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3.13.5 Transition Planning for Young People with Disabilities to Adults Services

Contents

  1. IATT – Introduction and Context
  2. Key Strategic Aims and Objectives
  3. IATT's Role and Responsibilities
  4. Service Model: 1st, 2nd and 3rd Tiers
  5. Early Identification and Pro Active planning


1. IATT - Introduction and Context

The Inter-Agency Transition Team is the lead service for the co-ordination and joint working arrangements for those Young People with complex special needs who are subject to multi-agency involvement as they move towards adulthood.  Key to this is the co-ordination and joint working in order to meet Every Child Matters and National Standards Framework requirements.

The Inter-Agency Transition Team (IATT) is based at Lewisham Centre for Children and Young People, 32 Rushey Green, London , SE6 4JF (Tel: 020 7138 1408 or 020 7138 1415 or 020 7138 1416).


2. Key Strategic Aims and Objectives

IATT’s aim is to:

“Develop and maintain Inter-agency funding, planning and ownership of TRANSITION issues for Young People with the most complex special needs/disabilities by driving forward with Every Child Matters and National Service Framework requirements in order to significantly improve the service experience and outcomes for Young People who require multi agency involvement as they move towards adulthood ” 

IATT’s objectives are:

  • To offer a co-ordinated approach to delivering the service.  Ensuring less duplication of professional tasks and roles, improved referral processes and clarity of purpose from a dedicated specialist team.
  • Better targeting of limited resources, especially, but not exclusively, to those young people with the most complex support needs requiring services from three or more agencies.
  • Improved support and information to young people and Parents/ Carers and increased user participation.
  • Improved outcomes for young people with greater access to educational, training or career opportunities, and co-ordinated person centred care planning and support throughout the transition process.
  • Clear and transparent service eligibility criteria;
  • Improved inter-agency data collection process and shared information system(s).
  • Jointly developed and agreed Transition planning process, procedures and tools between key agencies, led by IATT.
  • To promote a person centred approach to planning where the 5 key principles underpin joint working arrangements:
  • The young person is at the centre of the process
  • Family members and friends are full partners
  • Person Centred planning reflects the person’s capacity, what is important the person (now and in the future) and specifies the support needed to enable the individual to make a valued contribution to the community.
  • Person centred planning builds a shared commitment to action that will uphold the person’s rights.
  • Person centred planning leads to continual listening, learning and action and helps the person to get what they want out of life.

See Valuing People – Towards a person centred approach – Guidance for Implementation Groups (To follow)


3. IATT’s Role and Responsibilities

IATT’s Key Role and Responsibilities are:

  • To oversee the inter-agency Transition Planning process and engage with all key agencies such as, SEN service, special schools /schools / LSC/ Lewisham College; Connexions / Prospects; SCH - Children with Disabilities Service / ALDT / PD / Sensory Imp; PCT Child Health / Adult clinicians / services in order to achieve this.
  • To ensure the flow of information/data between agencies relating to 13 plus SEN Young People is timely and accurate.
  • To develop and maintain a database/listing of all young people with SEN needs within the transition age group in order to monitor, review and track Young People who require additional support through the transition years (14-25).
  • To set up group work/sessions for Parents to help prepare them for the impact of transition planning on their son or daughter and on family life.
  • To work in partnership to develop training materials/sessions and good practice guidance on transition planning and disseminate to relevant teams / services.
  • Set up multi–agency meetings to monitor and review the transition process for each age group or cohort of students as appropriate, this might include:

At age 13/14 (Year 8/9)

  • Entry into Transition process and initial year 9 reviews.
At age 16 (Year 10/11)
  • Ensure the Sect 140 review has been planned/happened,
  • Are any post 16 educational plans processed, jointly agreed and approved?
  • Review progress via Inter-Agency School leavers Forum.

