Transition of Children to Adult Services Policy

Transcription

1 Post holder responsible for Procedural Document Author of Policy Division/ Department responsible for Procedural Document Nigel Lawrence, Assistant Director of Nursing Specialist Services Nigel Lawrence, Assistant Director of Nursing Specialist Services Dr Hannah Cottis, Consultant Paediatrician Specialist Services/ Child Health Contact details 6571 Date of original document 31 July 2015 Impact Assessment performed Ratifying body and date ratified Review date (and frequency of further reviews) Yes Clinical Effectiveness Committee 17 th September 2015 January 2018 (every two and a half years) Expiry date September 2018 Date document becomes live 21 st September 2015 Please specify standard/criterion numbers and tick other boxes as appropriate Monitoring Information Patient Experience Strategic Directions Key Milestones Maintain Operational Service Delivery Assurance Framework Integrated Community Pathways Monitor/Finance/Performance CQC Fundamental Standards Regulation No. 9 Other (please specify): Develop Acute services Infection Control Note: This document has been assessed for any equality, diversity or human rights implications Controlled document This document has been created following the Royal Devon and Exeter NHS Foundation Trust Development, Ratification & Management of Procedural Documents Policy. It should not be altered in any way without the express permission of the author or their representative. Review date: August 2017 Page 1 of 22

2 Full History Status: Draft Version Date Author Reason /07/2015 ADN (Specialist Services). Consultant Paediatrician /08/2015 ADN (Specialist Services). Consultant Paediatrician New Policy, to meet Paediatric transition to adult services standards Updated Policy following consultation, to meet Paediatric transition to adult services standards Associated Trust Policies/ Procedural documents: In consultation with and date: Transition from Children to Adult Services Steering Group July 2015 Paediatric Consultants July 2015 Bramble Business Meeting August 2015 Trustwide consultation 7-21/08/2015 PEP 1/9/15 Consent for Examination or Treatment Policy Child Protection Policy Safeguarding Adults Policy Access Policy Contact for Review: ADN (Specialist Services) Executive Lead Signature: Adrian Harris Medical Director Review date: August 2017 Page 2 of 22

3 CONTENTS Page 1. INTRODUCTION PURPOSE DEFINITIONS MAIN BODY OF POLICY/STRATEGY ARCHIVING ARRANGEMENTS PROCESS FOR MONITORING COMPLIANCE REFERENCES APPENDIX 1: GETTING READY QUESTIONNAIRE 11 APPENDIX 2: STEADY QUESTIONNAIRE 12 APPENDIX 3: GO QUESTIONNAIRE APPENDIX 4: TRANSITION LEAFLET 14 APPENDIX 5: PARENT/CARER TRANSITION PLAN APPENDIX 6: HELLO TO ADULT SERVICES QUESTIONNAIRE APPENDIX 7: TRANSITION PLAN...17 APPENDIX 8: MOVING THROUGH THE PROGRAMME.. 18 APPENDIX 9: COMMUNICATION PLAN. 19 APPENDIX 10::RAPID IMPACT ASSESSMENT SCREENING FORM.. 20 Review date: August 2017 Page 3 of 22

4 1. INTRODUCTION Transition is recognised as a gradual process of empowerment that equips young people with the skills necessary to manage their own healthcare as they move towards and into adult services and lifestyles. It is a carefully planned process undertaken over time which includes (but is more than) a planned transfer to adult services. More children with long-term conditions now live into adulthood. There is a growing need for health services to ensure a seamless transition of young people to adult health care services. This is achieved by maintaining good liaison between Paediatricians, Physicians, General Practitioners (GP), Nurses, Allied Health Professionals (AHP), and external agency professionals. Inadequate transitional care impacts on long-term health outcomes for children and young people. The purpose of this Policy is to provide guidance and principles of good practice in relation to the transition of young people from paediatric to adult services within the Royal Devon and Exeter NHS Foundation Trust. SCOPE This Policy Includes: All healthcare professionals working with children and young people (aged years) within the Trust All young people with a life-long condition until they are successfully transferred to adult services It is the responsibility of all clinicians working with young people during the transition period to ensure that this Policy is adhered to. 2. PURPOSE To provide a service that is: Centred on young people and placed in the context of young people s lives and their changing circumstances. Age and developmentally appropriate in line with You re Welcome criteria ( _ pdf) and takes into account the young person s maturity, cognitive ability and specific needs with respect to their long - term condition in addition to their social/personal circumstances and psychological status. Inclusion of the whole family in decision making about appropriate care for the young person is essential. A streamlined progression from paediatric to adult services. A multidisciplinary, multi-agency approach with involvement from professionals in primary, secondary and tertiary care alongside those in education and social care. 3. DEFINITIONS 3.1 Transition: a purposeful, planned process to firstly prepare young people moving from a child-centered to adult-orientated service and secondly addresses the medical, psychological and educational/vocational needs of adolescents and young adults with chronic physical and medical conditions as they move from child-centered to adult-oriented health care systems (Department of Health (DH), 2006). Review date: August 2017 Page 4 of 22

