The Children's Continuing Care Team's main purpose is to coordinate an open and fair assessment of health and care needs, for children or young people. The outcome of the assessment is to determine whether or not individual needs meet the eligibility criteria for continuing care funding using the Children’s Continuing Care framework set out by the Department of Health 2016.
Some children and young people (up to their 18th birthday), may have very complex health needs, which may be the result of congenital conditions, long-term or life limiting or life-threatening conditions, disability, or the after-effects of serious illness or injury. These needs may be so complex, that they cannot be met by the services which are routinely available from GP practices, hospitals or in the community commissioned by clinical commissioning groups (CCGs) or NHS England. A package of additional health support may therefore be needed, which is known as continuing care. Continuing care is not needed by children or young people whose needs can be met appropriately through existing universal or specialist services through a case management approach. (National Framework for Children and Young People's Continuing Care, 2016).
The key outcome for families is to provide a holistic, fair and thorough assessment of the child/young person’s needs in order to assess whether they require extra support to help meet the complexities of their needs. This means that the child/young person has needs that cannot be met solely by existing universal services such as their G.P or services provided by specialist teams like community nurses. The process begins by a referral being made to the Continuing Care Nurse and this is usually completed by the child’s/young person’s key worker such as their School Nurse, Community Nurse or Social Worker. If the child or young person meets the referral criteria for assessment, then contact is made to the parents or carers of the child/young person to undertake ‘Children and Young People Continuing Care’ assessment.
At the assessment, the Continuing Care Nurse discusses with the family all the elements of the National Framework for Children’s Continuing Care in order to gain a wider picture of the whole family’s needs including environmental, educational and social factors which help to form a holistic assessment. The Continuing Care nurse also takes into consideration the views and aspirations of the family and the child/young person where possible, as to what support they feel they need. As part of the process, the assessment requires information such as reports and risk assessments from other professionals involved in the child/young person’s care. This is to form evidence to support the assessment and decision process. Consent from parents or a person with parental responsibility is sought at the assessment in order to collate the information.
Following this the Children’s Continuing Care Nurse writes up the assessment using all of the information the has been gathered using the decision support tool as a guide. A recommendation is then made following the assessment process and the assessment is taken to a multi- agency panel so that health, education and social care can discuss, work together and decide if the child/young person has a continuing care need. This allows other services to be aware of the child/young person and act accordingly as to who can support your child/young person’s needs best.
The process should be completed within 6 weeks of the referral being received; however, flexibility needs to be considered depending on the complexities of individual assessments. If the child/young person meets the criteria for continuing care the family are notified of the decision and the continuing care nurse/co-ordinator begins to look at a suitable package of care taking into account, the child/young person and family’s needs.
The package of care is then delivered to the child/young person and a review takes place after 3 months, then yearly. A review will also be required if the child/young person’s needs change significantly before this time.
The funding for a care package is either provided solely by health or depending on the outcome of decisions at the panel there may be elements of social or educational funding discussed to supplement the package. Alternatively, to this the option of a Personal Health Budget can be discussed with the child/young person’s/family/carers.
You can find all the information about the child/young person continuing care process in the document called ‘National Framework for Children and Young People’s Continuing Care’ https://www.gov.uk/government/publications/national-service-framework-children-young-people-and-maternity-services