Herts young people's health transitional service

  • The Young People’s Health Transition Service aims to coordinate transfer of health care from paediatric to adult services, for young people with complex physical health needs or with life limiting conditions throughout Hertfordshire. We will work collaboratively with Education, Health, and Social Care to achieve our goal and support a smooth individualised transition pathway into adult services. 

    The service consists of two transition nurse coordinators and an administrator.

    Every young person will have a named transition nurse coordinator to ensure continuity of care. They will facilitate and coordinate a holistic, person centred approach to ensure transition planning is undertaken including; healthcare, social care, education, community living, employment and leisure activities.

    Young people who have been in residential schools outside of Hertfordshire, have had their transition process supported by the transition nurse coordinators, enabling them to return back into county and have their complex needs met locally.

    Parallel planning for those young people with unstable health needs are recognised and undertaken.

    Contact the service

    Telephone: 01923 470680
    Email: hct.transitionherts@nhs.net

    Children's community nursing service offer

How the service is provided

The Young People’s Health Transition Service provides individualised transition pathway for young people and their families depending on their needs. We act as a link between all services to encourage the best outcome for our young people. We acknowledge that every individual is different and that their pathway into adult services can change. To ensure the support we offer is affective and offer support with any changes to the young person’s pathway we provide 3 monthly update calls, to promote and support the transition pathway. The Young People’s Health Transition Service focuses on the important Age’s within transition that every young person should go through. These important stages happen at 14 years when the transition pathway should start and we receive the referrals for the young person. At 17 years we move on to at the adult services and the provisions the young person will need entering adult services and this is done by completing an adult continuing care checklist. At 18 years we start discussions around the legal aspect of transition and parental responsibility. At 19 years if the pathway is completed and the young person is fully established in adult services, we start discussions around discharging the young person from  

The Young People’s Health Transition Service. However, if the pathway has changed and more support is needed, we will continue to provide transition support until the young person in 21 years old

The transition nurse coordinators will work collaboratively with the young people, their family and multi-agency professionals to ensure a smooth, planned transition process by:

  • facilitating the transition process of health care from paediatric to adult services
  • acting as a resource on health care matters to young people, families and multidisciplinary teams
  • identifying and addressing the training needs of the receiving adult services to enable the health needs of the young person to be met appropriately
  • supporting the young people on the caseload providing continuity until the young person is established in adult services
  • identifying and highlighting ‘gaps’ in services to commissioners

Who is eligible for the service

Any young person  registered with a GP in Hertfordshire, aged 14-21 years with complex physical health needs where there is not an identified health referral pathway at the age of 14 years. 

These young people often require jointly commissioned services by health, education and social care.

Complex physical health needs

Any young person aged 14 to 21 years with complex physical health needs where there is not an identified health transition referral pathway at the age of 14 years.

Technology dependent children, complex or intense medical, nursing or other clinical needs i.e. two of the following:

  • complex, chronic, respiratory conditions requiring ventilatory support CPAP/BIPAP
  • child with a tracheostomy
  • child receiving total parenteral nutrition via a central line
  • renal dialysis i.e. peritoneal/haemofiltration
  • acquired brain/spinal injury
  • administration and monitoring of complex drug regimes
  • artificial feeding via naso-gastric, naso jejunal or gastrostomy tube
  • restricted mobility, requiring regular and frequent positioning, moving and handling in order to treat/prevent pressure sores
  • oxygen dependence

Life-Limiting Conditions

A young person aged 14 to 21 years who has developed a condition in childhood, which is likely to result in their premature death (before the age of 40 years) and who may have palliative care needs. These may include the following conditions:

  • Duchenne Muscular Dystrophy
  • Cystic Fibrosis
  • progressive conditions such as Battens Disease, CJD, Mucopolysaccharides
  • neurological disability such as severe Cerebral Palsy, brain or spinal cord injuries
  • cancer when treatment fails
  • irreversible organ failure

Exemptions

The service does not accept referral for a young person who are under Children Continuing Care Teams. 

The service does not accept a referral for a young person aged 21. 

 

What will happen at your appointment

Between the ages of 14 to 21 young people usually have to make important decisions about their education; leave home; get a job and start having relationships. These decisions and changes can be both exciting and challenging. For disabled young people it can be a confusing and complicated time, as they often receive support from a number of different agencies, including health, social care services and education. Planning should start well in advance of leaving school, so that the young person’s needs and choices are fully explored.