5 3.2 Clinician: the professional responsible for the young person s care i.e. Doctor, Nurse Specialist or Allied Health Professional. 3.3 Key Worker: a professional who has the responsibility for collaborating with professionals from their own and from other services and developing good working relationships to ensure co-ordination of care for the young person. 3.4 Parent/or carer: a mother, father, close relative or close friend who are adults (older than 18 years) and who have been closely involved in caring for the child or young person. 3.5 Young person: For the purpose of this Policy the term is used to describe young people between the ages of years. 4. DUTIES AND RESPONSIBILITIES OF STAFF 4.1 The Deputy Chief Executive / Chief Nurse has responsibility for ensuring that appropriate processes are in place for the transition of young people (13-25yrs) from child-centred to adult orientated services. 4.2 The Paediatric and Adult Care Consultants have a responsibility for ensuring that the process agreed within this Policy is followed robustly to ensure effective transition between the services. 4.3 The Paediatric Liaison and Transition Nurse acts as a communication lead between all the individuals involved in effective transition. 4.4 The Senior Nurse (Acute Paediatrics) and Paediatric Matrons have a responsibility for taking action on any non-compliance from the identified measurement tools that monitor compliance against this guidance. 4.5 Specialist Nurses have a responsibility to ensure this Policy is championed and followed robustly when transitioning children to adult services within a specialist service framework. 4.6 Paediatric Governance Group has the responsibility to ensure that standards are met, actions are carried out and areas of concern are raised and escalated appropriately. 4.7 The Transition Steering Group is responsible for developing the transition service, ensuring that this transition Policy is followed accurately, and that it is revised as practice evolves. 5. MAIN BODY OF THE POLICY Key Principles Transition needs to address the medical, psychological and educational/vocational needs of the young person and the needs of their parents/carers Every young person with any long term condition should have a planned transition of care evident within their health care records Most patients identified as eligible for transfer to adult medical services will be transferred following the Ready Steady Go transition pathway. However, the Trust recognises that this programme may not meet the needs of all patients and in this Review date: August 2017 Page 5 of 22

6 situation, an alternative, individualised transition pathway may be used which shares the same philosophy A named lead professional who offers support around the transition should be identified for each young person Some young people will require multi-disciplinary team (MDT) meetings, which should ideally include the GP in complex care cases. The lead professional can be any member of the MDT The MDT will ensure that the young person, and their carers, are appropriately supported and engaged with throughout the transition process Three Main Stages of Transition 1. Getting Ready (Appendix 1) The aim is to introduce the concept of transition to the young person and family/carer early; it allows the young person to develop their autonomy whilst being supported by their family. The young adult needs to become aware of their own health care needs, and the implications of their medical condition. 2. Steady (Appendix 2) The young person and their family develop an understanding of the transition process and what to expect from the adult services. The young person should gain an appropriate understanding of their condition and practice skills relevant to their needs and begin to set their own goals. Facilitating self-medication, self-care and parent free consultations can help young people begin to take responsibility for their own health care needs. 3. Go (Appendix 3) By this stage the young person and their family should be feeling confident about leaving the Paediatric system and the young person should have a considerable degree of autonomy over their own care. Transition Process Young people and carers are introduced to Ready Steady Go through the Transition: moving into adult care information leaflet (Appendix 4). If there are any concerns with a child s or young person s ability to give informed consent refer to the Trust s Consent for Examination or Treatment Policy available here At the next consultation the young person completes a Getting Ready questionnaire (Appendix 1). Through a series of structured questions, a personalised transition programme is designed to meet their individual needs. The issues are addressed over the following 1-2 years and not in a single consultation. As young people gradually develop the confidence and skills to take charge of their own healthcare, the Steady questionnaire (Appendix 2) is completed. This builds on the young person s knowledge and skills around their condition. Finally the Go questionnaire (Appendix 3) ensures that the young person has all the necessary skills and knowledge to transfer safely and confidently to adult services. Review date: August 2017 Page 6 of 22

