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Contents

1. Statement of Purpose
2. Transition and Information Management
3. Eligibility Criteria for Adult Services - (Health and Social Services)
4. Resource Panels and Transition Meeting Forums
5. Information and Duties for Practitioners

1. Statement of Purpose

The protocol to which this executive summary relates is aimed at those working with young people such as:

• Looked after Children (LAC) with disabilities who leave care at age 18;
• People with physical disabilities and long term health conditions;
• People with learning disabilities and/or learning difficulties;
• People with mental health conditions;
• People with Autistic Spectrum Conditions (ASCs);
• People with Emotional and Behavioural difficulties;
• Vulnerable Young people  and Vulnerable Adults.

1.1 What is a transition protocol and why do we need one?

The multi-agency transition protocol has been developed with the primary purpose of supporting the systematic and consistent delivery of positive 'outcomes' for young people in transition in Trafford.

1.2 Person Centred Approaches

The protocol is underpinned by an awareness of and commitment to 'person centred' approaches. This applies to all cohorts of young people, whatever their individual circumstances. At all stages of the transition process practitioners based within Trafford are advised, expected and actively encouraged to focus on the needs of the individual and for planning to be led by the service user's choices and preferences as far as is practicably possible.

1.3 Consultation - Involvement with Trafford partner agencies and with young people and parent(s) / carer(s)

The protocol has been developed as a recommendation from Trafford's comprehensive multi-directorate Learning Disability Review (2011). The review was informed in part through direct consultation with service users and carers. The feedback from this consultation helped to highlight the need for a clear operational framework for practice, thus leading to the creation of the Multi-agency Transition Protocol.

Consultation has also taken place with a broad range of Trafford partner agencies working with young people in transition and their parents / carers.

2. Transition and Information Management

The timely and effective sharing of information regarding a young person's needs, choices and preferences is central to effectively managing the process of transition.

Each practitioner (and associated team) has responsibility for ensuring that consent to share information is received from young people / parents / carers.

Teams must be in a position to share relevant transition information with adult services such as within the planned formal Transition Meeting forums*, both prior to and following formal referrals being made. (*see Section 4, Resource Panels and Transition Meeting Forums)

2.1 Central Transition Database (CTD) 

The Central Transition Database is managed by the Transition Coordinator and holds a significant amount of key transition data. The CTD is currently required as many of the teams working with people in transition across both children's and adult services have their own separate electronic recording systems that are not integrated with each other.

2.2 Pre-referral stage -  sharing information with adult services prior to a formal referral

A formal referral within health and social care services is usually classed as being a clear request for a specific practitioner or team to start to offer in-depth support to an individual (the person being referred)

However, as the transition process tends to take place over a period of years it is very often important to start to share information with partners in adult services well before a full formal and comprehensive referral needs to be made.

2.3 Pre-referral stage documentation

At the pre-referral stage, information should be shared with adult services / Transition Coordinator within the formal Transition Meeting forums for inclusion on the CTD via:

• Individual team's lists / spreadsheet of Transition case data - (This method should be used for transferring information regarding multiple cases);
• Initial Transition Information Sharing Form (ISFs).

ISFs are available on request from the Transition Coordinator and will be disseminated to relevant teams.

2.4 Sharing information via individual team case lists and via individual case specific ISFs:  Key points - 

• The Transition Coordinator should be informed of all young people from age 14 upwards who are known to CYPS and who are in transition via team's transition case lists and ISFs;
• Sharing information via team's transition case lists and /or via an ISF is not in itself a formal referral to adult services;
• Team's transition case lists and ISFs provide data to populate the Central Transition Database which in turn informs transition planning;
• CYPS may need to forward updated case lists and ISFs to adult services at intervals throughout the transition process, as individual circumstances for young people change.

2.5 Referral stage - Formally referring young people to adult social care and health services

Children's Services are responsible for ensuring that Adult Services are provided with all the definitive, comprehensive and up-to-date information that they will require to support a person in transition.

The level of case complexity will determine the level of detail that is required. At the very minimum level, CYPS practitioners should all aim to refer to adult services using one or more of the following -

• Single Agency Referral Form (SARF) - (minimum information required);
• Common Assessment Framework (CAF) - (this is the recommended referral format for young people who are well known to the referring service as it facilitates the full and holistic collation of relevant information).

