Background Moving from children’s to adult services can be a difficult transition for teenagers/young adults (TYA) and their families. Services are poorly coordinated; provision can be inequitable, leading TYA/their families to become socially isolated/ disengaged.(RCN 2014, Public service works 2011).
Introduction We completed a 12 month Transition project, achieving the following:
Identified young adults (17–25years).
Home visits with TYA CNS and keyworker from children’s services, creating a plan of care, naming professionals, exploring Advance Care Planning.
Set up monthly Young Adult Days. (Including friends and siblings.)
Methods With funding develop TYA (formally transition) services.
Offering social/therapeutic days every Saturday, with siblings/friends.
Appointment of Young Adults Clinical Nurse Specialist.
Continue to identify TYA.
Offer assessment, co-ordination/advocacy. Focus on access to education, employment, welfare/ benefits.
Engage with regional/national forums regarding transition/development of services.
Development of Social Media as a tool for creating/Supporting communities of TYA.
Increase in referrals, high attendance of social/therapeutic days.
Co-ordination of TYA care.
Involvement of TYA in development.
Growth in autonomy/independence of TYAS.
Increase number of volunteers.
Develop training for younger volunteers.
Acceptance of TYA as part of adult services by staff/volunteers.
Changing the wider perception of palliative care.
Preferred place of care and death discussions. (Out of 40 referrals no advance care planning had been completed).
Conclusions TYA with cancer/non cancer diagnosis, have expensive, complex multi-agency support needs. Joint working improves outcomes which can be measured with palliative care being seen as a layer of support. The service is influential in changing perceptions, illustrating the benefits of developing a shared care model including prevention of social isolation. With the benefit ofadvance care planning.
Recommendations Continue to use qualitative/quantitative indicators- collating data-referrals and attendances to social and therapeutic days.
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