Planning should explore what they want from the change, what worries them, any questions or concerns they want recorded, and what they want to keep in their everyday life. Whether they are leaving hospital, moving home or changing services, planning should start with who they want nearby, which routines help them feel settled, what worries them and what they hope will become possible.
People should actively participate in decisions that affect them, including during hospital discharge planning, alongside their families, carers, or advocates, as appropriate. Simple notes or personal records can help carry the person’s preferences between teams. Participation will look different for everyone. Some people may want to join planning meetings, while others may find it easier to share their views through photographs, communication aids, visits or conversations with someone they trust. Creating a timeline with milestones can also help plan the transition.
In practice, this could mean supporting the person to:
- Explore everyday details: what the person wants to keep familiar, what they would like to change and who they want involved, to promote continuity across the move.
- Make the change easier to picture: use photographs, visits or introductions suited to the person.
- Show how their views influence the plan: record what they have expressed and explain what will happen as a result, so important skills and routines are carried forward.
- Keep listening after the move: ask what feels comfortable, what is difficult and what needs adjusting.
Within a PBS approach, this helps the team plan around the person’s experience of change. Support should fit different situations and not rely only on formal meetings. For example, if meeting several unfamiliar workers feels overwhelming, introductions could happen individually, alongside a trusted supporter.
What Makes a Transition “Safe” in PBS Terms?
In PBS terms, a safe transition protects the person’s physical safety, emotional wellbeing, dignity and choice throughout the change. A safe transition should represent a seamless move from one care setting to another, supported by clear communication, continuity of care, and timely follow-up. It also depends on strong medication management, especially for people with co-occurring conditions. This is a major safety area, and evidence-based guidelines and research consistently emphasise the need for effective coordination.
Applied to transition planning, this involves:
- Preparation that suits the person: accessible information, introductions and time to become familiar with new surroundings.
- Continuity in what matters: maintaining trusted relationships, preferred activities and important routines wherever possible.
- Support that responds early: recognising individual signs of distress and addressing communication, health or environmental needs.
- Meaningful choice: giving the person opportunities to influence arrangements, express concerns and request changes.
- Agreed responses to risk: clear guidance that prioritises prevention, de-escalation and the least restrictive approach.
- Ongoing review: checking how the person is experiencing the transition and adjusting support accordingly.
Key Stages of a PBS-Informed Transition
A PBS-informed transition begins with getting to know the person and continues as they settle into their new surroundings. Each stage builds on what they share and what their support network learns, from identifying needs early and planning together to preparing the receiving team and reviewing daily life after the move. These stages help everyone understand their responsibilities while keeping support responsive to the person’s wishes, wellbeing and pace.
Early Identification and Preparation
Early identification in children, young people and older adults tends to focus on those whose health status, medications, mobility, or home support needs may make transitions harder. Therefore, Positive Behaviour Support (PBS) begins as soon as a transition is anticipated, giving the person time to explore what the change will mean for their everyday life. Whether preparing for a move home, a change of service or a hospital visit, early conversations establish what matters to them, what worries them and which familiar relationships and routines they want to maintain. For young people entering adult services, preparation should connect their wishes for the future with the support they will need. Giving the person access to information, opportunities to ask questions and gradual introductions are key elements of helping the person participate in their own care.
Comprehensive Assessment Before the Move
Before the move, positive behaviour support brings together an understanding of the person’s communication, sensory experiences, physical and mental health, daily routines and relationships. The assessment should include communication needs, daily routines, health conditions, unmet needs, and any factors that may contribute to distress. Where someone experiences challenging behaviour, functional assessment helps identify the circumstances that trigger or maintain it and the support that may help. To build a fuller picture, where appropriate, care teams include chart reviews, recent records, and input from family or current staff.
Therefore, comprehensive assessment is an ongoing process because factors affecting behaviour can change as circumstances change, and it helps determine what support is required before the move.
Co-Producing the Transition Plan
A transition plan informed by positive behaviour support should be developed with the person while decisions are still open. Co-produce the transition plan with the person so it reflects their goals, preferences, and daily routines, and follow a clear framework to keep support consistent and practical. With co-production, it is easier to also set out who is responsible for each action, what guidance staff should follow, and how the person’s concerns will be recorded. The plan can then be refined over time as feedback is received and circumstances change.
For hospital-to-community care transitions, co-production involves discharge arrangements, life planning and housing options with the person and their support network. People need opportunities to influence where they will live, who will support them and how their daily life will take shape, using communication methods that work for them.
Preparing the Receiving Environment and Team
Positive behaviour support helps translate assessment findings into everyday arrangements before the person arrives. It may involve adjusting lighting or noise, providing privacy, maintaining preferred routines and ensuring communication aids are available. The receiving team needs practical knowledge of what helps the person feel comfortable, their individual signs of distress and the agreed responses that protect safety and dignity, so they can implement the plan safely. Across care transitions, a shared PBS plan helps teams provide consistent support, while allowing adjustments for the new setting. Staff should have the training and guidance needed to use proactive strategies and the least restrictive responses.
Stabilisation and Review After the Transition
After the move, support continues through follow-up, observation, and regular reviews rather than ending once the person arrives. The person may need time to become comfortable with unfamiliar surroundings and expectations, and their experience should guide any adjustments. This review period helps with identifying what is working, which situations still cause distress, and what adjustments are needed to maintain continuity. The person and their support network should help identify what is working and what remains difficult. PBS plans need updating as understanding develops, with earlier review if distress, risks or restrictive interventions increase. This keeps support responsive throughout the settling-in period.
Conclusion: Making Transitions an Opportunity, Not a Crisis
A transition can open the door to greater independence, new relationships and more say in everyday life. Giving these possibilities room to grow takes preparation, trusted and consistent support and a willingness to listen when something feels difficult. Positive Behaviour Support helps bring these considerations into planning, so the person’s communication, preferences and wellbeing shape each step. Success becomes visible in daily moments: feeling comfortable with a new support worker, returning to a favourite activity or making choices with growing confidence. Safer transitions work best when planning is person-centred, with continuity across services and support that stays effective after discharge or a move. No single approach fits all situations, so teams should keep refining support based on what they learn.
Safe Transitions with Unique Community Services
At Unique Community Services, we work alongside the person, their family, commissioners and health and social care professionals to plan support around the life they want to lead. Our Transitional Support Programme provides personalised, step-by-step support from hospital into community living, with a focus on life skills, emotional wellbeing and community connections. Our teams draw on Positive Behaviour Support to understand individual needs and help shape everyday support around them.
Meet Jane and see how our care teams created person-centred discharge plans by being involved from the start.
Planning a transition for yourself, a family member or someone you support? Speak to our team today.
Offices: Manchester and Leeds
We provide care across the UK.
