Mental health service transitions for young people

Key messages

Adolescents are a very special group of individuals requiring highly specialised skills (1)

• It is important that young people gain understanding of their mental health problems. Staff should be able to offer information to young people, parents and carers about treatment and support options.
• All staff should be aware of local services and transition processes, and should provide accurate and timely information to young people and their families/carers, as well as ensure that all agencies involved in supporting a young person in transition receive the necessary information (e.g. discharge plans, review reports and referral letters).
• Managers need to regularly audit case files of young people requiring transition from child and adolescent mental health services (CAMHS) to other services, to ensure that all assessments, discharge summaries and paperwork to support the referral are completed. They will also need to put in place processes to track all young people's outcomes, not just those transferring to adult mental health services (AMHS).
• Managers should ensure that staff know what services are available and that there are networks and other ways to help staff share information among themselves and between services. Consistent information technology (IT) systems are vital to ensure appropriate communication of information.
• Staff need to work collaboratively with other services in order to support young people throughout the transition process - for example, in assessment and planning.
• Managers should ensure that services are working together strategically to plan and implement transition. Multi-disciplinary services are required for 16-25-year-olds that have the ability to accept referrals from a variety of sources, to incorporate CAMHS/AMHS and to integrate voluntary sector providers, non-health agencies, universal services and general practitioners (GPs). Developing and disseminating joint protocols can help with multi-agency training.
• It is important to focus on the whole life of the young person when assessing needs and planning transition, including their family, friends, housing, school, college and work, as these factors will affect their overall wellbeing.
• It is vital that young people are fully involved in planning their transition. Planning should start in good time – at least six months in advance.
• Young people need access to a consistent, proactive, designated lead professional and also appreciate support from mentors, advocates and their peers. Young people often find structured peer support very helpful. Key workers should be proactive and keep in regular contact with young people.
• Managers should ensure that allocation and management of staff caseloads minimises the need to change a young person's lead professional or care co-ordinator, especially when the young person is in transition between services. They should also allocate staff time and plan team caseloads to facilitate a period of parallel care by CAMHS and AMHS.
• All staff should be welcoming and accepting of young people, and able to relate to them across the age range. A welcoming reception area is important, as is some degree of flexibility in relation to the occasional missed appointment or late arrival.
• It is important to offer flexible services which fit with young people's lives. This includes exploring opportunities to base services in non-health and community settings where possible and appropriate, and offering flexible appointment times (e.g. evening and weekend provision, drop-in sessions and telephone advice).
• It is important to monitor outcomes and seek regular feedback from young people using services, in order to make improvements and achieve the best possible outcomes.
• It is also important to consider the needs of groups of young people known to experience difficulty accessing services, as this will place them at risk now and in the future. Local transition processes should be tailored to ensure that these match with the needs of all young people. Consulting with organisations that specialise in working with specific groups is useful in establishing how access to services can be improved (e.g. traveller education services or social services care teams).
• Managers should monitor the use of their service to ensure that no groups are under-represented in the planning and provision of support at transition, and need to develop staff appraisal processes to include this aspect of transition support. Gaps in provision may include young people with attention-deficit hyperactivity disorder (ADHD), conduct disorder, autism spectrum disorders (ASDs), emerging personality disorder, and those without a firm medical diagnosis.
• It is easy for young people who are inpatients in hospital to become invisible, especially if their placement is stable and/or they are some distance away or out of area. Ensuring they receive good transitional planning and support is of key importance if they are to be successfully discharged from the inpatient unit.
• Managers should commission training for staff on use of assessment and care planning approaches (such as the CAF and CPA used in England and Wales or the FACE assessment tool used in Northern Ireland) and other monitoring processes. They should also collect outcome- and service-level data and consider the use of targets and national quality criteria such as the 'You're welcome' criteria (2) as a means of monitoring service performance.
• The application of eligibility criteria means that young people may not be eligible for some adult services and may slip through the net, leading to severe and sustained risk to their health and wellbeing. Staff need to be able to offer advice about other support options. Eligibility criteria should be included in transition protocols.