Depending on the case, the practitioner's role and the stage of referral/joint working with adult services, CYPS will also need to include all other relevant supporting information as part of the phased transition handover. This may be one or more of the following:

• A comprehensive professional's /clinic letter (with supporting documentation where appropriate);
• Detailed case summary;
• A completed care leavers 'Pathway Plan' (assessment) - (statutory requirement for 'relevant' care leavers);
• Risk Assessment(s);
• Mental Capacity Assessments (the Mental Capacity Act applies from 16+);
• In depth health records (see list in Section 2.6 Referring and Sharing health documentation and assessments at transition).
  
  

2.6 Referring and Sharing health documentation and assessments at transition

The relevant health related documentation that should be shared with adult services for transition cases may take numerous forms and can relate to a wide range of health related needs, for example:

• General records of health:
  • GP's / Dentist's /  Sensory (Sight and Hearing practitioner) details.
• Mental Health / Behavioural/ Emotional:
  • Psychological formulation/assessment;
  • Psychiatric report;
  • CPA records/related care plans.
• Behavioural assessments:
  • Behaviour Support Plans;
  • Functional Analysis.
• Risk assessments (depending on area of need):
  • Forensic Issues / assessments.
• Physical health needs / Support plans / Guidelines relating to:
  • Epilepsy;
  • Physiotherapy /  Moving and Handling;
  • Occupational Therapy;
  • Speech and Language;
  • Communication;
  • Eating and Drinking Guidelines.
• Health Action Plan (Learning Disability specific);
• Continuing Health Care (CHC) assessment.

2.7 Specialist Health Pathways

Children's services practitioners should ensure that all relevant young people are referred onto the appropriate specialist health pathways - these include:

• CPA - Care Programme Approach - (predominantly Mental Health cases);
• PIMD - Profound Intellectual and Multiple Disabilities (pathway);
• CBP - Challenging Behaviour Pathway.

The formal processes of such care pathways, in addition to normal transition planning should reinforce the person's transition into adult services and ensure that the 'health' transition is comprehensively managed.

2.8 Health Action Plans (specific to people with a learning disability)

Transition is highlighted as a priority life stage for which the completion of HAPs is advised (Valuing People 2001). It is good practice that these be offered by CYPS to relevant young people and completed in time so that they can be actively used to facilitate the transition into adult health services.

3. Eligibility Criteria for Adult Services - (Health and Social Services)

Practitioners must recognise that there are different eligibility criteria between children's and adult services. This means that a young person who receives support from CYPS may not automatically be deemed eligible to receive similar support from adult services. The initial question for CYPS must therefore be - 'is the young person eligible for an adult service(s) and if so, which team(s)?'

There are many questions that may cause doubt about what the most appropriate team(s) in adult services will be. For example:

• Does the young person have a Mental Health condition?
• Is the person (or could they be) eligible for Continuing Health Care funding?
• Does the young person have a formal diagnosis of Learning Disability;
• Does the person have a dual diagnosis? E.g. Learning Disability and Mental Health;
• The person may have an Autistic Spectrum Condition, but this has not been formally assessed;
• The young person does not have a formal disability or mental health condition, but due to other reasons it is likely that they will be classed as a Vulnerable Adult under the FACS criteria (see Section 3.1 Fair Access to Care Services criteria (FACS) - Social Services only) if so, why?
• As defined under the Mental Capacity Act 2005 (relevant from age 16+), does the young person have 'capacity', on a decision specific basis, with regard to important matters affecting their life as they go through transition?  Such as where to live; who to live with; financial concerns; etc.

In all cases it is good practice for a young person's eligibility for adult services to have been firmly established as soon as possible within the person's 16th year of age and no later than 17 and 6 months, depending on level and complexity of need and planning required. It should not been seen as the duty of the service that a person in transition is being referred to (unless specifically the remit of the team) to carry out in-depth clinical 'diagnostic' assessments.