7 The young person should be introduced to the adult team ideally at least a year prior to transfer. Young people should be given the opportunity of being seen on their own. This can be offered, depending upon the emotional maturity of the young person, from around the age of 13 years. All children being seen on their own should be chaperoned during the consultation, in line with safeguarding policies. The parent or carer should complete a parent/carers transition plan (Appendix 5). This is designed to help parents and carers feel confident about their knowledge and skills during the period of transition. The point of transfer to adult services is mutually agreed by the young person, parents or carers, and professionals. Any issues, concerns, and progress are documented in the transition plan by the healthcare team/lead professional. On transfer to adult services, the young person will begin the Hello to Adult Services programme and complete the Hello to Adult Services questionnaire (Appendix 6). Intermittently, the Hello to Adult Services questionnaire should be reviewed, in order to maintain the young person s knowledge and skills around their condition. Those young people or adults whose first presentation with a long term condition is in adult services should be started on the Hello to Adult Services programme. It can be used for all young people and adults regardless of age or sub-specialty. Timing The process of transition from paediatric to adult medical services should commence at approximately 13 years of age (as deemed appropriate developmentally). Not all young people will be ready to move into adult healthcare at the same time. The young person s maturity, cognitive ability and specific needs with respect to their long term condition in addition to their social circumstances and psychological status need to be taken into account. Every effort should be made to put the young person and their family/carers at the centre of this process. The timing of transfer should be tailored to individual patient s needs depending upon their emotional maturity and cognitive and physical development. It normally occurs around the time of the young person s 18th birthday but for those with complex needs the process may take longer. Communication Copies of key letters and summaries should be given to the young person during transition. This may be kept in a Personal Health Record. Communication between paediatric and adult teams should be accurate and relevant and facilitate a smooth and safe transfer. Clear, concise, and useful information needs to be shared with the patient's GP at all key points in the Ready, Steady, Go process Review date: August 2017 Page 7 of 22

8 Safeguarding Any concerns raised during the transition process that the young adult s needs will not be fully met should prompt early involvement of appropriate support services. If there are specific safeguarding concerns then guidance outlined in the Trust s safeguarding policies should be followed closely. For children with complex needs who are already known to social care, their named social worker will also need to be involved during the process of the transition. Transition for young people with a learning disability a. All young people with a learning disability who have started on the Ready Steady Go pathway should be referred to the Adult Learning Disability Liaison Team. A Learning Disability Liaison nurse will attend a joint appointment with the receiving and referring teams to support the young person, ensuring reasonable adjustments are made. b. All young people with a learning disability should be simultaneously referred to the adult learning disability services either directly or via the known keyworkers within the Integrated Services for Children. 5.3 Key documents: Transitional Care Plan. This document is a checklist to ensure the patient has all the skills necessary for a successful transfer to adult services (See Appendix 7). Patient information leaflet on transition. This describes the transitional care process (See Appendix 4). Parent/Carer Transition Plan. This helps parents and carers develop their confidence to empower them with the knowledge and skills to enable them to support their child during the transition to adult services (See Appendix 5). Hello to Adult Services Questionnaire. This is the key tool for identifying the extent to which the patient is ready for transition to adult services. It identifies which skill sets/knowledge base require further development before successful transfer to adult services can be undertaken, and the young person has the confidence and skills to take charge of their own healthcare (See Appendix 6). Moving Through the Programme Flow Chart. This provides clear guidance on how to use the Ready Steady Go programme (see Appendix 8). 5.4 TRAINING REQUIREMENTS Professionals may need to consider further development of their knowledge and skills in working with young people, including: the biology and psychology of adolescence; communication and consultation strategies; multi-disciplinary and multiagency teamwork; and an understanding of the relevant individual conditions and disorders and their evolution and consequences in adult life. An E-Leaning package developed by Royal College of Paediatrics and Child Health (RCPCH), Royal College of General Practitioners (RCGP), Royal College of Nursing (RCN) and other royal Colleges is available to all staff so they can develop the necessary skills to help young patients make necessary changes to lead a healthier and more active life. This can be found at: Review date: August 2017 Page 8 of 22

