Children and Young People's Continuing Care (incorporating Adult Continuing Healthcare)

The Children and Young People's Continuing Care Service based in Staffordshire follow the National Framework for Children and Young People's Continuing Care (2016) and applies from birth up to a young person’s18th birthday. The Framework provides guidance to determine if a child or young person's complex health needs require support, in addition to that provided by the local core and specialist NHS services for example, the Children's Community Nurse team, School Nursing team, or specialist services such as the Diabete’s team, CAMHS, Dietician, Physiotherapy, Occupational Therapy. The local Continuing Care service receive checklist referrals from health professionals, for children and young people who have complex physical, learning disability, mental health needs, and also for those children and young people who require end of life care.

In the first instance a multi-agency (or multi-professional) meeting is required to understand what health needs the child or young person has, and to determine if NHS Continuing Care should be considered. This meeting should include the child or young person, their parents, health professional/s, and where applicable a social worker, and an education representative. Those at the meeting will need to be fully aware of what NHS Continuing Care is and what the process entails.

The most appropriate health professional will take the lead in completing a checklist (or referral form), with the support from all others at the meeting by identifying the child and young person’s complex health needs, and how these are being managed, (or not being managed) by all the existing services in place and also the parents or carers.

Following receipt of the checklist a Nurse Assessor will review, to make sure the document has been correctly completed and where necessary arrange a meeting to complete a more in-depth assessment of needs, known as a Continuing Care Assessment. This will be led and managed by the Nurse Assessor. This assessment includes 4 elements:

1. The preference of the child or young person and their family
2. A holistic assessment of the needs of the child or young person and their family
3. Reports and risk assessments from a multidisciplinary team or evidence collated during the Education, Health and Care plan assessment
4. The Decision Support Tool for children and young people

Following completion of the Continuing Care Assessment the case is presented to a senior multi-agency panel who determine eligibility and is based on the Nurse Assessor recommendations. As a result of the decision made at panel, if a package of health support is required the service will arrange this with the child, young person and their parents. Part of the Continuing Care service remit is to ensure the commissioned package of health care is safe, appropriate and of a high standard, and in accordance with individualised planned health care. The health care is usually delivered by trained and competent carers.

As needed the package of health support will continue throughout the period of time of transition into adulthood. During the latter stages of transition (between 17 and 18 years old) a different framework will be utilised to assess the requirement of NHS funded care, from the age of 18 which is the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care (2022). A member of the adult Continuing Healthcare (CHC) team will engage with the Children’s service to support this process and also provide guidance with regards to the adult CHC process applied, using the separate framework. Throughout transition (between the ages of 14-18 years) the Children’s Continuing Care service will liaise closely with the local children’s multi-agency (or multi-professional) services and will thereafter include multi-agency adult services when moving closer towards 18 years. The child, young person and their parents or carers will be central and integral to all discussions throughout the transitional period.

The Continuing Care service will help and support the child, young person, parents, carers, and professionals to understand the process of NHS Continuing Care. The Department of Health National Framework for Children and Young People's Continuing Care 2016 and leaflet attached provides information on NHS Continuing Care.

Parents/carers, professionals and other person's wishing to have more information can freely contact the service for more advice and guidance on NHS Continuing Care. The contact details for children and young person's Continuing Care service and adult CHC team is included.

We accept referrals primarily from health professionals, and will provide advice if parents/carers or other professionals wish to apply for Continuing Care for their child.

Training is available for professionals, please request this via the children's Clinical Administrator.

The children and adult national frameworks, pre-assessment and applications (Decision Support Tools) are attached.