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Children and Young People Continuing Care

Description

The NHS East Riding of Yorkshire Clinical Commissioning Group (CCG) is a GP-led organisation, with an annual budget of around £365 million, responsible for planning and buying (commissioning) hospital, mental health and community health care services in the East Riding area.

As health service commissioners, the East Riding of Yorkshire CCG has a duty under Section 3 of the NHS Act 2006 to arrange health care provision for the people for whom they are responsible to meet their reasonable health needs. This is the fundamental basis of commissioning in the NHS. Where there is provision which has been agreed in the health element of an Education, Health and Care (EHC) plan, health commissioners must put arrangements in place to secure that provision. As part of our Local Offer we commission health services for children and young people (CYP) which are delivered by health professionals including paediatricians, psychiatrists, nurses, occupational therapists, speech and language therapists, physiotherapists, clinical psychologists, dieticians and specialist nurses for conditions such as epilepsy, asthma and diabetes and community children's nursing teams for complex health, learning disabilities or mental health needs.

An NHS CYP's continuing care package may be offered when a child or young person under 18 years of age has needs arising from disability, accident or illness that cannot be met by existing mainstream, universal, targeted or specialist services alone but require regular and planned complex intervention.

The aim of the care package is to support the child/young person's parents or carers to manage their child/young person's care at home and/or in other settings. It may require the provision of services from the NHS, social care, education, or other organisations to enable the person to meet their full potential in the community.

Children and Young People are assessed using the:

National Framework for Children and Young People's Continuing Care (DOH 2016) (external website)

This framework is designed to support Clinical Commissioning Groups (CCGs) in determining if a child's needs are such that they can only be met through a package of continuing care.

It is important to note that diagnosis of a particular disease or condition is not in itself a determinant of a need for continuing care; not everyone with a disability or long term condition will be eligible.

A child or young person is referred to the CYP's Continuing Care Team upon completion of a Pre- assessment Checklist. This will be done by either visiting the child or young person and their family or as a paper exercise with their social worker or health care professional with support from the continuing care nurse. The Clinical Commissioning Group will consider the information, provided through the checklist, to establish if they are likely to need a full assessment. A health assessor will then collect evidence of the child's health needs and the current health care being provided; drawing on the information from health and care professionals.

Where it is indicated that a child/young person may be eligible, a multi-disciplinary team meeting will be held. Within this meeting the collated evidence and the assessor's recommendation will be discussed and a decision reached as to whether or not the child or young person has a continuing care need. This will then be taken to CYP's Continuing Care panel to be approved and support package agreed. A decision about eligibility will usually be made within 6 weeks of a multi-disciplinary meeting being carried out.

A bespoke care package is then arranged called a continuing care package. Some of the care may be provided through existing services, some may need to be specially arranged. The health care package is designed to complement support and services offered by Social Care and Education. Children and young people who are eligible for continuing care have complex needs and developing the right package of support in a safe way, can take time.

Please note that a Fast Track approach to CYP's Continuing Care is used if a child or young person has urgent health needs and/or nursing needs and is rapidly deteriorating and/or in a terminal phase of life. It is also used if a child or young person's health is likely to deteriorate rapidly before the next routine CYP's Continuing Care review. It is not only for people at end of life.

Flowcharts to simplify the CYP's Continuing Care Process have been provided to help you navigate this service:

Children and Young People's Continuing Care Process Flowchart (Word 156kb, opens in new window)

Mainstream and Universal Services are services which all CYP and their families can expect to access without additional resources. Universal services are expected to make reasonable adjustments to accommodate CYP with SEND.

Targeted Services are services for CYP with additional needs over and above what is available to them through universal services. Often these services will be short-term and embedded into universal services.

Specialist services are those which CYP and their families may require following individual assessment and referral by specialists. Typically, they will be long-term and for CYP with complex needs.

For those registered with a GP outside of the East Riding, for example York GPs (Pocklington area) or HUll, please visit your local CCG website.

Parking and accessibility
Outreach services available across the East Riding.
Registered service and regulatory body

Regulated by the East Yorkshire Clinical Commissioning Group (CCG) Governing Body.