9 All professionals who have regular involvement in transitioning children to adult services should complete this training. 6. ARCHIVING ARRANGEMENTS The original of this Policy will remain with the author Assistant Director of Nursing, Specialist Services. An electronic copy will be maintained on the Trust Intranet, P Policies T for Transition.. Archived electronic copies will be stored on the Trust's archived policies shared drive, and will be held indefinitely. A paper copy (where one exists) will be retained for 25 years. 7. PROCESS FOR MONITORING COMPLIANCE WITH AND EFFECTIVENESS OF THE POLICY/STRATEGY No Minimum Requirements Evidenced by 1. Compliance with Transitional plans Transitional plan completion Approximately 25 sets of notes 2. Satisfaction survey Engagement with young people 7.1 Frequency In each financial year, the Paediatric Liaison and Transition Nurse will audit 25 sets of clinical records to ensure that this Policy has been adhered to and a formal report will be written and presented at the Transition Steering Group and the Bramble Business Meeting. 7.2 Undertaken by Paediatric Liaison and Transition Nurse 7.3 Dissemination of Results At the Transition Group, this is held quarterly and at the Bramble Business Meeting which is held monthly. 7.4 Recommendations/ Action Plans Implementation of the recommendations and action plan will be monitored by the Transition Steering Group, which meets bi-monthly. 7.5 Any barriers to implementation will be risk assessed and added to the risk register as appropriate. 7.6 Any changes in practice needed will be highlighted to Trust staff via the Governance Managers cascade system. Review date: August 2017 Page 9 of 22

10 8. REFERENCES Department of Health (2006). Transitions: Getting it right for young people. London: HMSO Department of Health (2004). National Service Framework for children, young people and maternity services: Core standards. London: HMSO Department of Health (2008). Transition - Moving on Well. London: NHSE NHS Confederation (2012). Children and young people s health-shaping the future and improving outcomes. London: NHS confederation University Hospital Southampton. Transition to adult care: Ready Steady Go. ( itiontoadultcare.aspx accessed May 2015) BIBLIOGRAPHY Action for Sick Children (1995) Caring for all our Children. A training pack in multicultural health care for providers. London Audit Commission ((1993) Children First. A study of Hospital Services. London, HMSO Convention on the Rights of the Child (1999) Second Report to the United Nations Committee on the rights of the Child by the United Kingdom - Executive Summary. Department of Health (1989) The Children Act. London: HMSO. Department of Health (1997) A bridge to the future. Nursing Standards, Education and Workforce planning in Paediatric Intensive Care. NHSE. London. Department of Health (1997) Paediatric Intensive Care A framework for the Future. NHSE. London. Department of Health (2007) You re Welcome quality criteria. NHSE. London. Department of Health (1993) A Handbook on Child and Adolescent Mental Health. The Health of the Nation. Department of Health (2008) Transition - Moving on Well. NHSE. London Hogg C (1996) Health Services for Children and Young People: A guide for Commissioners and Providers (The Quality Review Series). London, Action for Sick Children. NAWCH (1991) Just for the Day by Rosemary Thornes. London. National Association for the Welfare of Children in Hospital (1990) (Quality Review Series) Setting Standards for Children in Health Care Royal College of Paediatrics and Child Health (1997) Withholding or Withdrawing Life Saving Treatment in Children. A framework for Practice. London. Royal College of Nursing (2008) Adolescent Boundaries and Connections. London. Review date: August 2017 Page 10 of 22