At age 17/18/19 and above (Year 12/13 and beyond)

  • Ensure key plans are being made and are appropriate  
  • Monitor and review plans  
  • Have Adults services been informed/engaged in planning meetings?
  • Have they agreed any ongoing funding commitments? 
  • Have FACS (Fair access to Care service – eligibility framework) issues around differing thresholds for adult services being explained to Parents and students?
  • Are the plans of student’s placed Out of Borough (OOB) being reviewed / tracked and monitored?
  • Have the necessary assessments taken place for support services, housing, health care, direct payments, benefits  - especially if the young person is returning to Lewisham?


4. Service Model – 1st, 2nd and 3rd Tiers

The team will broadly offer the following types of service to partner-agencies and those young people and their families within the 3 priority bands mentions above.

1st TIER  - CO-ORDINATION, MONITORING AND TRACKING OF THE TRANSITION PLANNING PROCESS and STUDENTS; PLUS an Information Giving and Signposting role.
  • The development of a comprehensive transition planning process and protocols in Lewisham.  Which will include a transition Planning Pathway document to explain the cross agency roles and responsibilities against a Young Person’s transition timeline as they move towards adulthood.
  • The local overview and inter-agency co-ordination role relating to transition planning for all students with complex SEN.
  • The development and maintenance of a comprehensive database/listing in order to track and monitor SEN students into and through the transition planning process.
2nd TIER - CONSULTATION / ADVISORY / JOINT WORKING ROLE
  • To work alongside the lead agency/professional, offering information, advice, support/guidance to ensure co-ordinated transition planning takes place. But IATT will not accept casework responsibility where there is already a lead professional / key worker / allocated or duty worker already involved.
  • IATT will offer “outreach” surgery sessions to Children with Disabilities Service, LAC, Prospects, Connexions Staff and
  • others (as appropriate). 
3rd TIER - TASK CENTRED TRANSITION PLANNING WORK

IATT will offer intensive assessment or appraisal/planning/implementation and review (APIR) service only where there is no obvious other lead professional /key worker involvement and the young person/family situation is complicated or Complex needs exist or a SEN matrix level of 6 and above has been assigned. In these cases IATT will offer Short-term and task centred casework on transition planning related issues only. 

  • IATT will not undertake long-term casework where IATT are the only resource; IATT will aim to link Young People/Carers/Parents into other longer-term services and support networks – assisting with smooth transitions/promoting a positive experience of moving on and good endings!


5. Early Identification and Pro Active Planning

One of the key tasks that needs to be achieved is to identify at an early stage which young people may need ongoing services / support through their teenage years and possibly on into adulthood.

We have therefore agreed the following actions and planning processes will be undertaken to ensure that young people getting a service from Children with Disabilities Service will have their individual transition planning process met in line with agreed inter-agency protocols. 

At 13 years / School year 8 Children with Disabilities Service actions will be:

  • ANNUALLY gather a list of young people of 13 + years on Children with Disabilities Service active caseload together and identify who / how the transition planning will be undertaken over the next 5 year(s).
  • Liaise with IATT  / Prospects or Connexions to identify who the transition lead professional will be, ensuring Parent / Carer / young person involvement in agreement of LP role.
  • Agree with Transition plans / targets / actions needed over the next year, link into YEAR 9 school transition review or LAC reviewing process.
  • Individual workers link into IATT monthly “surgery” sessions at Children with Disabilities Service for advice / support / joint working or training as appropriate.
Good Practice guidance Rationale
  • Early identification by Children with Disabilities Service and cross checking against IATT database will ensure that all young people with High / Complex special needs are known to the all the key agencies.
  • Cross checking with IATT and / or Prospects / Connexions PA SEN to clarify if this case is allocated at Children with Disabilities Service or a duty case; discuss/agree who is most appropriate to be lead professional, and clarify who is covering all the main aspects of transition planning.
  • Clarify who is involved with the various aspects of planning for Young Person and their family. This helps identify gaps in needs or services / planning aspects not being addressed.
  • Information leaflets / Letters to Young People to be developed in conjunction with IATT 7 others to help explain process and issues.
 Information sharing is critical to improved co-ordination, joint working and improved targeting of resources, reducing duplication of effort and for families and young people will offer clarity of professional role and purpose.

