Continuing Care - moving from Children's to Adults services

When a young person who receives a Continuing Care package (special health support) turns 14, it's time to start planning for their future support as an adult. This is called Transition Planning.

This ensures that when the young person turns 18, you will have a good understanding of adult Continuing Healthcare services and all the necessary support is in place.

There are 5 stages in this transition planning:

• 1. Age 14 – getting the transition plan ready
• 2. Age 16 – formal referral to adult services
• 3. Age 17 – final stage of planning
• 4. Age 18 – Transfer of care
• 5. Age 18+ – Review
• View the full transition policy

1. Age 14 – getting the transition plan ready

Your child will be offered a transition plan to help them think about their future. It looks at:

• what’s going well
• what they’d like to stay the same
• what they’d like to change.

You’ll work on this plan together with your child’s continuing care nurse and update it each year.

The nurse will explain how children’s and adult's health care systems are different, so you know what to expect.

One professional will be your main contact to help coordinate everything. For children in Continuing Care, this will usually be their nurse. The nurse will let adult services (the Continuing Healthcare Team) know your child is getting ready to move on, and they will share important documents with health, social care, and education teams.

At Age 15:

You’ll be invited to review and update the transition plan, including any significant health changes over the past year or changes to your care needs.

2. Age 16 – formal referral to adult services

As in previous years, you will have a chance to update the plan and bring up any questions or concerns you have.

As your child gets older, the transition plan starts to look at more detailed areas to help prepare for adulthood. 

Things you and your child will start thinking about:

• Making decisions: can they make choices about their care and future? Mental capacity and liberty protection safeguards will be considered.
• Consent: who can give permission for things like sharing information or making health decisions?
• Planning how finances will be managed.
• Daily tasks: learning to manage things like ordering medication or using equipment, depending on their needs.

What the professionals will do:

• Referral to Adult Services: your child's nurse or named worker will formally refer them to adult health services (Continuing Healthcare), using the Continuing Healthcare Checklist. 
• Determine funding options: the checklist helps decide if your child will be:
  - Fully funded by the NHS
  - Jointly funded by NHS and the council
  - Fully funded by the council
  - Not eligible for NHS funding (but may still get other support)
• Seek consent: before sharing information, the named worker/ nurse will seek the right consents. They will check if your child can give permission and understand what’s happening, through a mental capacity assessment.

At this point the children and young person's continuing care and adult's continuing healthcare teams start working more closely together. Your nurse, social worker, and a representative from the adult's continuing healthcare team will meet with you and your child to review their needs.

3. Age 17 – final stage of planning

As your child approaches 17, they will consider what their package of care in adulthood may look like.

Professionals will:

• Do a full assessment using a 'Decision Support Tool' to see what support your child may need as an adult. Both children’s and adult services will be involved to make sure all your child’s needs are understood.
• If your child is eligible for CHC funding, the adult team will decide what level of funding, care and equipment your child needs.
• Any care package agreed before their 18th birthday will start on their 18th birthday.
• Once the assessment is approved, work with you and your child to create an Adult Care Plan. The children’s nurse will help make sure all health needs are included.

4. Age 18 – Transfer of care

As your child approaches their 18th birthday, a full transfer to Continuing Healthcare and/ or social care and/ or universal or specialist health services should have been made.

One month before turning 18

A handover meeting will be held with:

• Your child
• Your family
• The children’s nurse
• The adult CHC team

This meeting introduces the care package and makes sure everything in the transition plan is complete and ready.

On their 18th birthday

• Your child’s new care plan officially starts with adult services, based on what was agreed during the assessment.

5. Age 18+ – Review

Once your child has moved to adult services, there’s a follow-up to make sure everything is working well.

Reviewing the care package

• Around 3 months after their 18th birthday, the adult CHC team will check if the care plan is still right for your child.
• The children’s nurse who knows your child will also join the meeting to offer advice and support.
• If everything is going well, the children’s team will officially let the relevant people know that your child has successfully moved to adult services.

View the full transition policy

This policy is written for professionals and explains the full process in detail. On this webpage, we’ve highlighted the key stages that families need to know about. Professionals will guide you through each step as you go through them together.

Appendix documents for the policy