Skip to main content
Wolverhampton Information Network

NHS Children and Young People's Continuing Care

The Children's Continuing Care Team's main purpose is to co-ordinate 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.  

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 the Black Country Integrated Care Board (ICB), 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.

Since September 2014, under section 26 of the Children and Families Act 2014, children and young people with a SEND are entitled to a single plan which consists of a multi-professional assessment to agree an Education, Health and Care Plan (EHCP). The 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. 

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 following link - 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
Mobile: 07831 569532
Black Country Integrated Care Board (ICB)

Where to go

Black Country Integrated Care Board (ICB)
Civic Centre
St Peters Square
West Midlands

Time / Date Details

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

Other Details


Referral required
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: 17/01/2023

Back to top