Before the first home visit The Young People’s Health Transition Service will make a telephone contact to you to welcome you to the service. We will send out a welcome pack with information regarding transition and the support we will offer you and your family. During the first home visit The Young People’s Health Transition Service will complete an initial assessment which will outline the needs of the young person and support they require. 

The main role of the transitional nurse coordinator is to facilitate and coordinate services during the transition process for young people with complex physical health needs or with life-limiting conditions and their families.

The young people’s health transitional service work closely with other services during transition such as:

  • community doctors
  • GPs
  • children’s and adult health care professionals
  • children’s and adult social care
  • School nurses
  • education
  • Connexions
  • short breaks and hospices
  • commissioners
  • community and voluntary services

Useful information

The young people’s health transitional service will offer visits and support in a variety of settings including:

  • home
  • school
  • short breaks

Contact the service

The service can be contacted Monday to Friday, 9am to 5pm.

Herts Young People's Health Transitional Service
Peace Children's Centre
Peace Prospect
Watford
WD17 3EW
Telephone: 01923 470680

Resources

Websites

Hertfordshire County Council’s local offer pages
Information about services available in your local area for parents, children and young people aged 0-25 with special educational needs and disabilities (SEND).
https://www.hertfordshire.gov.uk/microsites/local-offer/preparing-for-adulthood/health/health.aspx

Transition Information Network
A source of information for disabled young people, families and professionals.
https://councilfordisabledchildren.org.uk/transition-information-network

Together for Short Lives
UK wide charity working to achieve the best possible quality of life and care for every child and young person who is not expected to reach adulthood.
www.togetherforshortlives.org.uk

Easyhealth
Health information that is easy to understand, learning difficulties, learning disabilities, easy read, simple language.
www.easyhealth.org.uk

Skill
National Bureau for Students with Disabilities, promoting equality in education, training and employment for disabled people.
www.skill.org.uk

Scope
Charity organisation for disabled people to have same opportunities as everyone else.
https://www.scope.org.uk/transition

Mencap
A comprehensive series of fact sheets about transition along with a range of support and training services.
https://www.mencap.org.uk/advice-and-support/children-and-young-people/education-support/transition-adult-services

Preparing for Adulthood
This website contains information about transition.
www.preparingforadulthood.org.uk

The Share Study
Results from ‘The Share Study’ are now available: online survey for parents of children with life-limited conditions about experiences of lockdown. Highlights experience of isolation and anxiety:
https://www.togetherforshortlives.org.uk/forgotten-families-families-feel-more-isolated-than-ever-under-lockdown/

Local offer

Have you heard of the Local Offer?  If you are a young person with, or have a child with special educational needs and disabilities, (SEND) the Local Offer is Hertfordshire’s central source of information for SEND services and support. Visit www.hertsdirect.org/localoffer for an easily accessible one stop shop.

Making a referral

Young people can be referred by any professional currently working with them.

On receipt of a completed referral form the Team Administrator will register the young person onto the appropriate area caseload for a triage by a Transitional Nurse Coordinator; if referral criteria is met the Team Administrator will send a letter to the young person to inform him/her that a referral has been made to the Transition Service and offer a home visit for an initial nursing assessment by a Transitional Nurse Coordinator. In this letter, we will be requesting permission to seek and share information with the wider Multidisciplinary teams to support the transition process.

If a referral does not meet the service referral criteria the referrer will be notified and no contact will be made with the family and the referral will be ended.

Click here for guidelines for professionals about the service which includes information on making a referral.

Click here for the basics about transition for families

If you wish to ring to find out if your referral is appropriate or if you have a general enquiry please call the team on 01923 470680.

Click here for a referral form

Patient experience

We always like to receiver feedback and include some of the comments below:

  • We would be lost without transition service, as services are not the same in adults as they are in children’s services.  
  • Transition is delivered in bite size chunk make it so much easier for us understand and follow, we are always worried we will miss and important step.

  • Transition services are on top of everything, they are a great team and always willing to help. The fact they are at the end of the phone when we need them is fantastic. 

  • The transition service have been amazing at navigating around a very complected system into adult service. It's nice just having someone to vent to

If you would like to share your story, please contact the Patient Experience team on 01707 388036 or email pals.hchs@nhs.net.

We would also love to hear about your experience on our service; please complete our survey with your feedback.

