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P-173 Innovations in the transition process
  1. Phillipa Sellar
  1. St Christopher's Hospice, London, UK


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.

Introduction We completed a 12 month Transition project, achieving the following:

  • - Identified young adults (17–25 years).

  • - 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.)

The next two years-methods With funding continue to 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.

Undertake ACP.

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.

  • 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.

Conclusions Teenagers/Young adults with cancer/non cancer diagnosis, though small in size, have expensive and complex multi-agency support needs including social care, health, education, housing, leisure and employment. Joint working improves outcomes and could be measured with palliative care being seen as an extra layer of support alongside treatment. The project is influential in changing perceptions and illustrates the benefits of developing a shared care service model.

Recommendations Continue to use qualitative/quantitative indicators- collating data-referrals and attendances to social/therapeutic days. Explore existing outcome measures.

Initial assessment/identify any key community paediatric, education, employment, Social Services etc. professionals and arrange joint visits by Young Adults Co-Ordinator.

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