The inter-agency transition planning process can clarify which agency/team/worker is covering what aspects of the emerging transition plan over the next 5 years.
  • Work towards a single annual reviewing process that includes all the requirements of LAC and Transition planning process for those Young People for whom this is appropriate. Children with Disabilities Service and IATT to jointly develop format to ensure transition elements are included in LAC reviews.
  • IATT to develop appropriate training on this issue in respective teams.
 Ensure principles of person centred planning and inclusiveness are applied and that Parents and Carers also have their needs wishes listened to.

At 14 and 15 years / School Year 9 and 10 Children with Disabilities Service actions will be:

  • If cases already closed Children with Disabilities Service issue a standard letter to Parents / young person outlines where to go to for transition planning support, (Education, Employment or Training issues to Prospects / Connexions service at their school; Social Care issues by self / referral to Children with Disabilities Service; GP / School Doctor if there are health/medical issues). Letter copied to IATT.
  • Lead Professional / Allocated Social Worker attends YEAR 9 / 10 school based review and contributes to annual review report on Young People “allocated” in Children with Disabilities Service.
  • Individual workers link into IATT monthly “surgery” sessions at Children with Disabilities Service for advice / support / joint working or training as appropriate.
  • Identify all cases of Young people in Children with Disabilities Service that might require multi-agency planning and ongoing support into adulthood and then refer them to the LD or other SCHOOL LEAVERS FORUM co-ordinated by IATT.
Good Practice guidance Rationale
  • Children with Disabilities Service alerted to other Young People (not known / not active in Children with Disabilities Service) by IATT or PA Prospects where there are concerns / unmet social care needs. Children with Disabilities Service to assess as appropriate.
 This will help early pick of those most vulnerable young people who will need additional support to identify and achieve a safe and supported transition towards adulthood.
  • Children with Disabilities Service to consider short-term allocation of other cases (closed, not active, not known, or duty) providing they meet the Children with Disabilities Service criteria;
 To ensure transition issues identified and Young Person’s social care needs are addressed within the inter-agency process.
  • Achieved a single annual reviewing process that includes all the requirements of LAC and Transition planning process for those Young People for whom this is appropriate.
 Ensure principles of person centred planning and inclusiveness are applied and that Parents and Carers also have their needs wishes listened to.

At 16 years / School year 11

  • Lead Professional / Allocated Social Worker attends YEAR 11 school based review and contributes to annual review report on Young People “allocated” in Children with Disabilities Service.
  • Identify all cases of Young people in Children with Disabilities Service that might require multi-agency planning and ongoing support into adulthood; then onward referral to the LD or other SCHOOL LEAVERS FORUM co-ordinated by IATT.
  • Cases known to Children with Disabilities Service does not automatically mean that Children with Disabilities Service are “lead agency or are  key worker/professional” or that cases will be assessed or allocated, a case by case decision will be made at the time.
Good Practice guidance Rationale
  • Children with Disabilities Service to consider short-term allocation of other cases providing they meet the Children with Disabilities Service criteria (closed / not active, not known, or duty) to ensure transition issues identified and Young Person’s social care needs are addressed within the inter-agency process.
  • Detailed discussions with young person / Parents / Carers about possible ongoing social care support / service needs beyond 18 years and likely declining support / service entitlement.
  • A full Carers assessment will be undertaken by Children with Disabilities Service Staff at this stage.
  • Training / good practice guidelines to be jointly developed by Children with Disabilities Service and IATT (include case studies) around this process.
  • Ensure Parents / Carers/ young person aware of issues relating to transfer to adult provision and implications of FACS
  • Also DIRECT PAYMENTS  and / or INDIVIDUAL BUDGETS should be explored with family – new Department for Education target for all 16 year olds with disabilities.
  • Adult services fully informed of Young People who may require ongoing support into adulthood and copied into review papers and must be consulted on and informed of likely ongoing care costs beyond 18 years.
  • Children with Disabilities Service and AwLD and other Adult teams, with the support of IATT to develop an agreed detailed protocol around this issue:
    • what age do AwLD / adults want “paper information only” (? 16 year 11)
    • what age / point in time will AwLD / adults attend review meetings
    • what age / point in time will AwLD / adults  start joint working with Children with Disabilities Service (and other Children’s Teams)
  • If appropriate case to be presented to respective funding panel(s).
  • NSF / Department for Education guidance indicates that the case transfer process within the Transition plan should be flexibly applied and depending on individual circumstances should be phased (not a strict cut off point or date), where joint working for a period is commonplace and could happen between 17 to 19 years. Transfer of Financial responsibility may be another issue!