Herts young people's health transitional service

  • The Young People’s Health Transition Service aims to coordinate transfer of health care from paediatric to adult services, for young people with complex physical health needs or with life limiting conditions throughout Hertfordshire. We will work collaboratively with Education, Health, and Social Care to achieve our goal and support a smooth individualised transition pathway into adult services. 

    The service consists of two transition nurse coordinators and an administrator.

    Every young person will have a named transition nurse coordinator to ensure continuity of care. They will facilitate and coordinate a holistic, person centred approach to ensure transition planning is undertaken including; healthcare, social care, education, community living, employment and leisure activities.

    Young people who have been in residential schools outside of Hertfordshire, have had their transition process supported by the transition nurse coordinators, enabling them to return back into county and have their complex needs met locally.

    Parallel planning for those young people with unstable health needs are recognised and undertaken.

    Contact the service

    Telephone: 01923 470680
    Email: hct.transitionherts@nhs.net

    Children's community nursing service offer

How the service is provided

The Young People’s Health Transition Service provides individualised transition pathway for young people and their families depending on their needs. We act as a link between all services to encourage the best outcome for our young people. We acknowledge that every individual is different and that their pathway into adult services can change. To ensure the support we offer is affective and offer support with any changes to the young person’s pathway we provide 3 monthly update calls, to promote and support the transition pathway. The Young People’s Health Transition Service focuses on the important Age’s within transition that every young person should go through. These important stages happen at 14 years when the transition pathway should start and we receive the referrals for the young person. At 17 years we move on to at the adult services and the provisions the young person will need entering adult services and this is done by completing an adult continuing care checklist. At 18 years we start discussions around the legal aspect of transition and parental responsibility. At 19 years if the pathway is completed and the young person is fully established in adult services, we start discussions around discharging the young person from  

The Young People’s Health Transition Service. However, if the pathway has changed and more support is needed, we will continue to provide transition support until the young person in 21 years old

The transition nurse coordinators will work collaboratively with the young people, their family and multi-agency professionals to ensure a smooth, planned transition process by:

  • facilitating the transition process of health care from paediatric to adult services
  • acting as a resource on health care matters to young people, families and multidisciplinary teams
  • identifying and addressing the training needs of the receiving adult services to enable the health needs of the young person to be met appropriately
  • supporting the young people on the caseload providing continuity until the young person is established in adult services
  • identifying and highlighting ‘gaps’ in services to commissioners

Who is eligible for the service

Any young person  registered with a GP in Hertfordshire, aged 14-21 years with complex physical health needs where there is not an identified health referral pathway at the age of 14 years. 

These young people often require jointly commissioned services by health, education and social care.

Complex physical health needs

Any young person aged 14 to 21 years with complex physical health needs where there is not an identified health transition referral pathway at the age of 14 years.

Technology dependent children, complex or intense medical, nursing or other clinical needs i.e. two of the following:

  • complex, chronic, respiratory conditions requiring ventilatory support CPAP/BIPAP
  • child with a tracheostomy
  • child receiving total parenteral nutrition via a central line
  • renal dialysis i.e. peritoneal/haemofiltration
  • acquired brain/spinal injury
  • administration and monitoring of complex drug regimes
  • artificial feeding via naso-gastric, naso jejunal or gastrostomy tube
  • restricted mobility, requiring regular and frequent positioning, moving and handling in order to treat/prevent pressure sores
  • oxygen dependence

Life-Limiting Conditions

A young person aged 14 to 21 years who has developed a condition in childhood, which is likely to result in their premature death (before the age of 40 years) and who may have palliative care needs. These may include the following conditions:

  • Duchenne Muscular Dystrophy
  • Cystic Fibrosis
  • progressive conditions such as Battens Disease, CJD, Mucopolysaccharides
  • neurological disability such as severe Cerebral Palsy, brain or spinal cord injuries
  • cancer when treatment fails
  • irreversible organ failure

Exemptions

The service does not accept referral for a young person who are under Children Continuing Care Teams. 

The service does not accept a referral for a young person aged 21. 

 

What will happen at your appointment

Between the ages of 14 to 21 young people usually have to make important decisions about their education; leave home; get a job and start having relationships. These decisions and changes can be both exciting and challenging. For disabled young people it can be a confusing and complicated time, as they often receive support from a number of different agencies, including health, social care services and education. Planning should start well in advance of leaving school, so that the young person’s needs and choices are fully explored.

