The Atlas of Shared Learning

Case study

Supporting young people through transition into adult care services

Leading change

The Children and Young People Lead Nurse at Sheffield Teaching Hospitals (STHFT) led the development of transition services including its clinical pathways for children and young people (CYP) with complex care needs. This change, focussing on the transition of care from children’s health services into adult health services has led to improved experiences and use of resources within the Trust.

Where to look

The transfer of health care for children and young people into adult services can often be difficult. In many cases, the health needs of young people will have been met by the same people who have looked after them for as long as the child or young person can remember. As they reach adulthood they ‘transition’ to an adult healthcare environment they may be faced with having to consult with several different health teams, therapy teams and adult social care services (CQC, 2014). This transitional time can often be hard for those living it especially as the more complex the needs of the child or young person, the more complex the transfer of care can be NICE (2016).

Nurses at STHFT recognised unwarranted variation in practice within the Trust where children were being transitioned between services, recognising gaps within coordination, information available to children and families and in some clinical specialist service areas, leading to delays in care.

What to change

The Children and Young People Lead Nurse role was created to support children and young people in transitioning between children’s and adult services, offering support to all clinical specialist areas within the hospital. The Children and Young People Lead Nurse engages with families, children and young people with complex needs and provides specialist advice and support to staff to ensure prompt, safe transition into adult services. This role also aimed to support the development of pathways and standardised practice to ensure high quality care at transition was available to all complex needs children within the Trust.

How to change

The Lead Nurse developed the role by working seamlessly with the transition team at Sheffield Children’s Hospital and establishing a dedicated caseload of children and young people, to give a clear overview of the transition work being carried out by each clinical specialty. They provide education and training sessions for staff and partner agencies in understanding the needs of adolescents, as well as those with complex needs.

Development of the transition leads meetings within the Trust supported those working directly with families by ensuring central oversight of processes including hearing feedback from families and staff using services. This included identifying areas of good practice and areas where improvements could be made. The embedding of a new young person’s health passport and ‘transition summary’ forms using a child’s digital records is supporting clinicians’ decision making in all care settings.

Adding value

  • Better outcomes – An initial audit demonstrated that before the changes, 57% of young people over a three-month period were referred to the Mental Health Liaison Service (during their working hours), while following the work in the Emergency Department and with mental health services the number has increased to 81%. This increase has been a result of the patient flow aids used in the department and the increased identification of needs following training and advice.
  • Better experience – Having a coordinated approach to transition has been beneficial to the experience of patients with families reporting positively about the new approach. Having a nursing leader act as a central point enabled patients and families to access services better, creating better patient/service relationships and better outcomes with less delays in care. The new approach has also led to an increased awareness of the voice of the young person and their role in their care which is positive.
  • Better use of resources – The number of multidisciplinary team meetings (MDTs) being attended by STHFT staff has increased, which because of better of joined-up working has reduced duplication in practice and increased a coordinated approach to the young person’s transition. This is expected to positively free up time and resources for use elsewhere. Joint meetings have been developed, attended by managers from the Clinical Commissioning Group (CCG), social care and health transition services. This means that needs from multiple perspectives can be tackled at once and lead to more effective service development and more efficient use of resources in the longer term.

Challenges and lessons learnt for implementation

Key to achieving engagement and support staff understanding within the trust and health partners across Sheffield was ensuring that the transitional nurse was visible, making the time to get out to speak with partners, staff on wards and to supply training to the trust staff.

  • On-going audit against the NICE (2016) guidelines is planned to ensure the Trust is responding to these and evidence the impact of the service.
  • Due to the success of the project, further recruitment is underway to develop the team which will include a Medical lead, Learning and Disability Nurse and administrative support.

For more information contact

Rachel Macqueen
Children and Young People’s Nurse
Sheffield Teaching Hospitals
Rachel.macqueen@sth.nhs.uk