At 17 years / Year 12

This section can’t be clarified until some of the previous sections have been agreed.

Lead Professional / Allocated Social Worker to attend review, contribute to review report on Young People who’s case is “allocated” in their service; At this point in time this may be jointly done with the respective AwLD / Adults teams Transition Lead.

Good Practice guidance Rationale

It has been agreed by AWLD team, Challenging Needs (Lewisham Partnership), and Younger Adults with Physical Disabilities Team that a young person will transfer over to their service at or around their 18th birthday – see below (3).

  • To begin the process the Disabled Children’s Service would identify which young people had reached their 17th birthday, and would jointly undertake an Adults Core Assessment with AwLD / other Adult Team(s)
  • NSF / Department for Eduaction guidance indicates that the case transfer process within the Transition plan should be flexibly applied and depending on individual circumstances should be phased (not a strict cut off point or date), where joint working for a period is commonplace and could happen between 17 to 19 years. Transfer of Financial responsibility may be another issue!
  • Children with Disabilities Service would be comfortable with 6 months either way for both funding and casework transfer (= 17.5 years to 18.5 years)
  • Double check that that Parents / Carers/ young person aware of issues relating to transfer to adult provision and implications of FACS
  • This is irrespective as to whether they are still in full time education.  This was agreed as it was felt to offer the Adults Service a year’s grace of planning for when the young person leaves school at 19. It would give the Adults worker an opportunity to work with the young person before major changes happened which would ease the difficulties associated with transition.
  • The ADULT JOINT CORE ASSESSMENT whilst not looking at actual service provision, would concentrate on the needs of the young person, as an adult, and slowly begin introducing the Parents to the idea of their “child” being considered an “adult”. 

    There will also be an outline of the current support package that Children’s Services are providing. The aim will be to keep a consistent level of service going seamlessly throughout the transition.
  • It is well known that Parents find this part quite difficult, and the needs and rights of Parent/Carers are not given the same consideration, as they are when the children are under 18.  It is hoped that by this process being undertaken by a worker who understands the difficulties from a children and families perspective, this may ease the transition process.

At rising 18 years / Year 13 (before 18th birthday)

This section can’t be clarified until some of the previous sections have been agreed.

Lead Professional / Allocated Social Worker to attend review, contribute to review report on Young People who’s case is “allocated” in their service; This time this may also be jointly done with the respective AwLD / Adults teams Transition Lead.

Liaise with adult’s services about timing of transfer of case. Write transfer /closing summary / transition report in good time. Copy to IATT, respective adult service and young person and Parents.

The whole process is significantly improved if there is “ named leads” in both sides of the process, so Transition Lead SW in Children with Disabilities Service liaising directly with their equivalent on the adults side (AWLD, Sensory, Younger Adults).

Good Practice guidance Rationale
  • Ensure transfer summary and care plan arrangements are agreed and in place. When the young person reaches their 18th birthday, their file is transferred over to the appropriate adults team. 
 Good quality written transfer summary, with input from Parent / Carer and Young person will aid the process, ensuring transfer of information is accurate and timely.
  • The file is to include a further copy of the Adults Core Assessment (as it may be a year since the original one was forwarded and it may have been updated since then), an Adults Referral Form, a completed Transfer Summary, and a completed Transition Checklist (to be developed). 
 The family should have been written to advising them of who to contact in the future and Disabled Children’s Service should have made all necessary changes on SWIFT.

End