11 Appendix 1: GETTING READY QUESTIONNAIRE Review date: August 2017 Page 11 of 22

12 Appendix 2: STEADY QUESTIONNAIRE Review date: August 2017 Page 12 of 22

13 Appendix 3: GO QUESTIONNAIRE Review date: August 2017 Page 13 of 22

14 Review date: August 2017 Page 14 of 22 Appendix 4: TRANSITION LEAFLET

15 Appendix 5: PARENT/CARER TRANSITION PLAN Review date: August 2017 Page 15 of 22

16 Appendix 6: HELLO TO ADULT SERVICES QUESTIONNAIRE Review date: August 2017 Page 16 of 22

17 Review date: August 2017 Page 17 of 22 Appendix 7: TRANSITION PLAN

18 Appendix 8: MOVING THROUGH THE PROGRAMME Review date: August 2017 Page 18 of 22

19 Appendix 9: COMMUNICATION PLAN COMMUNICATION PLAN The following action plan will be enacted once the document has gone live. Staff groups that need to have knowledge of the strategy/policy All staff working within services where children transfer to adult services The key changes if a revised Policy/strategy NA new policy The key objectives How new staff will be made aware of the Policy and manager action This Policy aims to set out best practice for all healthcare professionals enabling the delivery of a well-planned transitional process for young people. The document sets out the requirements to ensure all young people (12-18 years) receive a quality service when transitioned from childcentered to adult-orientated services. , Trust intranet must reads, and on induction Specific Issues to be raised with staff Training available to staff Any other requirements Issues following Equality Impact Assessment (if any) Location of hard / electronic copy of the document etc. All staff who have regular contact with children/young adults in their daily working roles should be made aware of the Policy. Particular attention should be drawn to using the Ready Steady Go programme Training is available at and should be completed by staff involved in the transition of children to adult services 3 positive impacts for age, disability and sex The original of this Policy will remain with the author Assistant Director of Nursing, Specialist Services. An electronic copy will be maintained on the Trust Intranet, P Policies T for Transition.. Archived electronic copies will be stored on the Trust's archived policies shared drive, and will be held indefinitely. A paper copy (where one exists) will be retained for 25 years Review date: August 2017 Page 19 of 22

20 APPENDIX 10: EQUALITY IMPACT ASSESSMENT TOOL Name of document Division/Directorate and service area Name, job title and contact details of person completing the assessment Transition of Children to Adult services Policy Specialist services, Child Health Nigel Lawrence, Associate Director Nursing Specialist Services Extn Date completed: 15/05/15 The purpose of this tool is to: identify the equality issues related to a policy, procedure or strategy summarise the work done during the development of the document to reduce negative impacts or to maximise benefit highlight unresolved issues with the policy/procedure/strategy which cannot be removed but which will be monitored, and set out how this will be done. 1. What is the main purpose of this document? This Policy is designed to assist all healthcare professionals involved in the care of young people to ensure young people receive a seamless and quality service when transitioned from child-centred to adult-orientated services. 2. Who does it mainly affect? (Please insert an x as appropriate:) Carers Staff Patients Other (please specify) 3. Who might the policy have a differential effect on, considering the protected characteristics below? (By differential we mean, for example that a policy may have a noticeably more positive or negative impact on a particular group e.g. it may be more beneficial for women than for men) Please insert an x in the appropriate box (x) Protected characteristic Relevant Not relevant Age Disability Sex - including: Transgender, and Pregnancy / Maternity Race Religion / belief Sexual orientation including: Marriage / Civil Partnership Review date: August 2017 Page 20 of 22

21 4. Apart from those with protected characteristics, which other groups in society might this document be particularly relevant to (e.g. those affected by homelessness, bariatric patients, end of life patients, those with carers etc.)? This policy provides a programme to guide when transitioning children to adult services which should be used for all children/young people moving into adult services as it recognises the unique needs of children, young people and their families/carers This policy provides opportunity to use transition methods that meets the unique needs of individuals such as those with learning difficulties. It follows the philosophy of Ready Steady Go for all children, ensuring all children and young people have equity in service provision when transferring to adult services 5. Do you think the document meets our human rights obligations? Feel free to expand on any human rights considerations in question 6 below. A quick guide to human rights: Fairness how have you made sure it treat everyone justly? Respect how have you made sure it respects everyone as a person? Equality how does it give everyone an equal chance to get whatever it is offering? Dignity have you made sure it treats everyone with dignity? Autonomy Does it enable people to make decisions for themselves? 6. Looking back at questions 3, 4 and 5, can you summarise what has been done during the production of this document and your consultation process to support our equality / human rights / inclusion commitments? I used research and the model currently being rolled out across the NHS as this is a proven process that works for all children transferring I talked to other professionals and young people. This Policy does not discriminate, but promotes equity for all children Review date: August 2017 Page 21 of 22

22 7. If you have noted any missed opportunities, or perhaps noted that there remains some concern about a potentially negative impact please note this below and how this will be monitored/addressed. Protected characteristic : None Issue: How is this going to be monitored/ addressed in the future: Group that will be responsible for ensuring this carried out: Review date: August 2017 Page 22 of 22