3.1 Fair Access to Care Services criteria (FACS) - Social Services only

FACS is a system for deciding whether people with social care needs require a service. It applies to all the local authorities in England. The FACS assessment contains four bandings of needs: Critical, Substantial, Moderate and Low, across a range of assessed social care categories. A person is deemed to be eligible for support only if they are assessed in any particular category of having either Substantial or Critical need(s). 

3.2 Vulnerable Adults: 

If a person has a FACS eligible need and a learning disability it is most likely they will be supported by the Community Learning Disability Team. If they have a FACS eligible need and Mental Health condition, support will be provided via the Community Mental Health Team. If a person has a FACS eligible need but no clear diagnosis they are likely to be classified as a 'Vulnerable Adult'.  In such cases a senior management decision will be required to delegate a team to provide the required support.

4. Resource Panels and Transition Meeting Forums

4.1 Resource panel structures across CYPS, Health and Adult services

There are number of separate procedures for senior management across each directorate to consider requests for funding for services for young people.

The main 'Resource Panels' are:

• Children's Services (CYPS);
• Adult Services;
• Health Services - Continuing Healthcare.

It is important to recognise that each resource panel operates independently. The 'eligibility criteria' for services are often different between directorates and teams. Therefore,  a decision by CYPS 'panel' to fund services for a particular young person does not currently mean that the Adult services 'panel' would automatically approve the continuation of funding as the person enters adult services at age 18. 

4.2 Transition Meeting Forums

The process of 'transition' tends to take place within a wide operational and policy context across both Children's and Adult's health, social and educational services.

Due to the broad scope of transition there are a relatively large number of key stakeholders. To manage the range of transition processes a number of key meeting forums are required. These are:

• Transition Program Board -  Monthly;
• Transition Governance Meetings -  Monthly (or as required);
• Practitioner Transition Meetings -  Quarterly (or as required);
• Team to Team transition meetings  - dependent on arrangements;
• Individual cases transition meetings -  as and when required.

The roles and functions of these meetings are briefly discussed below.

4.3. Transition Program Board -  (Strategic)

Trafford's Transition Program Board (TPB) provides the overall strategic governance for transition in Trafford. The TPB meets on a regular basis to agree on, prioritise and review work streams for transition. The TPB is made up of a broad range of senior representatives from key stakeholder organisations.

4.4. Transition Governance Meetings (TGMs) -  (Strategic and Operational)

The Transition Coordinator and managers (or representatives) from social work and health teams from both CYPS and adult services will attend the TGMs. It is the role of the Transition Governance Meeting/group to:

• Establish and maintain a clear operational plan to implement the Transition Protocol;
• Oversee the on-going implementation of the Transition Protocol to ensure that responsibilities allocated to agencies are consistently implemented;
• Regularly review and evaluate the transition process in Trafford;
• To ensure that the views of young people and parent(s)/carer(s) are actively sought and listened to and that these views are reflected in transition policy and service planning;
• Any young person's 'case' that may require in-depth support through transition may be brought to the TGM by the relevant responsible manager for formal discussion.

4.5 Practitioners Transition Meetings (PTMs) - (Operational)

The Transition Coordinator and practitioners from social work and health teams from both CYPS and adult services will attend the PTMs. It is the role of the Practitioner Transition Meetings to:

• Promote effective partnership working between frontline practitioners working with young people in transition;
• Identify risks and barriers to transition planning and to work to implement effective solutions;
• Ensure that relevant young people have an actively managed and holistic 'transition plan' into adult services;
• Report relevant matters to linked management and decision making forums. E.g. Transition Governance Meetings.

4.6 Team to Team transition meetings - (Operational)

Various teams across CYPS and adult services through which there is a consistent flow of cases may benefit from scheduled 'team to team' meetings to discuss and more effectively plan for forthcoming transitions.

Currently, for example, CYPMHS and TES have formed such a forum to meet on a quarterly basis and have agreed a process for making referrals directly from CYPMHS to TES for relevant cases. Such 'team to team' meetings and transition planning processes are encouraged on the basis that they will contribute to more 'seamless' transitions.