Staff training and experience

Staff are Registered Nurses for People with Learning Disabilities and Mental Health. They have an appropriate level of clinical expertise, links with other professionals and are experienced in supporting children and young people with SEND and their families. Continuing Care Nurses are competent in Early Vocabulary Signs and use a range of augmented communication methods to ensure the voice of the child is captured.

Contact
(01482) 394000
Back
Description

The NHS East Riding of Yorkshire Clinical Commissioning Group (CCG) is a GP-led organisation, with an annual budget of around £365 million, responsible for planning and buying (commissioning) hospital, mental health and community health care services in the East Riding area.

As health service commissioners, the East Riding of Yorkshire CCG has a duty under Section 3 of the NHS Act 2006 to arrange health care provision for the people for whom they are responsible to meet their reasonable health needs. This is the fundamental basis of commissioning in the NHS. Where there is provision which has been agreed in the health element of an Education, Health and Care (EHC) plan, health commissioners must put arrangements in place to secure that provision. As part of our Local Offer we commission health services for children and young people (CYP) which are delivered by health professionals including paediatricians, psychiatrists, nurses, occupational therapists, speech and language therapists, physiotherapists, clinical psychologists, dieticians and specialist nurses for conditions such as epilepsy, asthma and diabetes and community children's nursing teams for complex health, learning disabilities or mental health needs.

An NHS CYP's continuing care package may be offered when a child or young person under 18 years of age has needs arising from disability, accident or illness that cannot be met by existing mainstream, universal, targeted or specialist services alone but require regular and planned complex intervention.

The aim of the care package is to support the child/young person's parents or carers to manage their child/young person's care at home and/or in other settings. It may require the provision of services from the NHS, social care, education, or other organisations to enable the person to meet their full potential in the community.

Children and Young People are assessed using the:

National Framework for Children and Young People's Continuing Care (DOH 2016) (external website)

This framework is designed to support Clinical Commissioning Groups (CCGs) in determining if a child's needs are such that they can only be met through a package of continuing care.

It is important to note that diagnosis of a particular disease or condition is not in itself a determinant of a need for continuing care; not everyone with a disability or long term condition will be eligible.

A child or young person is referred to the CYP's Continuing Care Team upon completion of a Pre- assessment Checklist. This will be done by either visiting the child or young person and their family or as a paper exercise with their social worker or health care professional with support from the continuing care nurse. The Clinical Commissioning Group will consider the information, provided through the checklist, to establish if they are likely to need a full assessment. A health assessor will then collect evidence of the child's health needs and the current health care being provided; drawing on the information from health and care professionals.

Where it is indicated that a child/young person may be eligible, a multi-disciplinary team meeting will be held. Within this meeting the collated evidence and the assessor's recommendation will be discussed and a decision reached as to whether or not the child or young person has a continuing care need. This will then be taken to CYP's Continuing Care panel to be approved and support package agreed. A decision about eligibility will usually be made within 6 weeks of a multi-disciplinary meeting being carried out.

A bespoke care package is then arranged called a continuing care package. Some of the care may be provided through existing services, some may need to be specially arranged. The health care package is designed to complement support and services offered by Social Care and Education. Children and young people who are eligible for continuing care have complex needs and developing the right package of support in a safe way, can take time.

Please note that a Fast Track approach to CYP's Continuing Care is used if a child or young person has urgent health needs and/or nursing needs and is rapidly deteriorating and/or in a terminal phase of life. It is also used if a child or young person's health is likely to deteriorate rapidly before the next routine CYP's Continuing Care review. It is not only for people at end of life.

Flowcharts to simplify the CYP's Continuing Care Process have been provided to help you navigate this service:

Children and Young People's Continuing Care Process Flowchart (Word 156kb, opens in new window)

Mainstream and Universal Services are services which all CYP and their families can expect to access without additional resources. Universal services are expected to make reasonable adjustments to accommodate CYP with SEND.

Targeted Services are services for CYP with additional needs over and above what is available to them through universal services. Often these services will be short-term and embedded into universal services.

Specialist services are those which CYP and their families may require following individual assessment and referral by specialists. Typically, they will be long-term and for CYP with complex needs.

For those registered with a GP outside of the East Riding, for example York GPs (Pocklington area) or HUll, please visit your local CCG website.

Age
0-25
How to access
  • Your GP or health worker can refer you
  • You will need to have an assessment