Supporting young people through transition into adult heath care services

The Registered Nurse for Children and Young People (RN CYP) was tasked with developing services for young people, with a particular focus on transitional health services at Sheffield Teaching Hospitals NHS Foundation Trust (STHFT).

The initial aims were:

• To identify transition services across the Trust.
• To develop transitional health services in line with NG43 and QS140 (NICE, 2016).
• To raise profile of the central team to promote need of transition services and young person-friendly care.
• To raise staff understanding across the Trust of adolescent and young adult (AYA) development and their needs and how as healthcare providers we need to work differently with this population.
• To improve care when young people aged 16-18 who present at the Emergency Department with mental health issues.
• To establish DNA rates for young people transitioning into STH services from children's services.
• To ensure better working with partner agencies to support young people moving into adult services. To ensure young people voices were captured to influence service development across the Trust.

Adolescence and young adulthood are distinct developmental phases that extend from 10 until around the age of 25 (Colver et al 2018). Adolescent and Young Adult (AYA) needs are different to the needs of both children and adults (Hagell et al 2017; NICE 2016).

Developmentally appropriate healthcare can be defined as the tailoring of healthcare to provide care that meets the needs of the adolescent and young adult population (McDonagh et al, 2017). If health services do not get care right for AYA there can be disengagement which can lead to poor health outcomes and increases in emergency presentations (NICE, 2016).

At STHFT it was recognised that transition was a period of risk for young people and that as a Trust we had variation in the level of transition services. A baseline audit across a number of transition services using the NG43 self-audit tool was used to identify areas of strength and areas to develop. It was recognised that in order for change to happen across the Trust an increased central transition team, working across the whole Trust, to drive change was required. It was recognised that the staff population at STHFT were predominantly trained in adult care delivery so did not necessarily have the understanding of the needs of young people. While training was offered it was only on an optional basis so there was no assurances that staff working with young people had received any training on the needs of this population.

A baseline audit, against standards identified by the RN CYP, was completed to identify if the care young people aged 16-17 were receiving when they attended the Emergency Department was appropriate.

A baseline DNA audit was completed to look at what the DNA rates were for young people transitioning into STHFT services from adult services and were we compliant with NG43 and QS140 when managing DNAs of young people moving into adult services. In order to ensure better working with external agencies, the invitation list for the STHFT care of children and young people steering group was extended to include a larger number of partner agencies.

A multi-partner Sheffield Transition evening was also organised by the RN CYP in collaboration with Sheffield CCG and Sheffield Children's Hospital (SCH). The RN CYP worked with the Voluntary services on a bid to the Pears Foundation for a Young People's Project Officer to work on developing a Youth Forum to ensure young people's views were obtained on STHFT services.

To understand transition services across STHFT an NG43 tool was sent to transition leads in specialty areas. This was to identify areas of improvement and any common challenges teams were facing.

For AYA services to develop across the Trust expansion to the central transition team was needed. Initially the team was 15 hours per week RN CYP with oversight be the Lead Nurse for CYP. Although there was medical input this was on a goodwill basis. The RN CYP contributed to the business case to expand the central transition and young adult care team.

While the AYA and transition training offered was well attended with good feedback received it was clear that we would not reach key staff on this informal basis. In one care group AYA training was added to the mandatory study day for nurses and support workers to ensure good coverage within that care group. The RN CYP also wrote a proposal for this training to be job specific essential training for all staff working regularly with young people.

The ED audit identified some areas requiring improvement when young people attended with mental health issues. In the first audit 57% of young people were referred to the Mental Health Liaison Team for assessment and 34% were referred to the Paediatric Liaison Team for information sharing with CAMHS/community providers. The DNA audit identified a DNA rate of 14% for young people's 1st adult appointment following transition. The rate of offering a 2nd appointment when the first was missed was 80% which was positive and was a good baseline for meeting QS140. However the notification back to the referring service was identified as an area that needed improvement. 

The Sheffield Transition evening was organised by the RN CYP in collaboration with Sheffield CCG, who funded the event, and Sheffield Children's Hospital, who played a key role in supporting the event and advertising. The event, held in both 2018 and 2019 saw around 35 stalls from a range of services including acute health, learning disability services, mental health, social care, youth and voluntary services all come together to be available to talk to young people and their families about what is available to them as the move into adult services.

The bid to the Pears Foundation was successful and led to the development of a Youth Forum at STHFT.

Following the NG43 audit, which was also completed by SCH, a formalised Cross-Trust programme to develop specialty transition services was developed. Please see supporting information document for details.

The business case was successful. The RN CYP now has 30 hours per week, a Learning Disability Nurse 37.5 hours per week, Lead CYP Nurse oversight, 6 hours per week medical leadership and a link to operational management support. This increase, has particularly supported patients as the team is now more able to key work the transition of young people with complex health needs.

In 2019 the team provided direct support to both patients &/clinical teams for 71 patients, leading to improved patient experience. The JSET proposal was accepted and as of 2020 around 430 members of staff will now be required to complete the AYA and transition training. it is significant that staff now will have appropriate training on the needs AYA.

Following the initial ED audit, the RN CYP worked with ED to produce guidance on the management of young people presenting with mental health issues. The latest re-audit, 2 years after the original, demonstrated an increase in referrals to the Mental Health Liaison Team from 57% to 88% and the number of paediatric liaison forms increased from 34% to 78%. While the DNA audit showed most young people who missed their 1st adult appointment following transition were offered a 2nd appointment. A number of patients were discharged after one missed appointment, so developments were needed to comply with NICE guidance.  The communication back to children's services of missed appointments also needed improvement. Following this the RN CYP wrote into policy that no young person aged 16-25 should be discharged following 1 missed appointment, that applies to transitioning young people or new referrals.

The policy also highlighted the need to copy referrers into DNA letters. While this has only just been accepted as Trust policy and so the impact has not yet been measured, the fact this has been accepted into policy is significant and should lead to better management of young people entering adult services.

The Youth Forum is now up and running and contributing to service improvement work at STHFT. It is essential that young people's views are captured and this formal mechanism is a recommendation in NG43 and is key to our on-going work, including incorporating their views into training, developing feedback systems and working with professionals to share their views.

While the population of AYA in adult services may be a relatively small population (at STHFT in 2016-17, 9% of all out-patients appointments were for 16-24 year olds) they are a group of patients with distinct developmental needs and if we fail to engage them in their healthcare at this crucial time the impact on their health, and consequently services, is significant.

Having a central team to not only lead and drive improvements in service delivery to this population but also to coordinate and support the most complex patients as they transition into adult services has resulted in improved patient outcomes as discussed in the findings.

The multi-disciplinary approach has worked very well at STHFT One of the biggest challenges is evidencing the impact of the changes on outcomes and financial benefits of the team. It is useful for teams such as ours to have a clearly defined work plan or set of objectives to evidence the effect the central team has to both patients and the organisation.

The multi-disciplinary approach taken at STHFT has been essential to make improvements. Organisational change requires input from both medical and nursing teams and the team reflects this. Having a registered children's nurse and a learning disability nurse has also been key in bringing the understanding of the needs of adolescents and young people with complex needs and why changes are needed to a predominantly adult trained workforce and thus has helped bring about some of the changes discussed.

This model is replicable in other areas and is an effective way of promoting transition and the needs of young people in adult services.