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Wolverhampton Information Network

NHS Children and Young People's Continuing Care

About the service

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.  A package of additional health support may therefore be needed, which is known as continuing care. 

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 the Black Country Integrated Care Board (ICB), clinical commissioning groups (CCGs) or NHS England.   

What we do
We ensure that all assessments are needs led and involve members of the multi-disciplinary team that support the CYP. We are able to support with discharge planning and assessment, alongside the coordination and planning of care packages.

How to access the service

  • A referral can be 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.
  • 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 or young person meets the referral criteria, then contact is made to the parents or carers of the child/young person to undertake ‘Children and Young People Continuing Care’ assessment.
  • An open and fair assessment of health and care needs, for children or young people will then take place. 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 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.
  • 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.

What is the Children and Young People Continuing Care assessment process?

  • 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. 

How are continuing care plans managed alongside the EHC plan

The Education Health and Care Plan (EHCP) process is a coordinated assessment of a child or young person’s needs, based on multi-professional input and focussed on the outcomes which make the most difference to the child or young person and their family. 

We therefore intend to align the Children and Young Peoples Continuing care process with the EHCP processes where possible. The joint assessment will ensure outcomes are established across education, health and social care that the views, interests and aspirations of the child or young person and their family are documented and that collaborative joint working leads to good practice.

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.

Transition to Continuing Healthcare (18 plus)

If your child/young person receives child and young person’s continuing care and it seems likely they may need similar support when they reach 18, this should be identified and discussed with parents/carers when they reach the age of 14 years initially. At the age of 16-17 the young person should be referred to the adult NHS continuing healthcare team for assessment. This is a multidisciplinary assessment and a decision regarding eligibility should be made when they reach 17 years old.

How are continuing care plans funded?

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.

Personal health budgets are used to deliver an agreed package of care and are personalised to the child/young person’s/family/carers needs.

How to give a compliment or compliant about the service

The Black Country ICB service feedback can be provided by visiting Customer services - Time 2 Talk :: Black Country ICB

Where you can find us

Find out more about children and young people’s continuing care -  Continuing Healthcare :: Black Country ICB and read the child and young person framework - National Framework for Children and Young People’s Continuing Care.

Who to contact

Contact Name
Children and Young People's Continuing Care Nurse
Contact Position
Individual Care Team
Telephone
Mobile: 07831 569532
E-mail
bcicb.cccteam@nhs.net
Website
Black Country Integrated Care Board (ICB)

Where to go

Name
Black Country Integrated Care Board (ICB)
Address
Civic Centre
St Peters Square
Wolverhampton
West Midlands
Postcode
WV1 1SH

Time / Date Details

When is it on
Monday to Friday from 08.00am - 16.00pm

Other Details

Availability

Age Ranges
The service is for 0-18 years.
Referral required
Yes
Referral Details

The continuing care process is a multistage process which CCGs, local authorities and their partners undertake in order to deliver a continuing care pathway for Children and Young People with continuing care needs.

If you have a child/young person who you think may be eligible for continuing care, contact the Children's Continuing Care Nurse Coordinator for a discussion.  If required complete a referral form and email to the Children’s Continuing Care (CCC) team. Once the referral has been accepted and if it triggers for a full assessment,  the Children’s Continuing Care Nurse Coordinator will contact the child/young person and their family. 

Please contact the Children's Continuing Care Nurse Coordinator for any queries regarding referrals.

Record Last Updated on: 29/02/2024

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