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Transition Challenges & Barriers (CAMHS to Adults), Goal / Aim, Driver…
Transition Challenges & Barriers (CAMHS to Adults)
Delayed allocation of worker which results in delay transfer to Adults to post-18. Unclear about what the purpose of transfer is (e.g. what is being asked)?
A timely allocation of an adult care coordinator
Availability of a suitable care coordinator
Recruitment of staff?
Agree on an appropriate Escalation Process
Having the 'right people' (medics) in the transition meeting
Ensure 'decision makers' can attend meeting
Agreement for 'Consultant to consultant' discussion to take place?
Agreement to have a medical rep at the transition meeting?
Disagreement on a YP’s presentation
An appropriate agreement on pathway for YP's next steps
Quality of information passed on from CAMHS which causes a lot of 'to & fro' of conversations and therefore delay
Greater awareness of staff on what needs to be captured on SBARD
CAMHS to suggest ways to overcome this challenge?
SBARD to be completed by staff who knows the YP well?
Process of transfer
To ensure there is a process that's agreed by all relevant stakeholders / staff
Review and identify areas where the process isn't working
To review and create an appropriate process map and to communicate to all staff
Difficulty transferring CPA
A transfer CPA at an appropriate time
Staff unclear the process / timing for a transfer CPA
Relevant staff finds it difficult to schedule meeting to discuss / agree this between teams
Staff to raise with Adults Team Managers if there is difficulty scheduling a meeting with care coordinator? (Agree an appropriate escalation process)
Utilise existing Transition Meeting / bi-monthly meeting?
Actions are not always followed through?
Need to agree what regular meetings / forums are needed going forward / how they are structured
Staff need to recognised that these meetings need to be prioritised
Have a clear escalation process to minimise delays
Lack of agreement on when a transfer has occurred (i.e. when should the primary responsibility transfer from CAMHS to Adults)
Agree what transfers would look like under different scenarios?
Transfer point for Complex cases can be difficult to agree
Joint assessment by CAMHS and Adults (focus on patient's needs), with agreed clinical reasons / rational for any extension of transition period
General perception that all transitions between CAMHS and Adults are bad
Shared appreciation and respect for both sides on transition
lack of understanding of current challenges (e.g. CAMHS provides services that Adults don't)
Conduct 'teaching' sessions between teams to better understand what offers are available in each service
understanding who has this perception and why they feel that way
joint workshop for both services - for information sharing
Disconnection between services
To bring Adults and CAMHS closer together and understanding of how everyone works and what everyone does
Current pathways are complex and difficult to navigate
Write / map out current pathways for both services
CMHT not always clear on what their responsibilities are in transition
For both services to have clear understanding of responsibilities during transition.
Currently there isn't an agreement Role & Responsibilities
Compile a R&R document agreed by all stakeholders and communicate to all.
Diagnostic? There are different approaches to certain diagnoses from both services
To have a different group working on Neuro / PD / Forensic CAMHS
Adults are not commissioned to provide treatment for clients with ASD / emerging PD
Follow up with SMT on any new commissioning arrangements for these client groups
Unclear expectation on the duration of transitions
Agreement on duration of transition for YP and agreement for complex cases.
There are different opinions at times.
Set up timescales / tracking system on feeding back outcomes/ updates in the runs up to a YP's 18 bday
Review how Transition Meetings are conducted - enhanced on occassional basis to focus on complex cases
Staff do not know what a good transition should look like
Staff on both teams have a good understanding what the principles are for a good transfer
Currently there is not an agreement on the standards are for a good transfer.
Create a Standards of Good Transfers that includes what's good and what's bad
What Adults are commissioned to provide – may not match with some of the treatment that CAMHS provide
To understand what Adults are commissioned to provide, and for us to agree an approach where adults are not commissioned to provide a service but CAMHS are.
Agree a consistent approach of commissioning between CAMHS and Adults
To raise as a risk to relevant board
Escalation process (e.g. what happens when it’s not working)
Agree timescale and tracking of each transition case and time period of escalation. Agree escalation process that works for all stakeholders.
Currently there isn't an agreed escalation process that works for all stakeholder
Create a forum to discuss transition escalation / difficulties / complex situations. Reinstate monthly Transition Meeting?
Agree process to escalate appropriately
Goal / Aim
Driver
Activities
Goal / Aims
Driver
Activities