BarnsleyChild Health Team
Transition To Adult Services Care Pathway
This pathway has been produced in order to improve the care of young people moving from children’s to adult care services within the Barnsley area.
It should be completed for all young people aged 14 years under the care of the Barnsley child health team, unless they are being transitioned using a disease specific pathway and stored in the young person’s hospital notes.
Lead Professional:
Date Health Passport Completed:
Date Pathway Commenced:
Date Pathway Completed:
Contents.
Page / Contents2 / Contents & how to complete this document
3 / Community child health transition pathway
4 / Signature list & transition Meetings Attended
5 / Contact page
6 / Early stage transition – age 14 years
7 / Mid stage transition – age 15 years
8 / Mid stage transition – identification of health educational needs
9 / Mid stage transition – identification of social needs, plans and aspirations
10 / Late stage transition – age 15 – 16 years Main stream
11 / Late stage transition – age 16 – 17 years Complex
12 / Late stage transition - age 17 – 18 years Complex
13 / References
How To Complete This Document.
- If the young person is in main stream schoolplease complete pages 4 - 10 only. The pathway should be commenced at age 14 years and completed by age 16 years.
- If the young person is in special school or not in education due to health reasons, please complete pages 4 - 12 butDO NOT complete page 10. The pathway should be commenced at age 14 years and completed by age 18 years.
BarnsleyChild Health Transition Pathway.
Signature List
If you are completing any part of this care pathway please fill in your details below, then use initials throughout the pathway.
Date / Name / Designation / Sign / Print / InitialsTransition Meetings Attended.
Date / Location / InitialsContact Page.
List Of Professionals Involved With The
Young Person.
Children’s Services.
Role / Name / Location / Contact DetailsLead Consultant
MDT.
Role / Name / Location / Contact DetailsAdult Services.
Role / Name / Location / Contact DetailsEARLY STAGE Transition: Age 14 Years.
Date:Age:
Activity / Initial To Confirm CompletionDiscuss transition process with young person and carers and provide information leaflet.
Discuss differences between children’s and adult care, including the issues of consent and mental capacity (refer to guidelines if necessary).
Discuss how health works in partnership with education and social care to ensure all needs are met.
Discuss current and ongoing health, education and social needs and how these are to be met in adult services.
If young person has EHCP (Education Health Care plan) ascertain their lead professional for the transition process.
Introduce health passport (All About Me).
If relevant attend any multiagency transition meetings and document on page 7.
Update any relevant professionals of outcome of clinic review.
Identify any issues or potential concerns from above which need to be carried forward and any parent/carer needs with appropriate action taken:
Initials:
MID STAGE Transition: Age 15 Years.
Date:Age:
Activity / Initial To Confirm CompletionReview outcome of early stage transition and any identified issues or concerns raised or carried forward.
Identify any health, education or social needs and any plans or aspirations and document on pages 9-12. Ensure the outcomes from pages 9-12 are achieved in a timely manner.
Discuss the ongoing process with the young person and their carers and address any concerns.
Discuss multiagency transition plan and progress.
Ensure health passport is completed.
If appropriate attend any transition planning meetings and document on page 7.
Update any relevant professionals of outcome of clinic review.
Identify any issues or potential concerns from above which need to be carried forward and any parent/carer needs with appropriate action taken:
Initials:
MID STAGE Transition.
Health, Educational, Social Care Needs,
Plans & Aspirations.
Health Needs
Date / Need / Action Plan / Initial When AchievedEducational Needs
Date / Need / Outcome / Initial When AchievedSocial Needs.
Date / Need / Outcome / Initial When AchievedYoung Person’s Plans and Aspirations
Date / Aim / Plan To Achieve Outcome / Initial When AchievedLATE STAGE Transition – For Young People
In MainStreamSchool.
Age 15-16 years.
Date:Age:
Activity / Initial To Confirm CompletionReview health, education and social needs, young person’s plans and aspirations documented on pages 9-12 and ensure all outcomes from these and the young person’s individual transition plan are met.
Address any issues or concerns highlighted at previous review and carried forward.
Address any new concerns.
Discuss date for transition over to adult services.
Ensure young person and carer have contact details for adult services taking over their care.
Inform all relevant professionals of outcome of clinic review.
Identify completion date on front of transition pathway.
Outcomes from this care pathway which have not been achieved:
Reasons why outcomes not achieved:
Parent/carer needs addressed:
Initials:
LATE STAGE Transition – For young People
In SpecialSchool Or Not In Education For
Health Reasons.
Age 16-17 years.
Date:Age:
Activity / Initial To Confirm CompletionDiscuss acute episode care pathway with young person and carers AND ensure Lorenzo alert is in place.
Consider mental capacity (refer to trust policy and guidelines).
Review outcome of early stage transition and any identified issues or concerns raised or carried forward.
Identify any health, education or social needs and any plans or aspirations and document on pages 9-12. Ensure the outcomes from pages 9-12 are achieved in a timely manner.
Review young person’s individual multiagency transition plan and discuss the ongoing process with the young person and their carers and address any concerns.
Identify who is responsible for meeting any continuing care needs.
If appropriate arrange, attend or send information to any transition planning meetings.
Update other professionals involved.
Identify any parent/carer needs with appropriate action taken:
Initials:
LATE STAGE Transition.
Age 17-18 years.
Date:Age:
Activity / Initial To Confirm CompletionReview health, education and social needs, young person’s plans and aspirations documented on pages 9-12 and ensure all outcomes from these and the young person’s individual transition plan are met.
Address any issues or concerns highlighted at previous review and carried forward.
Address any new concerns.
Discuss date for transition over to adult services.
Ensure young person and carer have contact details for adult services taking over their care.
Inform all relevant professionals of outcome.
Identify completion date on front of transition pathway.
Outcomes from this care pathway which have not been achieved:
Reasons why outcomes not achieved:
Parent/carer needs addressed:
Initials:
1
Barnsley Child Health Transition Care Pathway/Terrie McNiffe & Jenny Dennis /September 2014/ Review September 2016
References: From The Pond Into The Sea CQC (2014). BarnsleyMultiagency Transition Protocol (under consultation) (2014).Lost In Transition RCN (2013). Adolscent Transition Care (RCN) 2013. Transition: Moving On Well Department Of Health (2008).Transition: Getting It Right Department of Health (2006).Great Ormond Street Hospital For Children, Transition Care Pathway (2000).