4.7 Transition Meetings for Individual cases - (Operational)

Depending on the level and complexity of a young person's needs, meetings between adult and children's services practitioners regarding individual cases are often required as a matter of good practice.  This can be for a broad range of reasons. For example:

• To identify possible barriers and risks to a young person's transition;
• To consider the most appropriate adult team(s) to support the young person;
• To address questions relating to the 'eligibility' of a young person for various teams or services;
• To support a multi-disciplinary assessment of a person's transition needs;
• To clarify, delegate and share duties between relevant practitioners in relation to a young person's transition;
• To monitor, manage and review a young person's transition plan.

4.8 Guidance on the role of Transition Coordinator for people in transition age 14-25

A selection of the Coordinator's duties are as follows:

• Report to the Transition Program Board on the progress of relevant strategic work streams /  goals;
• Chair and facilitate Practitioner Transition Meeting forums and support implementation of relevant work streams;
• Participate in Transition Governance Meeting forums and support implementation of relevant work streams;
• Support the day to day operational management of transition cases into adult services and execute professional duties within primary context of role in adult services;
• Work in partnership with stakeholders - provide advice and central point of contact for all relevant teams / professionals / agencies supporting young people in transition;
• Formally consult with young people /  parents /  carers to inform service development strategies;
• Facilitate the process of requests from the YPLA / EFA for social care funding for SEN school leavers who have applied for and have been offered a residential place at a specialist college (ISP);
• Manage the Central Transition Database;
• Support the process of strategic planning to meet the needs of young people in transition;
• Monitor and actively support the implementation of the Transition Protocol across relevant teams.

5. Information and Duties for Practitioners

5.1 Initial guidance on the role of all relevant CYPS practitioners involved in supporting young people at transition

Practitioners from children's services should be consciously and proactively helping to prepare young people from the ages of 14 upwards and their parent / carer(s) for the changes that can occur throughout transition to adult services.

5.2 Managing expectations

There are various differences between the nature and type of services and indeed the legal and policy frameworks between children's and adult services.  With this in mind, when working with young people and their parent / carer(s) it is important for CYPS practitioners to be considerate of the fact that it is not possible to guarantee that a young person will continue to receive the same level, type or amount of support in adult services that they received under children's services.

5.3 Training

Each team / practitioner is responsible for identifying their own training needs to ensure that they have the required knowledge base to support effective transitions for their service user group.

5.4 Key changes in law that affect young people in transition

Some examples

• Practitioners working with young people in transition should familiarise themselves with the difference in assessment criteria between the Children's Act (1989) and legislation relevant to adult services, namely the NHSCCA 1990 section 47;
• The Mental Capacity Act (2005) is applicable for people over the age of 16. Therefore, practitioners working in CYPS may find they need to assess the capacity of a young person from the age of 16;
• Parental consent - parents are not able to consent to medical treatment on behalf of their son /daughter who does not have capacity and who has reached 18 years of age. A multi-disciplinary 'best interests' decision may be required which takes into account the preferences of the parents.

5.5 Financial Charging for adult social care services  for people age 18+

However, HoTrafford operates a policy of charging individuals over the age of 18 to make a contribution from their benefits towards the cost of either 'community based' or 'residential' social care services that they may receive from the council.  Any charges that are made are done so on the basis of a means tested assessment based solely on the finances of the individual service user and not their wider family.

(Trafford does not operate a charging policy for service users under the age of 18)

The lead practitioner from adult services should ensure that when services are to be provided by Trafford to a young person over the age of 18 that:

1. In the case of 'community care' services a request for a financial assessment has been requested from Trafford Finance Department under the 'Fairer Charging' guidelines;
2. In the case of residential services the lead practitioner must personally carry out the financial assessment using the SS15 form under the Charging for Residential Accommodation Guide (CRAG) policy.

5.6 Changes to benefits concerning young people in transition

From the age of 16 it is sensible to advise young people and their parent / carer(s) to seek expert guidance on the changes to their benefits that can occur throughout transition. 

Practitioners should signpost to Trafford's Welfare Rights team where applicable.

5.7 Leaving Care grant

Young people who are Care Leavers are eligible for a full Aftercare service and will receive a Leaving Care Grant of approximately £1800 (2011 rate). This is accessible up until the person turns 25 years of age. The Leaving Care Grant is issued so that 'care leavers' can purchase furniture and equipment associated with setting up their own home.

