Initial contact - Positive transitions for young people

What are the outcomes we want to achieve?

The Young Adult

• The young adult is identified early on as someone who will need ongoing health and/or social care support and the family and all other relevant people are identified
• The young adult feels at the centre of their transition journey with parents, family and carers by their side
• The young adult's capacitated life choices are respected even when professionals don't agree with them
• Where the young adult lacks mental capacity, their wishes and feelings are still central, and the principle of the least restrictive option is properly applied
• "My needs will be identified and met together with positive outcomes I devise or agree with"
• The young adult feels they have a voice throughout the process and that they are listened to
• The young adult is encouraged to take decisions independently of their family with the help of an advocate where rights are triggered

The Professional

• Professionals look at the person as a whole and not just the disability
• Professionals communicate well to coordinate support

What tools and resources do we need to do a good job? What are the steps we have to go through?

Advice and Information

• Early advice and information on what to expect from services in formats which are appropriate and accessible for families
• Education Health and Care plan (EHC) plan and agreement in principle regarding the cessation or otherwise of the education element and hence the point at which Adult Services may or must take over the care element

Management

• An easily accessible electronic record of:
  • The child's relevant medical records
  • Health and care needs
  • The child's wishes and preferences
• A robust tracking tool for transitions
• A clear and transparent process for sharing information across agencies
• Independent advocacy where mandated and non-statutory advocacy where not
• Close coordination between adults and children services keeping the child and family at the centre of the process
• A range of information and resources in a format the person can understand, e.g. DVD made by other young people

Partnership

• Health information and support, e.g. sex, relationships
• Accessing community/ relationships education and activities
• A range of options to visit for accommodation and learning
• A range of supported employment options to choose from
• Robust communication system for professionals
• Working with partners such as children's services, education, employment, police
• Clear understanding of the ordinary residence rules for young people moving out of Care, and into different sorts of accomodation

What are the products we will have at the end of this process?

• Identify all young people who require support
• Transition plan covering accommodation, employment, education, good health
• Where a transition plan is not developed, written record why a transition plan is currently not considered appropriate along with information and advice on:
  • Prevention
  • Alternative support available
  • Information on what to do with circumstances change
• Positive outcomes for carers and help to combat fears of transition process
• Placing a person at the centre of their transition - early intervention, flexible approach

When does this process start and end and within what timescales should this process be completed?

• Planning should start at a time which is appropriate for the child and family and no later than when a reasonable understanding of what adult needs may look like is possible
• Planning should continue iteratively with the family at the centre of the process until adults services and support is fully embedded
• Planning should be flexible and tailored to individual needs

Who needs to be involved and what is their role? Who is taking the lead?

• The child or young adult
• Parents
• Anyone else who the person chooses to be involved
• Independent advocate or chosen representative
• Interpreter
• Transitions coordinator
• Care coordinator/ social worker from children's and adults health and social care services
• Relevant professionals with specialist knowledge, including police, education