Before the first home visit The Young People’s Health Transition Service will make a telephone contact to you to welcome you to the service. We will send out a welcome pack with information regarding transition and the support we will offer you and your family. During the first home visit The Young People’s Health Transition Service will complete an initial assessment which will outline the needs of the young person and support they require. 

The main role of the transitional nurse coordinator is to facilitate and coordinate services during the transition process for young people with complex physical health needs or with life-limiting conditions and their families.

The young people’s health transitional service work closely with other services during transition such as:

  • community doctors
  • GPs
  • children’s and adult health care professionals
  • children’s and adult social care
  • School nurses
  • education
  • Connexions
  • short breaks and hospices
  • commissioners
  • community and voluntary services

Useful information

The young people’s health transitional service will offer visits and support in a variety of settings including:

  • home
  • school
  • short breaks

Contact the service

The service can be contacted Monday to Friday, 9am to 5pm.

Herts Young People's Health Transitional Service
Peace Children's Centre
Peace Prospect
Watford
WD17 3EW
Telephone: 01923 470680

Resources

Websites

Hertfordshire County Council’s local offer pages
Information about services available in your local area for parents, children and young people aged 0-25 with special educational needs and disabilities (SEND).
https://www.hertfordshire.gov.uk/microsites/local-offer/preparing-for-adulthood/health/health.aspx

Transition Information Network
A source of information for disabled young people, families and professionals.
https://councilfordisabledchildren.org.uk/transition-information-network

Together for Short Lives
UK wide charity working to achieve the best possible quality of life and care for every child and young person who is not expected to reach adulthood.
www.togetherforshortlives.org.uk

Easyhealth
Health information that is easy to understand, learning difficulties, learning disabilities, easy read, simple language.
www.easyhealth.org.uk

Skill
National Bureau for Students with Disabilities, promoting equality in education, training and employment for disabled people.
www.skill.org.uk

Scope
Charity organisation for disabled people to have same opportunities as everyone else.
https://www.scope.org.uk/transition

Mencap
A comprehensive series of fact sheets about transition along with a range of support and training services.
https://www.mencap.org.uk/advice-and-support/children-and-young-people/education-support/transition-adult-services

Preparing for Adulthood
This website contains information about transition.
www.preparingforadulthood.org.uk

The Share Study
Results from ‘The Share Study’ are now available: online survey for parents of children with life-limited conditions about experiences of lockdown. Highlights experience of isolation and anxiety:
https://www.togetherforshortlives.org.uk/forgotten-families-families-feel-more-isolated-than-ever-under-lockdown/

Local offer

Have you heard of the Local Offer?  If you are a young person with, or have a child with special educational needs and disabilities, (SEND) the Local Offer is Hertfordshire’s central source of information for SEND services and support. Visit www.hertsdirect.org/localoffer for an easily accessible one stop shop.

Making a referral

Young people can be referred by any professional currently working with them.

On receipt of a completed referral form the Team Administrator will register the young person onto the appropriate area caseload for a triage by a Transitional Nurse Coordinator; if referral criteria is met the Team Administrator will send a letter to the young person to inform him/her that a referral has been made to the Transition Service and offer a home visit for an initial nursing assessment by a Transitional Nurse Coordinator. In this letter, we will be requesting permission to seek and share information with the wider Multidisciplinary teams to support the transition process.

If a referral does not meet the service referral criteria the referrer will be notified and no contact will be made with the family and the referral will be ended.

Click here for guidelines for professionals about the service which includes information on making a referral.

Click here for the basics about transition for families

If you wish to ring to find out if your referral is appropriate or if you have a general enquiry please call the team on 01923 470680.

Click here for a referral form

Patient experience

We always like to receiver feedback and include some of the comments below:

  • We would be lost without transition service, as services are not the same in adults as they are in children’s services.  
  • Transition is delivered in bite size chunk make it so much easier for us understand and follow, we are always worried we will miss and important step.

  • Transition services are on top of everything, they are a great team and always willing to help. The fact they are at the end of the phone when we need them is fantastic. 

  • The transition service have been amazing at navigating around a very complected system into adult service. It's nice just having someone to vent to

If you would like to share your story, please contact the Patient Experience team on 01707 388036 or email pals.hchs@nhs.net.

We would also love to hear about your experience on our service; please complete our survey with your feedback.