5.8 Continuing Healthcare (CHC) - what is it and how does it affect benefits?

Dependent on an in-depth assessment of the individual's health needs the NHS may be required to meet the costs of an individual's personal healthcare support, even in settings other than a hospital.  This funding is referred to as NHS continuing healthcare.  It is generally the case that a person who is assessed as 'eligible' for CHC funding would have a significantly high level of on-going healthcare support needs.

5.9 Transport, (including the relevance of adult's charging policy)

Trafford CYPS may be legally obliged to provide free transport to and from school for young people with a 'Statement' of Special educational Needs (SSEN). Trafford's CYPS will fund the transport until the 'Statement' ceases when the person leaves school.

Once a young person's 'Statement' has ceased, any person who may require transport to and from college or similar such destinations will require an assessment of need.  The young person or their parents / carers / advocate can make the referral to adult services to request this assessment.  

A charging policy applies to service users for whom transport is provided by Trafford.

5.10 Transition Information sharing -  recommended timescales for pre-referral information sharing and for making referrals

Children's Services - ages 14 - 18

Caption: table about Children's Services - ages 14 - 18

Young person's age	Actions of key agencies (health and social care)
Between age 14 - 16	Children's services to start sharing basic information with adult services about young people in transition (pre-referral stage).
Between 14 -  18	Children's services to continue sharing key information in planned Transition Meeting forums (see Section 4, Resource Panels and Transition Meeting Forums) at which level of priority of referral can be agreed upon
From age 15 -  refer by no later than by age 16 1/2	Refer most complex and high cost cases that require joint commissioning, very in-depth multi-disciplinary planning.
From 16 - no later than age 17.	Refer 'High' needs cases/ high cost cases that will require joint commissioning and in-depth multidisciplinary planning.
From age 16 1/2 to age 17 1/2	Refer High/Medium needs cases - that require a relatively high level of planning
From 17 to 17 1/2	Refer 'Medium' needs cases - that require a medium level of planning
No later than age 17 1/2	Refer 'Low' needs cases - that require a relatively low level of planning to ensure that transition is seamless.

Adult services - ages 14 - 18

Caption: table about Adult services - ages 14 - 18

Young person's age	Actions of key agencies (health and social care)
Between age 14 - 16	Receive and log basic information from children's services about young people in transition (pre-referral stage).
Between 14 -  18	Discuss case specific issues with Children's services in planned Transition Meeting forums - see Section 4, Resource Panels and Transition Meeting Forums
From age 15 -  by no later than by age 16 1/2	Following referral by children's services of most complex and high cost cases - allocated adult worker(s) commence partnership working with CYPS
From 16 - no later than age 17.	Following referral by children's services - allocated adult worker(s) commence partnership working with CYPS on 'High' needs cases/ high cost cases
From age 16 1/2 to age 17 1/2	Following referral by children's services  - allocated adult worker(s) commence partnership working with CYPS on High/Medium needs cases
From 17 to 17 1/2	Following referral by children's services  - allocated adult worker(s) commence partnership working with CYPS on 'Medium' needs cases
No later than age 17 1/2	Following referral by children's services - allocated adult worker(s) commence partnership working with CYPS on 'Low' needs cases

It is good practice that all case handovers / new services / care plans should be completed / agreed / ready to be implemented at least 3 months before the person turns 18

Adult services - ages 18 - 25

Caption: table about Adult services - ages 18 - 25

Young person's age	Actions of key agencies (health and social care)
From age 18	Continue to support the young person in their transition into adult services All relevant agencies work together in best interest of young person  -  e.g. coordinate reviews
From age 19	Support planning to meet needs on leaving school at age approx 19 Support young person's transition to college -  (local or specialist)
Possible College years -  from age 19 -  22 approx	Lead practitioner(s) will: Maintain links with college (if relevant) and attend college annual reviews (if relevant); Commence planning for longer term services e.g. supported accommodation; Close case to review team as and when stable.
22 - 25 : Final stages of transition	Leaving transition… Ensure all health and social care needs are met - Close case to review team as and when stable.

End